White Coat Underground

Alternative medicine—back to basics

A long time ago (in blog years) I wrote a series on alternative medicine over at my old WordPress blog. It’s time to dust off the old post and get back to some basics.

What is alternative medicine, anyway?

That’s a great question. I know it is, because I asked it. I get this question almost daily. The secret answer is that there is no such thing as alternative medicine. You don’t believe me? Why not–I am a doctor.

There are several ways to define alternative medicine, and sometimes it is contrasted with “complementary medicine”. CM refers to treatments that “complement” traditional medicine, while AM refers to treatments that stand in the stead of mainstream medicine. CAM is a broad category used to refer to both.

So what’s my problem? How can I say that there is no such thing?


Because so-called “mainstream” medicine is simply medicine that works. It has been studied, tested, deployed, followed, and it is proven to do what it says. Alternative medicine is any treatment that is not yet, or may never be, mainstream. If it is found to work, it becomes mainstream very rapidly. If it is not proven to work, it remains “alternative”.

So, I guess there is, after all, such a thing as alternative medicine. It is any treatment that doesn’t work. Why would anyone want that?

There’s lots of answers to that question. There are also several incorrect answers. The most common incorrect answer describes a conspiracy of doctors and Big Pharma. Others include the myth that patients are dissatisfied with their physicians and the care they provide. In fact, most people like their doctors. But they like their friends even more, and if a friend testifies about a great new potion, well, why not try it?

Why not, indeed. Your doctor knows quite a bit about the medications being prescribed, and the problems being treated. Your friend, alas, does not.

When someone offers you an “alternative therapy”, ask them what it is an alternative to. Does it work better that something else? Is it safer? How do you know? Why should I believe you?

Those questions apply to your doctor as well, but hopefully, you have already decided whether or not you trust your doctor and modern medicine. Try applying this simple test–when you have crushing chest pain and shortness of breath, who do you want to call: the GNC guy or an ambulance?

Don’t stop now…you’re on a roll!

As I get more and more questions, I realized that further explanation is needed to tease out the difference between “real” medicine and “alternative” medicine.

What’s the difference again?

Mainstream medicine is any medicine that works–the problem is the definition of “works”. Medical science has fairly stringent standards of evidence. A medicine or treatment is subjected to statistically valid trials, preferably randomized controlled trials, that can be replicated and similar results obtained. They are also proven safe, meaning the risk/benefit ratio is acceptable by some (often arbitrary) standard.

As an example of medical science working properly, let’s examine the treatment of heart disease. Over the last 15 years or so, huge advances have been made. For heart attacks, angioplasty or thrombolytic drugs can be given immediately. For ongoing treatment of heart disease, beta blockers, ACE inhibitors, aspirin, and statins are shown to reduce morbidity and mortality. These findings are backed up by repeated, large randomized controlled trials. That’s real, science-based medicine, with real results.

An additional negative example is of a particular medication in a class called “inotropes” that was felt to benefit patients with congestive heart failure. This was a logical guess made based on the way the medicine worked and the nature of the disease. A trial was done, and the medication was found to cause excess deaths over the control group. It’s regular use in that situation was abandoned (there are limited exceptions). That is the other side of the real medicine coin—if something doesn’t work, we are forced to give it up.

Examples of alternative medicines that have failed to prove their efficacy include homeopathy and chelation therapy. These have been subjected to scientific study, and they have failed to show efficacy. That is not a moral judgment. Something either works or doesn’t. But for some reason, they haven’t been given up, despite their repeated failure.

The other category of treatments are those that have never been subject to scientific scrutiny. Until they are, they should be presumed ineffective until tested, unless there is some compelling reason to believe they are safe and effective, and necessary. Lupron therapy for autism falls into this category.

Calling something ineffective is not a value judgment, only a finding of fact. People who willingly peddle unproven therapies are, however, misguided, if done in innocence, and immoral if done with foreknowledge.

The alternative to science-based medicine? Well, I guess we’d have to call it “faith-based” in that faith is the only thing supporting its use.

So why do people keep relying on faith-based medicine?

I first tried to define what was meant by alternative medicine and what makes it different from standard medicine. In this I used the rhetorical technique of redefining altmed as anything that isn’t standard medicine. In doing so, I may have underestimated the religious and magical thinking that goes on when it comes to alternative medicine.

Why this attraction, worship, reverence for altmed? Mainstream medicine is pretty impressive, with its vanquishing of polio and smallpox, its treatment of heart disease and diabetes. Why does it attract praise, but not adoring, irrational worship? It reminds me more than a little bit of the attraction people feel for creationism, despite the beautiful complexity of evolutionary theory.

But alternative medicines have been around for so long, and so many people use them!

Thank about that. Do you really want to entrust your health to “tradition”? What has this tradition actually accomplished? Has so-called traditional Chinese medicine eradicated any diseases? How about ayurvedic medicine? People in China and India with access seek out the same kind of care you would find in any large American hospital. They don’t rely on thousand year-old systems based on imaginary ideas that were developed before we even knew what all that mushy stuff under the skin does.

Ownership and Control

Not everyone can be a doctor. It’s long, hard, expensive work: four years of undergraduate, four years of medical school, three years of residency (for internal medicine–much longer for other specialties).

If you wish to involve yourself with altmed, you can be very educated, or not educated at all. It can be as simple as reading a magazine article and deciding that Potion X is a good thing. Anyone can “own” their knowledge of altmed–they don’t have to “purchase” it via a long, difficult, expensive education.

But wait, that’s not fair! Well, such is life.

Analogy

You don’t go to an “alternative” car mechanic–why not? Some families have a long tradition of “being good with” cars. Isn’t that good enough? Well, no. You usually take your car to an experienced mechanic who uses books and tools and car manuals to fix cars. But why listen to the professional? You “know your own car” better than anyone else, the sounds it makes, the way it feels–doesn’t that count? Can’t you use that intuition to fix it? Ever try that? How about an “alternative engineer” to build a bridge?

So why would you with your body? People who believe in altmed aren’t crazy (not any more than anyone else at least), so why do they make bizarre decisions regarding their health?

Perhaps it’s because people are “closer” to their bodies than they are to their car or a bridge. They wouldn’t trust themselves or some shaman to fix the car and drive it across the alternative bridge, but they do feel like they can work with their body more accurately.

They are right. It is impossible to prevent and treat disease without the cooperation of the patient. Patient’s have to be willing to follow dietary and lifestyle suggestions, take prescriptions when necessary, communicate to their doctors side effects they may experience. They must be able to tell their doctor about financial or other personal difficulties.

That’s work. I often have patients keep food diaries to see what they eat, check their blood sugar frequently to make adjustments to diabetic medications, perform preventative exams of their feet and eyes to prevent amputation and blindness. It’s hard work to be a doctor, and it’s hard work to be a patient. Avoiding it by seeking out voodoo doesn’t change that.

You sound angry…are you angry?

Yes. Very angry. The more time people spend seeking “alternatives” to proven medical science, the less healthy they will be. I have devoted my life to preventing and treating disease, and thanks to modern science, I do it well. It pisses me off to see people seduced by purveyors of woo. So, yes, I’m angry. When you see advertisements for “altie” cures, chiropractors, and homeopaths, you should be angry too.

Comments

  1. #1 Blake Stacey
    January 29, 2009

    There are several ways to define alternative medicine, and sometimes it is contrasted with “complementary medicine”. CM refers to treatments that “compliment” traditional medicine,

    I’m trying to suppress my internal copy-editor reflex, but sometimes I can’t help noting these things. Right the first time, wrong the second.

    Homeopathy does not compliment actual medicine. Their relationship is nothing so cordial.

  2. #2 PalMD
    January 29, 2009

    argh…shit…i hobbled it together from a bunch of old posts and apparently while on medication i edit even worse than usual.

  3. #3 Ryan
    January 29, 2009

    I’m a second year medical student who’s slaving away in the library this week for a big test Monday. Your article gave me the inspiration to keep pluggin along, thank you! Now if only all my professors could be this well spoken about the virtues of modern medicine!

  4. #4 Sam C
    January 30, 2009

    PalMD excused himself in a dark block:

    apparently while on medication i edit even worse than usual.

    Ah, that’s caused by the negative ions in the evil drugs that Big Pharma provides for you. They dechelate your bionic field in the region of the third and fourth chakras so you can no longer make rational judgements. You could probably release the block by using correctly positioned sham acupuncture needles – I believe integrative medicine* is flexible and open-minded enough to absorb the fact that the modern form of sham acupuncture has been shown to be more effective than meridional acupuncture. Of course, it the bionic field is only mildly dechelated, some appropriately placed crystals might provide sufficient healing Qi, perhaps quartz arranged at the quadrants to simulate a yagi antenna?

    * Yes, integrative medicine, doesn’t that make you warm and cuddly? So much more helpful a term than alternative or complementary. You see, allopathic medicine (so named because it is practised by pyschopathic alligators) is differential medicine, exemplified by the classic differential equation: u = dy / dx, which means they only claim to tell you (u) that you are dying (dy) of some disease (x).

    Excuse if this sounds incoherent, I was a bit depressed and only took half of my homeopathic remedy, which is a dangerous underdose.

  5. #5 PalMD
    January 30, 2009

    I was a bit depressed and only took half of my homeopathic remedy,

    Get it straight, sam…that’s an overdose.

  6. #6 Denice Walter
    January 30, 2009

    *Seduced* is exactly the right word.The “woo-er” relies on (so-called) personality,undercutting the influence of “rivals”(i.e. rational beings),flattering the target, promising the world, and invoking dire warnings and threats if the target should “look elsewhere” (e.g. EBM).Reading or listening to our most prolific woo-providers,I find so much to be pure and simple advertisement of a *persona* or a “brand”, selling a lifestyle and a viewpoint, and of course, the products to go with it.(Which isn’t so bad if you’re selling jeans or perfume).With the intrepid confidence commonly seen in the delusional, our woo-meisters are now boldly venturing into new territory : economic forecasting, psychotherapy,home businesses,utopian community-planning, and Mike (the Notorious D.U.M.?) Adams even *raps*! Which might be a positive development after all,perhaps they’ll spread themselves so thin that even the most ardent seducee will be able to see through the ruse.

  7. #7 Matthew D Bauer
    January 30, 2009

    You asked if so-called traditional Chinese medicine has ever eradicated any diseases. Well, yes. It pretty much eradicated one that is in epidemic numbers in the U.S. and most of the developed world: Iatrogenic disease.

  8. #8 PalMD
    January 30, 2009

    Wow, matt, that may be the dumbest thing i’ve read all week.

  9. #9 Anonymous
    January 30, 2009

    “argh…shit…i hobbled it together from a bunch of old posts and apparently while on medication i edit even worse than usual.”

    I recommend acupuncture, maybe with a homeopathy course. I’ve also heard that reiki and some chiropractice might work.

  10. #10 Ramel
    January 31, 2009

    “It reminds me more than a little bit of the attraction people feel for creationism, despite the beautiful complexity of evolutionary theory.”

    With creationism the beauty lies in ignorance, to see the beauty in evolution requires putting in the time and effort to understand both the theory and its implications. I wonder if the same is true for alt med?

  11. #11 Matthew D Bauer
    January 31, 2009

    I was being a smart aleck with my comment, I admit. But I believe the tragic reality of the iatrogenic epidemic has a place in the debate regarding unquestionably safer so-called “alternative” therapies – or “woo” therapies as you derogatorily refer to them. You say you are pissed off by people being seduced by the purveyors of woo and that those seeking alternatives to proven medical science will be less healthy because of it. Well, as a purveyor woo – a licensed acupuncturist – I am deeply saddened to know that hundreds of thousands of people die in the U.S. each year and millions are harmed by therapies “proven effective” by medical science when I know beyond a doubt that some of those unfortunate individuals could have been helped by safer alternatives.

    I would be happy to engage in an intelligent discussion of the relative merits of alternative therapies, particularly my specialty of acupuncture, but I ask you at least consider the very disturbing facts of iatrogenic disease. These facts should make anyone interested in the issue of health care both acknowledge that there is a serious problem (especially with drug therapy) and that this problem should compel us to give every honest consideration to possible safer alternatives.

  12. #12 PalMD
    January 31, 2009

    Matt, for a brief discussion of the common fallacy to which you have fallen prey, see this:

    http://www.sciencebasedmedicine.org/?p=316

  13. #13 Matthew D bauer
    January 31, 2009

    Thank you for bringing this article to my attention. I especially like the following line:

    “If you don’t understand the basics of a subject, it’s easy to form conclusions that seem logical, but these same conclusions seem silly to those who have a deeper understanding of a subject.”

    I couldn’t agree more. This is exactly the error you have made with acupuncture, proclaiming its positive clinical outcomes to be due to the placebo effect. You think you understand the subject but you do not so you form what seems to be a logical conclusion but this conclusion is “silly” to one who has a deeper knowledge of the subject.

    Rather then debating if adverse reactions are unacceptably serious or just the eggs that end-up being broken when you make omelets, let me cut to the chase and offer you the basics that you don’t understand about acupuncture: Unlike the goal of modern medicine which is almost entirely focused on bringing outside, man made remedies into the body – be they drugs, surgical procedures, radiation, etc., acupuncture attempts to stimulate the body’s natural, intrinsic resources; to help the body to do a more effective job of helping itself. This basic fact is the reason many studies on acupuncture are flawed in their design as these studies protocols’ were designed for studying remedies that seek to take over for the body’s own resources. You and other critics are not really to blame for this common misunderstanding. We in the acupuncture community have done a lousy job of stressing this fact and pointing out just why this critical difference makes all the difference in the world when comparing these two approaches.

    The problem we face with acupuncture then is that in order for its potential to be accurately evaluated, it requires those judging it to be open to the possibility that you could have a medical system whose sole goal is to improve the body’s natural efforts to heal itself. This method has never been seriously considered in modern medicine but I assure you that once you allow for this possibility, many of the issues that make science-based skeptics critical of acupuncture begin to be seen in a entirely new light.

    So what can acupuncture treat? Simple: Acupuncture may be able to help any condition that the body has the potential to heal itself but, for any number of reasons, is not achieving its full potential. Acupuncture cannot help the body to heal anything the body never had the potential to heal. One may think that any problem that lingers beyond the time-frame within which that condition normally heals shows that it is beyond the body’s ability to heal but this is not always true. We rarely achieve 100% of our self-healing potential any more than we get 100% of our brain or muscle potential. When acupuncture works, it works because it helps give a boost to the body’s self-healing efforts. Is there ever any help form the placebo effect? Sure, just like there is in every therapy including drugs and surgery. The difference though, is unlike drugs and surgery, trying to measure the effect of a therapy that stimulates intrinsic resources in far more difficult than measuring the effects of a therapy that takes-over for intrinsic resources.

    The more you try to “control” experiments when attempting to measure a therapy that seeks to stimulate intrinsic resources, the farther you stray from actual clinical practice. The flaw in the sham controlled acupuncture research is that the so-called “real” acupuncture is not real at all. True, they select points that are considered real acupuncture points, but they force the acupuncturists to only use those points throughout the whole experiment. No acupuncturists worth thier salt works that way. Those of us well trained (another problem with many of these studies is that those doing the acupuncture are often not well trained), learn that we have to adjust the treatment often, altering some points based on subtle changes in the patient’s response. This adjust-on-the-fly mentality comes with the territory when you are employing a therapy that seeks to facilitate the body’s own healing resources. This is another great difference form modern therapy that seeks to find the one “best” approach; the best drug, the best surgical approach. Because of this, these studies showing “real” acupuncture is around 45% effective while sham acupuncture is 40% percent effective, seriously underestimates the degree of effectiveness we see clinically for some of these conditions. Most fully trained acupuncturists who adjust their treatments along the way for example will see more like 70% effectiveness for low back pain, not the 45-46% the recent German study showed.

    If you doubt that acupuncture works by stimulating and taking advantage of the body’s own resources, try researching the numerous animal studies being conducted all over the world that show acupuncture causes measurable changes in body chemistry/physiology. These are not uncontrolled outcome studies by woo-woo acupuncturists, these are basic science studies by real scientists.

    It is just a fact that in addition to taking-over for the body with outside resources, it is also possible to heal by stimulating inside resources and that both approaches have their strengths and weaknesses. I have deep respect for modern medicine but knowing there is an entirely different approach that can be employed in certain cases that can help reduce adverse reactions can sometimes make me testy when I hear critics who don’t have all the facts lump acupuncture in with placebo woo.

  14. #14 Dianne
    January 31, 2009

    unquestionably safer so-called “alternative” therapies – or “woo” therapies

    Uh-huh. Because there are no iatrogenic deaths in “alternative medicine.” Yep. Acupuncturists never fail to sterilize their needles adequately or produce iatrogenic trauma. Alternative medicine never leads to liver failure (see kava), never increase the risk of cardiac disease (ephedra), never have adverse interactions with other medications (St John’s wort), never increase the risk of cancer (selenium), and never have teratogenic effects (some forms of vitamin A). And, of course, no manufacturer of herbal medications/supplements would ever consider adding anything to the medication that wasn’t on the label (PCSPES/DES/warfarin). And if you believe all that, I’ve got a bridge to sell you. Given the current economic crisis I’ll even sell it cheap.

  15. #15 Curt
    January 31, 2009

    Ah, but if you try to tell the homeopaths this; they scream of conspiracies involving the peer-reviewed journals.

  16. #16 The Perky Skeptic
    February 1, 2009

    The more you try to “control” experiments when attempting to measure a therapy that seeks to stimulate intrinsic resources, the farther you stray from actual clinical practice.

    :facepalm: …So… missing… the…point…

  17. #17 Joe
    February 2, 2009

    Matthew D bauer wrote “So what can acupuncture treat? Simple: Acupuncture may be able to help any condition that the body has the potential to heal itself but, for any number of reasons, is not achieving its full potential.”

    Great! Cite some clinical studies in real medical journals.

    MDB wrote “The more you try to “control” experiments when attempting to measure a therapy that seeks to stimulate intrinsic resources, the farther you stray from actual clinical practice.”

    Why should that be? Can you cite any concrete examples? I suspect your reference to “actual clinical practice” invokes actual magical thinking.

  18. #18 Matthew Bauer
    February 2, 2009

    “Uh-huh. Because there are no iatrogenic deaths in “alternative medicine.”

    There is a big difference between regulated and unregulated practice. Over the past 30 years, a great deal of effort has taken place in establishing a regulatory framework for the practice of acupuncture and Oriental medicine (A/OM) in the US. This includes establishing institutions for regulating licensing and education standards for A/OM. Many of the problems that happen with regard to A/OM take place where there is little or no regulation. All Licensed Acupuncturists in the U.S. for example, are required to use single use, pre-sterilized, disposable needles and to demonstrate proficiency in standardized clean needle technique (CNT).

    As for herbs, again there is a great difference between having Chinese herbs prescribed by a licensed/Certified practitioner trained and practicing within their scope of practice and unregulated herbs use. Take ephedra for example. We in the A/OM profession were vehemently opposed to the ephedrine containing Chinese herb ma huang being used in non-prescription herbal supplements for weight loss or boosting energy. For many centuries, that herb has been red-flagged in official Chinese Herbal Pharmacopeias as an herb that could cause heart damage and whose dosage needed to be carefully monitored. We stressed that this herb had been safely used for centuries primarily in formulas for respiratory ailments, but should only be allowed to be used by prescription by a qualified, TCM herbalist. Unfortunately, because of the abuse of this herb by supplement industry and the harm caused as a result, ma huang has been outlawed in the U.S. even to those of us trained in its use and regulated by law.

    And finally, I am by no means stating that all A/OM is always safe and never causes any problems or that all modern medicine does more harm than good. What I am stating is that when you employ a therapy whose goal is to stimulate intrinsic resources, this method will be many magnitudes safer than methods that seek to introduce outside resources into the body. Both approaches have their strengths and weaknesses and rather than stressing one approaches’ weakness and ignoring its strengths while doing the opposite with the other system, we should recognize that two approaches exist and try to figure out how to integrate the two.

  19. #19 bob
    February 3, 2009

    Matthew,

    You’re absolutely correct that there is a big difference between regulated and unregulated acupuncture. One is the fox guarding the henhouse, and the other is the henhouse being left unattended. Both are bad situations, in my opinion.

    Some other gems from your posts: “I know beyond a doubt that some of those unfortunate individuals could have been helped by safer alternatives.” They wouldn’t have been helped, they would have died from their underlying disease/condition. Why is this better? Because it’s natural? We have a term for that. Your “safer alternative” is placebo.

    “What I am stating is that when you employ a therapy whose goal is to stimulate intrinsic resources, this method will be many magnitudes safer than methods that seek to introduce outside resources into the body.” CAM mumbo-jumbo, and a bit more of the naturalistic fallacy. Hypocritical, as well, since you were defending herbs in the previous paragraph. Or do herbs somehow count as “intrinsic resources”?

  20. #20 Jason Welch
    February 8, 2009

    You have a valid point, up to a point. You ask why people still seek alternative medicine, even though the tested, high standards of modern medicine tell them that it is foolish to do so? How about Prevnar, Trovan, Tequin, Digitek, Celebrex, Phen phen, Paxil, and Vioxx as examples? How about asking people to spend over a thousand dollars a month on the only medication (that doctors just like you tell them) that will cure their ills? What about the fact that their visit alone, just to speak to your highness will cost them five hundred dollars? Finally, the fact that they can get these same “properly tested and safe” pills over either of our Nation’s borders for pennies on the dollar, as opposed to the exhorbanant figures that you (and your pharm. Reps) care to charge.

    Are drug prices the fault of the medical practitioners who recommend them? When you good doctors are paid a bonus on selling them, given prizes for pushing the most of them, and given goodies and freebies to dole out samples of them, then yes! Just think of yourself as a sales representative, but one who most certainly has the patient’s best interests at heart….and that trip to Maui for the conference.

    Maybe I’m wrong though. Maybe you and the other good physicians aren’t really in cahoots with the drug companies. The pharmaceuticals that Drug companies push (with their tried and tested methodology) by you upstanding doctors who know exactly what you’re doing, show how ignorant the masses are about modern mainstream medicine and alternative forms of therapy by routinely thinking with your pocket book to the tune of endangering the health of your patients on a daily basis. That, good sir, is one big reason that many Americans choose a chiropractor, or some eastern idea over you and your pretty white lab coat.

  21. #21 Lovely Abraham
    March 28, 2009

    What do you know about ayurvedic medicines? Go to kerala, India. Check with Kottakkal Arya Vaidya Sala, in Kottakkal. Go there and consult Mr. P.K. Varier.

    Its difficult to express the recovery we got from these medicines in few words. I have lot of experiences. My grand mother died when she was 93 years. used only ayurvedic medicines and she was having a very healthy body. one thing is there to agree that if you got affected by diseases which needs operation, you have to consult an allopothic doctor.

  22. #22 Emory Kent
    November 7, 2009

    There is only one truth. No one person or science knows all truth. If you would work together to find more of it rather than spending your energies bickering we all would benefit

  23. #23 PalMD
    November 7, 2009

    Welcome to the old, old thread!

    Science doesn’t claim to know everything, but to have a method of finding answers.

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