The flying carpet retort to "integrative medicine"

I didn't think I'd be discussing Dr. David Katz again so soon after the last time. In fact, when blog bud Mark Crislip (who clearly hates me and wants me to pop an aneurysm or have a heart attack, given how often he sends me links to articles as infuriating as this) sent me a link to Dr. Katz's latest article, "Cleaning the House of Medicine", published—where else?—in The Huffington Post, that home for "reputable" quack-friendly bloviation since 2005, when I first read the article, my first reaction was that Katz must surely be trolling supporters of science-based medicine. At first, I wasn't going to respond to him again. However, Katz's article represents a very common misconception about science-based medicine that is worth refuting. It is not my intention to be arguing back and forth with Dr. Katz every couple of weeks, but I did think it worth one more round. I think you'll understand why by the end of this post.

First, however, a brief recap is in order for readers who might not have been following the discussion over the last month or so. It all started a couple of weeks ago, when Jann Bellamy, in response to a special issue of the American Journal of Preventative Medicine edited by Katz and dedicated to making the case for integrative medicine in preventive medicine training, quite correctly discussed how "integrative medicine" is always all about the "potential." Indeed, after having spent considerable sums of federal grant money studying the "integration" of pseudoscience into medicine with respect to preventive care, the journal couldn't come up with any concrete examples how integrative medicine adds anything (other than quackery) to medicine. Dr. Katz, who is well-known in the world of quackademic medicine for his infamous 2008 speech in which he asserted that physicians need to use a "more fluid concept of evidence" in evaluating treatments, particularly "complementary and alternative medicine" (CAM), responded with another HuffPo article entitled "Science and Medicine, Fools and Fanatics: The 'Fluidity' of Woo". In lieu of reasonable, science-based arguments, Dr. Katz' article was little more than a rant that consisted mainly of outrage that mere mortals lacking his awesome academic credentials had had the temerity to question his awesomeness and dedication to science coupled with an accusation that we are just too rigid and simplistic in our thinking to understand the subtle complexities of how different standards of evidence must be applied to complex patients. Steve Novella and I both responded that we understand just fine, explained how doctors do this all the time without using quackery like naturopathy and homeopathy (both of which Katz has advocated), and pointed out his argumentum ad ignorantiam with respect to energy medicine.

There's where I thought it would end. Unfortunately, I was mistaken. Last Friday, Katz launched another broadside SBM supporters,\ couched in the form of an argument that medicine must "clean its own house" before worrying about his quackademic medicine. It's something I hear often enough that I thought it would be worth responding to, even if Dr. Katz was indeed trolling me.

Worry about what I think you should worry about

A frequent attack on SBM goes something like this: There are so many problems in medicine when it comes to the rigorous application of evidence to medical treatments, such as the distortion of evidence by big pharma, the overuse of various treatments, and the use of treatments without a good basis in evidence, that we really shouldn't worry so much about things like CAM or integrative medicine because there are far bigger fish to fry. In other words, worry and write about what I think you should worry and write about! If you don't, clearly I can discount you as ideologically blinded. Indeed, Katz makes exactly this argument near the end of his article, with the further implication that because we here at SBM focus mostly on integrative medicine and CAM it must be due to ideology, not science (or, of course, as implied elsewhere, because we are in the thrall of big pharma):

To the best of my knowledge, a rather boisterous group in cyberspace calling itself "science based medicine" is silent on all of this. They preferentially malign all alternatives to conventional medicine, implying that problems of evidence and its application lie entirely without, and not within. This, in turn, makes it clear that such protest is itself unconcerned with the underlying evidence, and born instead of ideological zealotry. If evidence matters, it matters equitably, and universally.

Of course, I agree (and I highly doubt that anyone known for supporting SBM and arguing against quackademic medicine would disagree) that evidence and science must matter equitably and universally. Indeed, over the years, I've lost track of how many times I (and other bloggers) have pointed out that we advocate applying a single science-based standard to all of medicine. Dr. Katz also clearly has only ever read criticql posts here about him, because he sets up a rather massive straw man argument by characterizing SBM supporters by claiming that we are saying that the problems of evidence and its application lie "entirely without, and not within." What? No, the problems with application of evidence are indeed within medicine. The reason I and others discuss CAM so frequently is because the reason it is becoming more "respectable" is not because it's being forced on medicine from without, but rather because certain, well-respected members of the medical profession (like Dr. Katz) are misapplying evidence from within, so to speak. After all, this is the physician who thinks naturopathy is a valid medical specialty and is willing to use homeopathy.

It was also at this point that I wanted to make like Ygritte in Game of Thrones and retort, "You know nothing Jon Snow David Katz." Clearly, Dr. Katz knows nothing (or next to nothing other than the occasional criticism of his statements) about what I and other bloggers advocate. He is also, as he so often does, positing a false dichotomy: That we must do what he thinks most important (clean up the house of medicine, defined by him to mean malign pharma influence, the inconsistent application of evidence, and the persistence of medical tests and interventions that are no longer supported by evidence) before we can do what we consider to be important (combat pseudoscience in medicine). There is no reason we can't do both, and, in fact, I do do both. He's just unhappy that I don't do just one. He's using one of the most irritating and disingenuous arguments of all: "You consider important what I consider important and act and write accordingly," or, as I call it with respect to blogging, "Why don't you blog about what I think you should blog about?"

Because I for the rigorous application of science to medicine, over the years we have written posts questioning all manner of "conventional" medical interventions. I'll start by mentioning just a few of my posts questioning various conventional medical interventions, such as vertebroplasty for osteoporotic compression fractures, which I referred to as "modern acupuncture." Then there's mammography, which has been a frequent topic on this blog ever since the USPSTF issued screening guidelines in 2009 that involved not starting screening until age 50 and then screening only every other year rather than every year and continuing to the publication last month of new guidelines by the American Cancer Society guidelines, which also backed off, albeit not as much, from starting mammographic screening at age 40. In the context of screening, I've discussed overdiagnosis in cancer screening and criticized a certain eminent radiologist who defends mammography at all costs, to the point where he wrote an e-mail complaining to me that reminded me of Dr. Katz's displeasure with us. I've discussed how surgical procedures are often adopted too rapidly, before there is adequate evidence that they are as good as or better than the procedures they supplant. That doesn't even count the times I discussed some downright abusive and criminal conventional doctors and spectacular failures of state medical boards.

I could go on, but got tired after finding just this much. You get the idea. Yes, we do write a lot about CAM and "integrative medicine." We make no apologies for that. If I'm sounding a little defensive, I make no apologies for that, either. Attacks based on ignorance of what I do irritate me. I write about plenty of other medical topics that have nothing to do with CAM. What they do have to do with is exactly what Dr. Katz accuses us of ignoring: Calling out areas of medicine where the application of scientific evidence is not so rigorous. He ought to love me for that, but he doesn't. I wonder why.

The flying carpet problem

Dr. Katz uses a recent systematic review published in JAMA Internal Medicine presenting evidence against certain medical practices that should be reconsidered in 2015 as his jumping off point:

A recent report in JAMA Internal Medicine highlights prevailing medical practices that should be "reconsidered" in 2015 based on the weight of evidence. The paper, appropriately, is written in the matter-of-fact style customary for the peer-reviewed literature. To some extent, that semblance of analytical calm belies the storm swirling between the lines of the report, and the mess it has long been making in the House of Medicine.

The authors, for instance, note that excessive zeal for cancer screening results in "unnecessary surgery and complications." As a statement, that is rather bland, and even when statistics are attached to show scale, as the authors do, it likely fails to evoke any deep impression. But consider any time you have been through surgery yourself, either as the patient, or as a family member. Unless you are the rare individual who has avoided the OR entirely, even by proxy, those occasions are likely indelible in your memory, and easy to recall.

Of course, this is nothing that we (myself in particular) haven't been discussing quite frankly on SBM since at least 2008. Just type the words "overdiagnosis" and "mammography" or "overdiagnosis" and "screening" into the search box of this. Heck, I even just recently co-authored an article in the New England Journal of Medicine discussing this very issue and how widespread mammographic screening programs appear not to have decreased the incidence of metastatic breast cancer at diagnosis. I note that this NEJM article came about because H. Gilbert Welch has read my blogs. Liking my posts on mammography, he invited me to co-author the article with him, and I jumped at the opportunity. In fact, I can't help pointing out to Dr. Katz that this NEJM article, as well as my Nature Reviews Cancer article about integrative oncology and Steve Novella's and my article on clinical trials of highly implausible treatments are extensions into the peer-reviewed medical literature of what we've been doing here at SBM since the beginning. We hope to do more.

But back to the study. Let's summarize its findings briefly. Basically, the authors, from Yale University, the University of Maryland, Johns Hopkins, and the Memorial-Sloan Kettering Cancer Center, did a structured review of studies published in 2014 selected for use of the following words in the title: overuse, overtreatment, overdiagnosis, inappropriate, and unnecessary. Results were limited to human studies and the English language and reviewed by the authors for relevance to overuse. The ten most relevant studies were selected, highlighted, and organized into the categories of overdiagnosis, overtreatment, and methods to avoid overuse. Here are the findings:

1. There Is No Benefit to Screening for Asymptomatic Carotid Stenosis. The authors cited the USPSTF review that showed that screening for asymptomatic carotid artery stenosis leads to false-positive results. There is no evidence that it reduces stroke on the side where carotid blockage is found.
2. Screening Pelvic Examinations Are Inaccurate in Asymptomatic Women and Are Associated With Harms That Exceed Clinical Benefits. The authors cite a review from the American College of Physicians that failed to demonstrate benefit of routine pelvic examinations in women who are asymptomatic.
3. Head Computed Tomography Is Often Ordered but Is Rarely Helpful. If you've ever done trauma (as I did during residency and as a part-time trauma attending back in the late 1990s), you know that we order too many head CTs. The study cited didn't necessarily show that ordering the first CT is not indicated, but rather questioned the use of serial CTs, leading the authors to conclude that a second head CT scan "rarely affects patient management" and that "clinicians should be judicious in ordering multiple CT scans in the same patient," as only 4% of these CTs showed clinically significant findings that changed the medical or surgical management of the patient.
4. Thyroid Cancer Is Massively Overdiagnosed, Leading to Concrete Harms. I discussed the overdiagnosis of thyroid cancer as part of a post about screening for cancer in general way back in 2008. Perhaps I should do an update focusing just on thyroid cancer overdiagnosis, which has many paralles with breast cancer overdiagnosis.
5. There Is No Benefit to Paracetamol or Acetaminophen for Acute Low Back Pain. A large, double-blind, placebo-controlled clinical trial tells us so.
6. Postoperative Opioid Use Continues Past the Postoperative Period. Basically, the authors cite a cohort study that showed that 3% of patients given a prescription for opioids after surgery are still taking them 90 days later. To be honest, I'm not sure I buy this one; undertreatment of pain appears to me to be more of a problem than overtreatment, at least in cancer patients.
7. The Harms of Perioperative Aspirin Outweigh the Benefits in Patients Undergoing Noncardiac Surgery. The Perioperative Ischemic Evaluation-2 [POISE-2] trial tells us so.
8. Renal Artery Revascularization for Renal Artery Stenosis Has No Clinical Benefit. There are several randomized trials that show that medical management does as well as stenting for blood pressure control and preventing deterioration of kidney function.
9. Medications to Raise High-Density Lipoprotein Cholesterol Level Do Not Improve Cardiovascular Outcomes. A recent systematic review and meta-analysis supports this conclusion.

Another systematic review from earlier this year suggests that testing doesn't reassure patients; testosterone supplementation might harm patients (discussed here by me as a pharmaceutical company-invented diagnosis whose purpose is profit); inappropriate antibiotics use can cause C. difficile colitis (well, duh!); and that dramatic regional variations in surgical practice is driven largely by physicians.

So, yes, medicine has a lot of "housecleaning" to do. Here's the problem. His implication is that because medicine has problems with treatments that are not as rigorously evidence-based as they should be our focus on CAM is misguided and based on ideology rather than science. To this, I respond: Nonsense! I also like to quote Ben Goldacre at this point:

Similarly, just because big pharma misbehaves and conventional medicine practitioners don't always use the most rigorous evidence does not mean that, for example, homeopathy or energy medicine works, as Dr. Katz seems to believe they might. It's also worth pointing out at this point that the reason we tend to emphasize the pseudoscience that is much of CAM is because (1) there are plenty of others in medicine now calling out big pharma and insisting on more rigorous evidence and (2) CAM largely gets a free pass because the expertise needed to analyze CAM claims in light of science is not an expertise possessed by many physicians. In other words, SBM fills a gap in the movement to promote a more rigorous application of science to the practice of medicine. In addition, contrary to what Dr. Katz thinks, we at SBM can walk and chew gum at the same time. We can call out the pseudoscience of CAM and integrative medicine while we advocate for more rigorous science in all areas of conventional medicine.

Let's look at an example of how we do this.

In which I walk and chew gum at the same time

At this point, I feel as though I've flipped the script and, to an extent, changed roles with Dr. Katz. Last time, I criticized him for referring to his own medical authority (and awesome CV) over and over again in comparison, presumably, to us mere medical mortals who blog. Here, I am about to assert my authority on this issue, because, well, you know nothing, Dr. Katz, about what we here at SBM do aside from criticizing pseudoscience in medicine. Also, doing so serves the purpose of demonstrating that it is indeed possible to walk and chew gum at the same time, as hard as it seems for Dr. Katz to believe.

Near the end of his article, Dr. Katz pontificates:

Were I tasked with rebutting the very case I am making in this column, I would say: Well, the articles cited here are evidence that conventional medicine is policing itself, seeking ever more evidence and a higher standard. That is just what we would hope to see.

That is the best, and perhaps only argument for the defense, and might matter if it managed to thrive, but alas, it is stillborn. The simple fact is that the products of conventional medicine -- Big Pharma, Big Tech, and the associated patents -- are routinely promulgated, widely practiced, and massively reimbursed, often for years, before there is evidence to support them. Evidence to repudiate them comes after, and this despite our prime directive: first, do no harm. In stark contrast, the often kinder, gentler, but unpatented offerings of other domains are repudiated for years until or unless evidence comes in to exonerate them, and sometimes, even then.

In other words, the prevailing pattern is that "we" (i.e., conventional medicine) are innocent until proven guilty, but everyone else is guilty until proven innocent. No special olfactory acuity is required to discern how bad that smells.

One can't help but note that I discussed that bit of CAM allegedly "repudiated for years." Let's just say that Dr. Katz's take on the matter is…exaggerated.

And, yes, it is rather amusing that Dr. Katz writes so bitterly about medical practices that lack rigorous evidence using an article from a peer-reviewed journal that is about as mainstream as there is, JAMA Internal Medicine, pointing out that those very practices should be questioned in light of new evidence. Heck, I'll even concede that if Dr. Katz had written this article ten years ago, he would have had a point about medicine not being sufficiently vigorous at calling out and abandoning practices for which the scientific evidence is not sufficiently strong. Apparently, though, Dr. Katz is unaware that over the last several years there really has been a movement to do exactly what he says he wants done: To subject conventional medical practices to heavier scientific scrutiny and discard the ones that don't make the cut.

My example of this movement in medicine is an initiative from the Foundation of the American Board of Internal Medicine (ABIM) called Choosing Wisely, whose goal is to advance "a national dialogue on avoiding wasteful or unnecessary medical tests, treatments and procedures." It did this by working with Consumer Reports to challenge medical specialty societies in 2012 to come up with lists of medical practices that should be questioned in light of evidence. Thus far, over 70 medical specialty societies have done so. I like the Choosing Wisely initiative so much that I've written several posts about it, including one recent post pointing out how thus far Choosing Wisely hasn't had much of an effect on medical practice because changing entrenched practices is very hard.

In fact, I'll let Dr. Katz—and you—in on a little secret. (Actually, it's not really a secret, given that I've mentioned it before.) I spend a lot of my time doing exactly what Dr. Katz says we as physicians should be doing and working to improve the quality of care by making it more evidence-based. In fact, I am the co-director of a statewide collaborative quality initiative (CQI). We are 25-hospitals strong and looking to expand to more. Our mission is "to collect accurate data on women diagnosed with breast cancer in Michigan. We will collect demographic, diagnostic, treatment, and outcome data, and use this information to evaluate current standards of care and to initiate quality improvement efforts that will advance breast cancer treatments in order to improve patient outcomes."

Indeed, one of our quality initiatives is based on Choosing Wisely, specifically the American Society of Clinical Oncology (ASCO) guideline not to do advanced imaging (PET, CT, or bone scans) in patients with early stage breast cancer without symptoms suggestive of metastasis. The reason, of course, is that in this group of patients metastasis is so uncommon at the time of presentation that the false positives far outstrip the true positives, leading to the sorts of additional interventions that Dr. Katz is so concerned about, and rightly so.

Isn't this exactly what Dr. Katz says those of us criticizing him don't do in our ideological hatred of all things CAM? What, I ask, has Dr. Katz done to improve the quality of care in integrative medicine and make sure that what is actually being administered "on the ground" in the clinic (rather than in his ivory tower of academic CAM, where he seems oblivious to what naturopaths actually do, such as using homeopathy) is actually supported by science and evidence? I put my money (and career) where my mouth is when it comes to both conventional medicine and quackery, contrary to Dr. Katz's delusion otherwise.

Near the end, he sneeringly writes:

The cleanup will certainly not come courtesy of those calling themselves "science-based," who live within its glass walls, tossing stones outward. They produce nothing more useful than shards of glass.

It will come courtesy of those who concede, with suitable humility, that no single domain of influence has a monopoly on dirty boots. It will come courtesy of those who like a level playing field, and respect the potential for baby and bathwater in any given tub.

It will come courtesy of those who acknowledge that the blank in "_____ based medicine" has a long and rather unsavory list of applicants: profit; pharmaceutical; habit; preference; patent; turf; privilege; and status quo, to name a few. It is up to us to fill in that blank with a designation that is both desired, and deserved; both what we want, and what we actually do. That requires a much harder task than calling out the dirt on everyone else's boots. It requires a serious devotion to cleaning our own house.

Which is exactly what I am involved in doing. It is possible to walk and chew gum at the same time. What, I wonder, is Dr. Katz doing to make the actual medicine more science-based? In fact, I'll take it one step further. I have yet to see a single "CAM" organization or advocate like Dr. Katz take any serious, concrete steps to make their practice more science-based by abandoning treatments unsupported by evidence. The reason, of course, is that if they were to do that they would have to abandon most of the practices they want to "integrate" into medicine.

Dr. Katz's double standard

Dr. Katz's latest screed is very much of a piece with his previous screeds. Although I didn't want to at first, I ultimately considered it necessary to counter his criticism, even though I suspected Dr. Katz was trolling us, because his criticism is one that is directed all too frequently at those of us who criticize the infiltration of CAM into medicine and argue for science-based medicine. Basically, he is accusing me (and others, such as Steve Novella) of hypocrisy because we write so much about the pseudoscience and quackery that is being "integrated" into medicine in the specialty known as "integrative medicine" but, from his perspective, do not write about problems with the evidence base of conventional medicine. He is wrong on both counts, and I suspect that, even if 95% of the combined output of the offending blogs was about evidence and science deficiencies in conventional medicine and 5% about CAM pseudoscience and quackery, Dr. Katz would still focus like a laser beam on that 5%. As I've shown above, I do write about issues with evidence in conventional medicine—and not infrequently, either. Also, unlike Dr. Katz, outside of my blogging and other activism, I do far more to promote what Dr. Katz claims he wants to promote than Dr. Katz himself does.

As I and the other bloggers have said time and time again, the best medicine is medicine that has a firm basis in science. It doesn't matter whether we are referring to conventional, big pharma-produced drugs, surgery, or diagnostic tests or whether we are referring to anything that is considered "alternative," CAM, or "integrative medicine." We always advocate for a single, science-based standard of evidence for evaluating medical practices. Yes, I concentrate more on CAM and "integrative medicine." I make no apologies for that because I believe that I (and Steve Novella and company) fill a niche that is not well covered by those advocating a the more rigorous application of science to medical practice and also because most physicians are genuinely unaware of just how much pseudoscience has infiltrated—excuse me, been "integrated" into—conventional medicine. Moreover, This integration of quackery into medicine in the form of what we like to call "quackademic medicine" is in itself a double standard, allowing into medicine treatments that someone like Dr. Katz would never approve of if they had been developed by big pharma or medical device companies. Just look at his conspiracy mongering about "big food" and "big pharma" conspiring for big food to profit by making people sick and then to have big pharma profit by treating those sicknesses, if you don't believe me.

Dr. Katz is correct that "if evidence matters, it matters equitably, and universally." We don't argue with that at all. In fact, we not only agree with that statement, but we champion it in word and deed. If only Dr. Katz would do the same, instead of advocating a double standard whereby pseudoscience and quackery can be integrated into medicine using a standard of evidence that he would never accept for any other medical treatment.