White Coat Underground

Naturopathy—a final word

First, I’d like to thank everyone who participated in the naturopaty primary care challenge. It was far more successful than I could have hoped. A number of naturopaths and their supporters responded, most of them quite rationally. It takes guts to walk into the fire.

It also takes fanaticism.

I have always rather assumed that most naturopaths and other “alternative” healers are, on the whole, motivated by good. After reading all the comments, I still hold that assumption—most “alternative” healers probably mean well. That does not, however, divorce them from an ethical responsibility to avoid harming people.

Aside from convincing me that they mean well, the commenters cemented my belief that they are terribly wrong. That will come as no surprise to the “other side”, but I was holding out hope that a naturopath would provide regular medical care “plus” (the “plus” being the non-evidence based botanicals, etc.). In fact, the naturopaths who responded (who may or may not be representative of the profession as a whole) were sorely unprepared to provide the most basic screening, prevention, and treatment. Now, I’m leaving out the outliers—those who seem obviously ignorant or crazy (for example, there were a number of “Pharma Shill Gambit” comments—those that assume that real doctors are in the thrall of “Big Pharma”). Just looking at the comments from those who seem to know the most, I’m rather frightened by this movement away from science-based medicine.

The responses fell into a few broad categories. The first was “vagueness”. One response came from “Anonymous” (I encouraged people to post anonymously for freer discourse). His/her response was to “go over everything” and “follow up well” (paraphrased). This type of response is completely inappropriate. Hopefully it was a misunderstanding, but I gave very specific patient information, and if that patient is sitting in front of you, a specific response is required.

The next type of response was the “insufficient” one. A commenter with the ‘nym “ProudND” gave some of the most cogent (and compassionate) responses, but gave rather insufficient advice. For example:

I’d make sure he was following up with a cardiologist (I do mostly women’s health and don’t pretend to be all things to all people and prefer collaboration.

Coronary heart disease is one of the most common afflictions of human beings. Non-interventional management of CHD is essential in primary care. You cannot be a primary care physician without the ability to take care of primary, secondary, and tertiary prevention of CHD. This is not “being all things to all people”; it’s fulfilling the basic requirements of the job. I was also hoping for more specifics, such as, if a statin is to be used, what is the goal LDL (and there can be reasonable disagreement as to whether the goal is 70 or 100, although I think the evidence points more toward 70). I was also hoping for more specifics regarding general health screening, but perhaps s/he knows the answer but did not state it (certainly a possibility).

Where it all comes together though is not in the vagueness or insufficient category, but in the “fanatically wrong” category. This was best exemplified by MM, who, if the other commenters are to be believed, is a rather well-known and respected naturopath.

You see, one of the problems with naturopaths, as opposed to other “alternative” healers, is that their education allows them to sound like they know what they’re doing. They are a lot like 2nd-year medical students—they know a lot, but they don’t yet know the extent of their own ignorance (and I think most doctors can tell you how humbling it is to move on from the pre-clinical to the clinical years). This also allows them to get it partly right, which in medicine can be mostly deadly. For example, MM correctly mentions some of the important screening measures, etc., but fails to understand the gravity of the patient’s condition. For example, she posits the following: “I recheck his vitals and his BP is lower, 140/82, which is okay for now.” That would be entirely correct for someone without CHD or diabetes, but it is almost never appropriate for someone with those conditions. This may, however, be a clarity issue, since at another point she seems to recognize that the BP must come down. It’s not clear.

Since we don’t know how “bad” this patient’s diabetes is, dietary approaches are completely appropriate, but her assumption that she will be successful with her dietary prescription is disturbing. I am always hopeful, but never arrogant enough to believe that I will succeed. Statements like “I am so successful in lowering glucose levels so quickly” are anecdotal, non-science-based, and lure a practitioner into a falsely elevated sense of their own abilities.

And speaking of arrogance (a fault of which I am often accused in this space) this quote is over-the-top:

…there is a risk of worsening of any established diabetic retinopathy. I have figured out a supplement regimen which prevents this worsening…

This is where one of the only Richard Dawkins quotes that I like comes into play:

If you are in possession of this revolutionary secret of science, why not prove it and be hailed as the new Newton? Of course, we know the answer. You can’t do it. You are a fake.

Now, I’m not saying she is a fake, but really, if this lone maverick has discovered some nutritional cure for diabetic retinopathy, how come she hasn’t conducted a real trial and had it published? The funding is certainly out there. No black helicopters from Big Pharma will descend on her lab to take away her secret. The usual answer is that the “Great Discovery” is really and act of great self-deception.

And speaking of shilling, she’s shilling for a dubious diabetes book and sells her prescribed supplements out of her office. Talk about conflict-of-interest!

I’m very impressed with MM, but only with her abilities as a cult leader.

Finally, one of the naturopaths who falls into the well-meaning healer category is someone who goes by the ‘nym “JenND”. She made a very telling statement, one which I’ve heard many times before, so it’s worth mentioning before we close:

And yes, I realize that an abundance of RCT’s would legitimize our treatments, but we’re working on that.

Science—you’re doing it wrong. You don’t work from conclusion to evidence, you work from evidence to conclusion. I find your abundance of faith disturbing.

Look, if you don’t yet have evidence for how to treat a condition, you fall back on what seems logical. If, however, you already have good evidence, that approach becomes your default unless or until new evidence leads us to a better approach.

Oh, and one last thing. MM’s website specifically mentions homeopathy. Mentioning homeopathy is sort of the Godwin’s Law of science-based medicine (perhaps Morstein’s Law?)—once you mention homeopathy without laughing, the argument is over, and you have lost.

Comments

  1. #1 Dr Benway
    April 15, 2009

    This story has a nice arc.

    Homeopathy is really growing on me. I think it’s my fav pseudoscience. I love that the future ruler of the UK is hawking the magical goodness of Ye Olde Duchy Original Remedies for the chilblains or whatever.

    Brings to mind the internist who supervised my outpatient practice during my internship. Every case I’d present, he’d preface his response with “Jesus, the poor bastard.”

    Ah, hoomans. Gotta luv ‘em.

  2. #2 Ramel
    April 15, 2009

    “I love that the future ruler of the UK is hawking the magical goodness of Ye Olde Duchy Original Remedies for the chilblains or whatever.”

    Yeah, it is deffinatly time for our second republic

  3. #3 The Perky Skeptic
    April 15, 2009

    “her assumption that she will be successful with her dietary prescription is disturbing. I am always hopeful, but never arrogant enough to believe that I will succeed.”

    :biting my tongue to keep myself from going off on another ‘WAAAAAAAH my LDL is still hiiiiiiiiiiiiiiiigh’ jag.:

  4. #4 Abel Pharmboy
    April 15, 2009

    PalMD, I really admire you for issuing this challenge and taking on the ND comments seriously and in the context of primary care. I agree with you that most alternative practitioners I’ve encountered online and in my community has largely been well-meaning. Where I am fearful, and I am not a physician, is when these practitioners fail to recognize the limits of their expertise as well as their own collusion with supplement companies and conflicts-of-interest in selling supplements from their offices.

    Your challenge is exactly the kind of treatment of alternative medicine that *should* be done in medical schools. You rationally addressed the nature of this practice, invited practitioners to demonstrate their facility and limitations with a clinical case, and drew the contrast between them and science-based medicine. I encourage medical and pharmacy schools to conduct this type of alternative medicine training: one where alternative practitioners can present their philosophies but then followed by a rigorous discussion by a faculty moderator based in medicine and critical thinking skills.

    This has been a great exercise and I applaud both your energy and your patience.

  5. #5 Tsu Dho Nimh
    April 15, 2009

    Mona Morstein wrote: I have not published this, which I probably should, I agree. Technical writing is not my forte, I admit.

    Repeating in case she misses the other post: Tell you what … I’m an ex-medical technologist AND a good technical writer. I also live in Phoenix, AZ so there should be no problem with logistics.

    email me: abacaxi at hotmail.com and let’s get this information out where it can do more people some good.

  6. #6 Doug Cutler
    April 16, 2009

    PalMD: Arrogantly calling Dr. Morstein a fanatic, a lone maverick or cult leader doesn’t magically erase her results with her patients, but nice try.

    She has at least put her full name as a doctor and has given every one of you chronic naysayers a small glimpse into what she really does.

    Where is your full name? Where is your professional website? What are your credentials?

    You easily put a lot of scrutiny on Dr. Morstein from behind a blog that has a lot of sheeples, but if you had the exact same scrutiny, you would fold like lawn-chair.

    I am sure you all mean well too. But seriously, was it really that hard to show some respect to the naturopathic doctors that posted? The only thing you showed were your “true” colors so don’t be shocked when your patients see them too.

    The paradigm is changing my misguided friends. Let that echo loudly in your ears!

  7. #7 Joe
    April 16, 2009

    For the paradigms they are a changing …

    Mr. Cutler, Ms. Morstein could have used a pseudonym as well. The names don’t matter. The facts matter, and she (and you) come up short on them; even when you could go to a medical text and copy them. How sad is that?

  8. #8 perceval
    April 16, 2009

    Doug, check out Science Based Medicine. PAL is a very transparent pseudonym – he’s on Facebook and Friendfeed as well.

    I completely agree with PAL – it is truly, truly astounding what internists (or our GPs) need to know, and you do need more than four years before you can be let loose on the unsuspecting population.

  9. #9 Dr Benway
    April 16, 2009

    And they must be four years of training in medicine, not four years of vitalism, non-peer reviewed sciency truthiness, and mind-your-manners-or-you’ll-make-us-look-bad.

  10. #10 The Perky Skeptic
    April 16, 2009

    MAN! These altmed supporters never fail to amaze me with their utter lack of Google-fu! They keep asking about the real names of blogging doctors, when only the SLIGHTEST search-engine ability is required to find what they seek. :facepalm: And with this level of technical capability, they intend to diagnose people’s medical conditions? OY!

  11. #11 Marilyn Mann
    April 16, 2009

    I just want to note that although my initials are MM, I am a different MM!

  12. #12 rob
    April 16, 2009

    the CAM movement is obviously an attempt by Big Supplementals to control the world and suppress science and reason.

    (i am nervously looking around for the black helicopters sent by Big Supplementals to come take me away.)

  13. #13 The Perky Skeptic
    April 16, 2009

    Anyone here ever play Mage: The Ascension?

    It’s a roleplaying game in which you, the heroes, take on the establishment which has asserted its Technocratic paradigm over the poor downtrodden Hermetic magicians, witches, shamans, goths, and homeopaths who are ONLY trying to LIVE THEIR LIVES AND HELP PEOPLE, ZOMG!!! (Ok, one of those magical styles I just slid in there myself– but only one.) Rob’s joking comment about the black helicopters made me think of it. In this game, they really ARE trying to suppress you and will TAKE YOU AWAY FOR RE-EDUCATION!!!!!!

    I used to really love that game. Absolutely can’t even look at it anymore.

  14. #14 Strider
    April 16, 2009

    PalMD
    “…one of the only Richard Dawkins quotes I like…”!
    You obviously haven’t read/viewed enough Richard Dawkins then! Here’s one of my favs (and you might like it, too, I imagine):

    “Science, in constantly seeking real explanations, reveals the true majesty of our world in all its complexity.”

    I believe it’s from “The Root of All Evil?”

  15. #15 rob
    April 16, 2009

    @The Perky Skeptic: who said i was joking?
    :)

    ugh. CAM drives me crazy. i was just thinking today about deaths caused by ignoring accepted medicine and applying some CAM treatment instead and christian scientists who ignore accepted medicine and pray. there was a couple whose child died unnecessarily of diabetes and was sentenced for it.

    i doubt CAM adherers will see any parallels.

  16. #16 Doug
    April 16, 2009

    The Perky Skeptic,

    Sulfur Homeopathic Remedy

    Constantly relapsing complaints
    Self-absorbed
    Haughty / Despises education & literary men and wonders why
    Philosophical reveries tending to the metaphysical, abstract & strange things
    Overly analytical
    Foolish happiness & pride
    Irritable, fault-finding
    Melancholy mood
    TYPES IN CAPS with exclamation points!!!!!!!

  17. #17 Prolix
    April 16, 2009

    You don’t work from conclusion to evidence, you work from evidence to conclusion. I find your abundance of faith disturbing.

    In life certainty is rare and we must often act without it. Who except the believer is going to go to the time and trouble to learn a system of medicine so it can be evaluated? Fortunately, the studies are being done and the evidence is coming in, as in this outcomes study of homeopathy in Germany:

    A total of 3,709 patients were studied, 73% contributed data to the 8-year follow-up. Disease severity decreased significantly (p < 0.001) between baseline, 2 and 8 years Physical and mental quality of life scores also increased considerably.

  18. #18 The Perky Skeptic
    April 16, 2009

    @Doug,

    MY GOD!!! HOW DO YOU DO IT??? Your diagnostic powerz truly boggle the mind! Only you forgot:

    Obsessive-compulsive fossil collector
    Delusions of hilariousness
    Thinks puce and mauve are different colors
    POSTS BLOG COMMENTS WHILE OVERCAFFEINATED!!!!!!!!!!!!

    And you didn’t use enough exclamation points. ;)

    @Rob,

    I think those ‘copters are coming any minute now… ;D

  19. #19 antipodean
    April 16, 2009

    Prolix

    Uncontrolled treatment studies with totally subjective outcomes in who knows what kind of patients and with massive dropouts are not evidence that a treatment philosophy works.

  20. #20 prolix
    April 16, 2009

    Dropouts are inevitable in any long term study. 72% reporting strikes me as pretty good. Quality of life assessments may be subjective, but subjective does not equate to worthless. I suspect that if the study returned the opposite result you would not be raising these objections.

  21. #21 Whitecoat Tales
    April 16, 2009

    Prolix, where does your pseudonym come from?

    I need to know. Because in my imagination, it comes from the name of the antipsychotic medication you’re taking – prolixen.

    That’s seriously an abysmal paper. No merit whatsoever. Find me an RCT.

  22. #22 prolix
    April 16, 2009

    One more point. If you truly are curious or concerned about the quality of care naturopaths give, most would be willing to have you sit in and observe their practice. This strikes me as a better way to judge than reading responses on a blog.

  23. #23 Whitecoat Tales
    April 16, 2009

    You all keep saying that! I have now contacted 2 separate naturopathic practices in my area. Both are extremely reluctant to let me shadow.

  24. #24 prolix
    April 16, 2009

    Because in my imagination, it comes from the name of the antipsychotic medication you’re taking – prolixen.

    Do you always insult people who disagree with you?

    Find me an RCT.

    Outcome studies also have their value. If you are looking for RCTs, Google and Medline are your friends.

  25. #25 prolix
    April 16, 2009

    Both are extremely reluctant to let me shadow

    If what I observe here is typical of your behavior, I am not surprised.

  26. #26 Whitecoat Tales
    April 16, 2009

    That argument is bunk.
    The blog is a medium very different from real conversation. If naturopath’s behavior on this blog is emblematic of their behavior on this blog, they insult anyone who objects to their methods. They claim real doctors are going to die by taking proven medications. They don’t understand the basics of science. They fleece people and have multiple undisclosed conflicts of interest with “Big Supplements”. They are religious zealots rather than science minded physicians.

    Oh wait, maybe you’re right, maybe it is an accurate representation.

  27. #27 prolix
    April 16, 2009

    You should not be surprised if people judge you based on your behavior on your blog. They are not going to grade you on a curve because “this is a blog” and they are not going to give you a pass because someone else behaved badly..

  28. #28 Doug
    April 16, 2009

    Whitecoat Tales: You said you were very “charming” so I am absolutely shocked to hear you can’t get a shadowing experience.

    If you were truly sincere you would take up my offer. Unless you need PalMD’s permission? And we have about what, 2 years before you start to see patients?

    So not much time to undo the pharmaceutical fed brainwashing. But we can do it! We can rebuild you. We have the technology. Better than before. Better, stronger, faster.

  29. #29 Whitecoat Tales
    April 16, 2009

    Perhaps the difficulty lies not in my charm, but in the fact that naturopaths don’t have medical licenses in my state.

    At any rate Doug, you’ll be recieving an email from me soon – I was actually on these threads looking for it now.
    I’m not sure what you mean by the “2 years until you see patients” thing, I’m a third year student, I see patients every day…

  30. #30 antipodean
    April 16, 2009

    Prolix

    Because you don’t understand medical science I’ll explain.

    All of the biases I mentioned in relation to the study that you have cited cause biases in favour of a false-positive finding. So you were right if the study were negative I wouldn’t bring up the biases in favour of false-positive findings. I’d bring up the biases in favour of a false-negative findings.

    And the study would still be crappy regardless.

    You use what you call outcome studies to demonstrate that treatments work in the real world. But you do this after those treatments for specific conditions have previously been shown in RCTs to actually work.

    The problem is that alternative medicine will never, ever, ever, abondon practices sown to be ineffective in scientifically robust RCTs. They will then publish an uncontrolled treatment cohort study of many treatments across many (possibly non-existent diseases) with subjective outcomes…

  31. #31 Joe Average
    April 16, 2009

    “I’m not sure how handing him a book qualifies as appropriate care, but if you’re following him closely…”

    “Why are you putting him on supplements? There is no evidence to support that practice. ” — PalMD

    “Is it really just for the extra recommendation of supplements? Any ND’s willing to explain?” — qetzal
    ********
    There are hundreds of studies on nutritional supplements and diabetes. Since Mona was given a tough time, and qetzal asked for supplement recommendations, here is the story of a sick patient who cured his diabetes by putting his nose to the books; Necessity is the mother of invention. It talks alot about nutrition and its role in Diabetes, and perhaps a better book for Mona to read.
    Note: this book is free to read on the internet.

    How an ex-diabetic engineer beat diabetes despite a coma and a 1337 glucose level
    http://books.google.com/books?id=F2VxOD4gOBMC&pg=PA361&lpg=PA361&dq=lysine+and+diabetes&source=web&ots=csBtKnzP-a&sig=4Fju73uXua5o0gOvk4M-z24qNFA&hl=en&sa=X&oi=book_result&resnum=8&ct=result#PPP1,M1

  32. #32 PalMD
    April 16, 2009

    Joe, science; you’re doing it wrong.

    Giving an anecdote does not show anything except that you have no idea what’s going on here.

  33. #33 Dr Benway
    April 17, 2009

    A turkey has an hypothesis: “Farmer John is a cool dude. He really loves me!”

    Farmer John brings the turkey some nice grain. The turkey says, “See, this proves it!”

    Next day, Farmer John brings the turkey more grain. Turkey says, “Even more proof!”

    Next day, delicious grain. Turkey says, “His love for me is clearly an established fact!”

    More than three hundred days go by as above. The turkey, who learned about the scientific method from a naturopath, says, “I was pretty sure he loved me after a few days of kindness. But now that I’ve enjoyed over three hundred days of tender care, I have so much more proof of his love.”

    The next morning, Thanksgiving.

    Now, for ten internets, can you name poor Mr. Turkey’s logical fallacy?

  34. #34 TastyBurger
    April 17, 2009

    Dr Benway: Affirming the consequent?

  35. #35 Dr Benway
    April 19, 2009

    TastyBurger, you winz teh internets!

  36. #36 TastyBurger
    April 20, 2009

    w00t!

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