White Coat Underground

Mark Crislip has a nice piece up at Science-Based Medicine about the battle against the medical “de-lightenment”. In his post, he looks at some data about what sorts of criteria anti-vaccinationists use in their propaganda. Not surprisingly, appeals to emotion and to pre-existing beliefs are much more common than actual facts. The question then becomes, “Why bother?” We on the side of science-based medical humanism tend to believe that education is the best solution to problems such as implausible health claims, but since these things function more as belief systems than as opinions informed by facts, what’s the use? Do we seriously think we can de-program the victim of a medical cult?

Certainly there are those who are nearly beyond our reach, but only nearly. As I allude to in my Quack Miranda Warning, there are a number of categories of people we need to reach. There will probably always be those who are quite beyond redemption, but my optimistic side believes (without too much data, granted) that there is a large group of those who, while not experts, and relying on their own interpretations of their own observations, are humble enough to be swayed by facts. I view the population as being in a dynamic equilibrium of sorts, with perhaps a core of unalterables, but a vast pool of those who might be swayed by fact or emotion into one camp or another. Our job is to help them favor the right side. And their is a right side. It is not a matter of two paths to the same destination because some things make and keep people healthy, and some do not.

The science of medicine is quite specialized and detailed, and much of it relies on at least a basic knowledge of biology, statistics, and probability. These skills are naturally not going to be the everyone’s strength. When we discuss ideas such as “plausibility” we sometimes mean something quite different from the lay public. And while we all view reality through the prism of our emotions, those of us devoted to a science-based medical humanism try to at least ascertain the facts in a way that is as objective as possible. This dispassionate approach can be difficult for those who are not used to it.

Many of us view being a healer as a calling of sorts. This adds a somewhat odd spiritual quality to the work, and makes us susceptible to confounding helping with deception. Our responsibilities to our patients are complex, and while deception is not always wrong, it is nearly always wrong and the bar of justification is quite high. When a dispassionate approach is applied in a humanistic way, it is oddly no longer entirely dispassionate but compassionate. As caregivers, it is easy for us to confuse that which makes us feel good with what is actually good for the patient. When we tell patients that a certain treatment is going to help them, knowing that it will not, we feel that we have done something, and we have—we have used the patient to fulfill our own needs to feel competent and caring.

In combating the promotion of fake medicine, we can still appeal to emotion, and we must. If, as Dr. Crislip showed us, we rely only on facts, we will be talking to ourselves and a small coterie of the dispassionate. We must remind people why we care about real vs. fake medicine. We must be Spock and Kirk, because this is not about utilitarianism, it’s about individual patients. We must remind people that this is about real people and real problems, that when you avoid vaccination you and yours may be harmed, and that the harm of avoiding vaccination is much more likely than any putative harm of vaccination itself.

But we must also attack the charlatans, because they are hurt people. They are immoral. True belief is not exculpatory. Those who promote useless practices such as acupuncture, homeopathy, and reiki are sapping people of resources and turning people away from the hard truth: there is no magic. Health and healing are difficult and capricious. No lasers, no hypnosis, no magic potion will stop smoking or cure obesity, or shrink a tumor. Anyone who suffers from these problems or treats them daily knows how difficult it is, and has seen our patients and loved ones reaching for any light in the darkness to help them find a way out. And we’ve seen the disappointment and self-loathing when they “fail” to be cured.

So-called alternative medicine hasn’t been shown to work—that is what is “alternative” about it. And it is cruel. It teaches people that if they are would just believe, close their eyes, and tap their heels, all will be well. When it doesn’t work, it isn’t the failure of the nostrum but of the patient who didn’t believe enough, didn’t pray hard enough, or just needs a few more treatments. This is the reason we care. We care because we want to help, and are willing to admit that we there is no cure for the arrow of time, an arrow which will pierce us all. We help people dodge the arrow as long as possible, but ultimately we all lose. Fantasies to the contrary are the tools of priests and shamans, not real healers.

Comments

#1 Denice Walter
March 14, 2010

I’m not so sure about *de-lightenment* used to describe the phenomenon: it makes it sound almost like a *good* thing, suggesting “delight”. Then again,”de-enlightenment” is rather clumsy.How about just saying the “dimming” of the genre ?
#2 Perky Skeptic
March 14, 2010

I agree– false hope is cruel. The ones I hate most are quacks and crooks who couch their nostrums in sciencey-sounding words– people who offer offshore stem cell injections for MS and autism is my current top pick for loading into Dara O’Briain’s sack.
#3 BaldApe
March 14, 2010

On anti-vaccine and homeopathy, I couldn’t agree more. But I just read an article today about controversial vision therapy treatments which, ISTM, points out another problem in some areas.

Some conditions have rather nebulous sets of symptoms. Many symptoms of one condition can also be symptoms of another one. When someone appears to have, say ADHD, but really has a rarer condition, it can appear that treatment for the rare condition cured ADHD. Of course that’s not what happened, but that’s the kind of thing that gets reported.

So researchers look at all of the diagnoses cases of ADHD, or autism, or whatever, and evaluate whether a treatment for an eye coordination problem fixes them. Surprise, surprise, it usually doesn’t.

Next thing you know, a useful treatment for a specific condition is labeled as quackery because of mis-reporting, or maybe a bit of over-reaching on the part of practitioners.

My son had problems finishing school work in the first grade, because he couldn’t track from the blackboard to his paper and back again efficiently. Fortunately, his teacher had experience with her own daughter, who had similar problems, and directed us to a vision therapist. The treatment worked, his classwork and reading improved, and he is now a successful mathematician working for a government contractor.

The treatments didn’t cure ADHD, because he didn’t have ADHD. They didn’t cure autism, tetter, ringworm or psoriasis either. (And I know that anecdotal evidence is fairly worthless, so I do acknowledge the possibility that it was the attention he received that improved work habits. I doubt that that’s what happened.)

I am just concerned that when unusual conditions are thrown in with a larger population in a test of a treatment, the useful effect of a treatment for the rare condition gets labeled as quackery.
#4 TheDissenter
March 14, 2010

Wow. Sounds like you are starting your very own “science-based” medical cult. How large does your ego have to be to join?

“And we’ve seen the disappointment and self-loathing when they “fail” to be cured.”

Interesting choice of words. I notice you didn’t say:

“And we’ve seen the disappointment and self-loathing when we fail to cure them.”

But I guess to you if a patient doesn’t respond to your “science-based” treatment, they have failed, not you. What a laugh!
#5 Ray C.
March 14, 2010

#4 TheDissenter: [wharrgarbl]

Begone, foul troll.
#6 Pareidolius
March 14, 2010

Great post.

I think you hit the nail on the head when you said it is a medical cult. I’ll add that crank magnetism is a huge part of it. As a recovered magical-thinker, I know that my veering off into woo as a teenager opened a Pandora’s Box of possibilities that had me totally entranced for the better part of 15 years. I was smart, but woefully lacking in critical thinking skills.

My fascination with quantum pseudoscience let me believe in brain/body duality and “creating your own reality”. That opened the floodgates of conspiracy theories where the corporations of “the man” were keeping “ancient knowledge” from us so they could profit.

Now, I always had a strong skeptical streak, but in order to believe this comforting (to me at the time) nonsense I had to work hard to ignore or shout down anything that threatened my world view.

On one level, I have some empathy for the wingnuts and “worried well” who visit science blogs. I know what it’s like to just be scared and want the rainbows and unicorns to keep the scary stuff away. I often think “what would have changed my mind back then?” The answer is “nothing.”

You see, I avoided anything that countered my beliefs. Oh, I might have read a headline (which would scare/offend me) and then I’d write a flaming letter or post, but would I have read the article? Hell no. In the back of my mind, I always knew that science was right. It was my biggest fear that they would kill my magic quantum kittens with their “negativity” (read: reality).

So what changed me? The terrible beauty and utter ordinariness of death, but that’s a long story. The Reality Based Community needs to keep the pressure on the quacks. I know that there is a vocal faction that says our blogs and communities are echo chambers and we’re preaching to the choir. Well, not necessarily. As people emerge from their stupor, they start reading so it’s vital that there’s good information out there, and lots of it. Plus, it takes years to get over that cult-like indoctrination. I’m still learning how to think critically after ten years, and it’s often in the flame wars of the comment section that I find my lessons.

So keep up the good work, and no, there’s no one thing we should be doing to reach those who simply won’t listen. But we need to be there with open arms when the cracks start to form in their worldview.

Well that was wordy, too much Darjeeling . . .
#7 TheDissenter
March 14, 2010

“Begone, foul troll.”

Sorry, let me rephrase:

Oh Emperor, what lovely clothing you wear!
#8 The Blind Watchmaker
March 14, 2010

@ TheDissenter

Just curious. What approach would you have your doctor take if you had a complex problem in which the optimal treatment is not apparent? Should your doctor abandon the scientific approach and give you false promises? I mean, just what is your point?
#9 Prolix
March 14, 2010

What’s notable in this discussion is how your discussion of alternative medicine is entirely fact free:

“we’ve seen the disappointment and self-loathing when they “fail” to be cured. ”

You’ve verified this **empirical** claim … how? With anecdotes?

“We help people dodge the arrow as long as possible, but ultimately we all lose. Fantasies to the contrary are the tools of priests and shamans, ”

Who exactly is claiming that their patients live forever? Where are these claims set down?

The alternative medical community and its patients have been studied. You could read some of these studies, maybe cite them, instead of spinning your fantasies about the community.
#10 History Punk
March 14, 2010

@TheDissenter

I, for one, welcome our new rational overlord. I’d like to remind PALMD that as a trusted blog personality, I can be helpful in rounding up others to toil in his underground science-based cult.
#11 Melissa Burch, CCH, RsHom(NA)
March 14, 2010

I, too, agree that false hope is charlatanism. I am a homeopath. Why isn’t anyone looking at the prescribing of very dangerous expensive drugs that many people are taking now that not only are bankrupting our health care systems but causing all sorts of side-effects and/or are being proven all too often to be ineffective.
Good healers come in many forms and every person will react differently to different people and to different forms of ‘healing’. I have experienced brilliant cures with homeopathy and also have had cases where there was no effect. If the ‘real’ truth was known about how to cure people, don’t you think we would all be healthier.
I think we should support all who are trying to make people’s lives better.
#12 History Punk
March 14, 2010

“I think we should support all who are trying to make people’s lives better.”

This muddled-mind vapidness is the origin for the proverb “The Road to Hell is paved with good intentions.” It’s not enough to want to do good, you actually have to do good. Results, and how you got them, really do matter. You can try and try and try to do good, if you fail, then it doesn’t really matter.

Melissa, out of curiousity, how many participation ribbons have you acquired over your life?
#13 PalMD
March 14, 2010

Ooh…I like that…”It’s not enought to want to do good, you actally have to do good.”

Melissa, I’m sure the care you give makes people feel cared for, but it’s based on a lie. Believing the lie yourself does not free you of moral responsibility.
#14 Pareidolius
March 14, 2010

Melissa with all the fancy letters after your name:

“Brilliant cures with self-correcting ailments” is surely what you meant in your earnest comment. I doubt you had brilliant cures with cancer, or congestive heart disease, HIV or malaria. I imagine that all the brilliance occurred in the worried well with ill-defined chronic problems category. Just a guess, since water really cures nothing but thirst. And I used to be a believer, bigtime. I spent thousands of dollars on nothing to cure nothing in my magical thinking years.

Indignant, quantum, “science doesn’t know everything”, handwaving reply in 3..2..1..
#15 SurgPA
March 14, 2010

@9 Prolix –
“The alternative medical community and its patients have been studied. You could read some of these studies, maybe cite them, instead of spinning your fantasies about the community.”
Please show me some links, as I’ve not seen any good studies. I’d be happy to read and evaluate them…

@11 Melissa –
“Why isn’t anyone looking at the prescribing of very dangerous expensive drugs that many people are taking now that not only are bankrupting our health care systems but causing all sorts of side-effects and/or are being proven all too often to be ineffective… I have experienced brilliant cures with homeopathy and also have had cases where there was no effect.”

Actually, people ARE looking at drugs/medications being prescribed. Each and every one. They are tested both for safety AND for efficacy (you know, they actually do what they’re alleged to do…) Yes they have side effects, and these are generally well-known and described. What’s more, there is a large organization, the FDA, who oversees this process and ensures that a medication which is alleged to do X and have Y risks actually does (and yes, I’m aware of the shortcomings of mour current pharmaceutical oversight system.)As a result, when I prescribe a medication, I can weigh the risk vs benefit balance with confidence that I actually know the risks and benefits. Do your homeopathic remedies have side effects? How do you know?

With regard to your “brilliant cures” and “cases with no effect,” you hardly make an argument for the efficacy of homeopathy. Bearing in mind that placebo effect approaches 50%, even a glass of water should have “cures” on occasion.

I apologize if I’m being rude and if I’m on a bit of a rant, but I’m sitting at a great conference (Johns Hopkins Perioperative Care) watching really, really good speakers who are clearly much better-informed than me back up every assertion with citations of quality studies that I can access and read, and reading a comment like Melissa’s reminds me of how vast the gulf is between medicine practiced as a science and all the well-intentioned but ultimately useless/harmful quackery out there.

Just to illustrate: post-op wound infections are a significant problem. Lots of effort has gone into finding ways to reduce their incidence. One method, high-flow oxygen perioperatively (80% vs 30% traditional use) was shown by 4 good studies to reduce infections, and people have started to adopt this. Now a fifth good study comes along and contradicts the first 4. How would the homeopathist community handle this? (I don’t actually know.) What science does is say “wait a minute, we have new evidence that contradicts old evidence. WE MIGHT HAVE BEEN WRONG! This warrants further investigation, new studies, until the body of evidence shows us in a reproducible way what the best treatment is.” Do alternative therapies even evaluate their treatments? Do they continuously reassess their body of knowledge/belief? Do they even know they should?
#16 Chris
March 15, 2010

Melissa Burch:

Why isn’t anyone looking at the prescribing of very dangerous expensive drugs that many people are taking now that not only are bankrupting our health care systems but causing all sorts of side-effects and/or are being proven all too often to be ineffective.

Just tell us the studies that show homeopathy is more effective for the following diseases that seem to require dangerous expensive drugs:

1) rabies (read about rabies and Andre Saine here)

2) bacterial strep infections

3) non-Hodgkin’s lymphoma

4) syphilis (one of those special miasms, just like psora)

4) Type 1 diabetes

Just list the PubMed articles that show homeopathy is effective for these non-self-limiting conditions.

When I was in 9th grade our science class was given the task to determine the chemical identity of a liquid. We were allowed to do some things to it, like find its boiling point, see if stuff dissolved in it, and other basic tests to determine what is was chemically. On a similar vein, if someone took your bottles of remedies and removed the labels, how would you be able to tell one from another?

Could you tell a bottle of 30C Nux Vomica from a bottle of 30C natrum muriaticum?

If you can, I know where you can win a cool million dollars!

Thank you.
#17 Chris
March 15, 2010

Ms. Burch, what is the point of putting your website (homeopahthyradio.com) in your name’s click-able link when it says this when we click on it? Kind of defeats the purpose of having your own web page:

Forbidden

You don’t have permission to access / on this server.

Additionally, a 403 Forbidden error was encountered while trying to use an ErrorDocument to handle the request.
#18 Vicki
March 15, 2010

Melissa–

If you want us to support everyone who is trying to make people’s lives better, why are you arguing with those who are trying to protect people from expensive, useless bottles of plain water? Advising people against fraud is a way of making their lives better.

Or, to address another part of your post, can we see the homeopathic papers that warned against HRT and selenium supplements?
#19 JohnV
March 15, 2010

“I have experienced brilliant cures with homeopathy ”

Then why don’t you publish them in a peer reviewed journal so information about your treatments can be disseminated to others?
#20 Uncle Glenny
March 15, 2010

Ms. Burch, what is the point of putting your website (homeopahthyradio.com) in your name’s click-able link when it says this when we click on it?

It’s your reductionist mindset. Take 250ml of a 6X dilution of LSD and it will make more sense.
#21 Prolix
March 15, 2010

For starters:

NCCAM Survey of alt med use
http://nccam.nih.gov/news/2008/nhsr12.pdf

JAMA survey on why patients use alt med
http://jama.ama-assn.org/cgi/content/abstract/279/19/1548

German survey of alt med users
http://www.ncbi.nlm.nih.gov/pubmed/15604623
#22 Prolix
March 15, 2010

“Just tell us the studies that show homeopathy is more effective for the following diseases that seem to require dangerous expensive drugs”

Of course, no such study could be done, because no ethics board would approve them.
#23 Chris
March 15, 2010

I guess not. Not even the test for the efficacy of homeopathy for rabies in mice.

I don’t know if you are familiar with the debate Dr. Novella had with homeopaths a while back. But one made a very testable claim (quoting Dr. Novella):

He even claims that homeopathy can cure rabies with 100% success. Rabies is almost 100% fatal, even with modern treatment, so this is quite an astounding claim. An audience member helpfully suggested that we can test this claim on animals that contract rabies, since they are just put to death in any case. I pointed out that if Dr. Saine’s claims are even remotely true it is amazing that such a simple study has not been done in the last two centuries, that we have been sitting on a cure for such a deadly disease all this time and yet homeopaths have never been able to silence critics with a controlled experiments. I also pointed out that homeopathically treating “rabies,” a disease, contradicts Dr. Bell’s “holistic” defense, but that’s a separate point.
#24 Katharine
March 17, 2010

I would bet a good bit of money that Melissa doesn’t do much journal-reading.
#25 Prolix
March 17, 2010

I doubt if a study where animals are deliberately infected with rabies and then treated homeopathically would be approved. And I doubt if homeopaths would be interested in pursuing such a study, as it is so alien to their daily practice. There are other, more common health problems they would rather study.
.
Andre Saine’s claims are no doubt based on his study of nineteenth century homeopathic journals. I am unfamiliar with the articles he would be basing his claims on.