I’ve been blogging long enough now that it’s hard for me to keep track of what I have or have not written, and on which particular blog. I used to be pretty compulsive about digging up old links to my first blog (now in storage) or to denialism, or even to this blog, but this can be paralyzing. I still try to make sure to link to other writer’s pieces, whether on denialism blog, or at other blogs that I like, but if I were to be overly compulsive about this, I’d never get any writing done.
And with that in mind, it’s time for a review of alternative medicine (one that is a bit more extensive than my last similar diatribe). I get a lot of questions, mostly of the “DrPal, why are you such a hater?” variety. I’m not a hater. I’m a stickler. My ethics require me to do the best for my patients, which includes treating them with respect. Respecting my patients requires telling them the truth about various interventions—does the evidence support them, and if so, how well? This week, for example, I was going over a medication list with a patient and asked him why he took mega-doses of vitamin C. He said to prevent colds, cancer, and because it seemed like a good idea. I informed him that multiple well-done studies have failed to show significant benefit to taking vitamin C supplements, and he agreed to stop them.
But what’s the harm? There may be none in this case (although the same can’t be said for vitamin A). But there’s lots of reasons to guide patients toward science-based therapies, not the least of which is your ethical responsibility. I have many patients who complain of taking “too many pills”. Sometimes they are, and sometimes it’s a doctor’s fault, sometimes not. If I have a patient with hypertension and diabetes, the evidence clearly shows that certain interventions, including lifestyle modification and medications, will save them a lot of grief. But a patient may also be on a host of non-proven supplements, which, if dropped, would make the patient seem much less “over-medicated”.
And this is one of those weird false dichotomies. Patients sometimes want to take something “natural” rather than a “medicine” (as long as natural doesn’t mean eating better and exercising more). If something is physiologically active enough to affect a disease state, it doesn’t much matter whether it’s “natural” or not.
But I’m getting ahead of myself. Let’s throw some organization on this post before it gets completely out of hand.
Alternative medicine can mean lots of things. There are some additional terms of note: complementary medicine usually refers to practices that integrate medicine with alternative medicine (and is often called “complementary and alternative medicine (CAM)”; and “integrative medicine”, which largely means the same thing. According to the National Center for Complementary and Alternative Medicine (NCCAM):
Complementary and alternative medicine is a group of diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine.
What does that mean? What makes something “alternative” rather than “conventional”? Here’s some proposed categories:
- Practices that lack of wide adoption by conventional doctors
- Practices that seem “weird”
- Practices without sufficient supporting data or putative, plausible mechanism of action
- Practices that are either hold-overs from pre-scientific times or whose “legend” makes them appear to be so
- Practices that sound “natural”
Admittedly I made this up, but it’s no worse than what NCCAM came up with, and it allows us to examine some of these practices.
For the first category, there are many practices not widely adopted by real doctors. Some perfectly conventional therapies take a while to propagate through the community, for example, the use of ACE inhibitors in diabetics with proteinuria. Still, propagate they do. But why do some practices remain alternative? Why, for example, has acupuncture failed to be adopted by most conventional doctors?
Because it doesn’t work any better than placebo, and if something doesn’t work any better than nothing, then there’s no reason to do it. It also doesn’t have a plausible mechanism of action, being based on ancient ideas of astrology and elan vital (or more properly “qi”). It also carries a myth of ancient origin when in fact it was largely promoted by Chairman Mao as a nationalistic (and cheap) alternative to “imperialist” medicine.
One argument I sometimes hear is that there are alternative practices that work we-know-not-how and therefore cannot be measured by known methods. This is absurd. Any time a patient claims to feel better, a data point is established.
One of the gravest sins committed by proponents of altmed is the false dichotomy between “natural” treatments and real medicines. There is nothing special about something that is “natural”, and many drugs are either natural products or derived from natural products. The unfortunate tendency in alternative medicine is to assume that “natural” is somehow better than “unnatural”.
The fact is that most “natural” remedies are produced and marketed by big corporations, often the same companies that make “real” drugs. “Natural” appears to mean “not prescribed by a doctor and not subject to FDA regulation”. There is no other difference.
What I’m trying to tell you, dear reader, is that there really is no such thing as “alternative medicine”—only that which either works or may plausibly work, and everything else. Anything that really works doesn’t stay alternative for long. Are there exceptions? Are there practices that should be widely adopted but that either are not, or are accepted only slowly? Sure, there must be. Medicine is fairly conservative, unless data is so overwhelmingly positive that to go slow would be unethical. But when they are adopted, there was always a plausible mechanism of action or data to support their use.
When you examine alternative medicine claims with even a bit of a skeptical eye, you quickly find that most are built on false premises, emotional attachment, misunderstandings, or outright lies. Non-anecdotal arguments in support of CAM are rarely positive, and usually resort to meaningless obfuscation (“well, medicine got it wrong before”, “Big Pharma is only out to make a profit”, “doctor’s just wanna make a buck”.)
If people eyed alternative medicine with even half the suspicion they have for real medicine, the CAM practitioners would be out of work by the end of the business day.