White Coat Underground

Last week I gave you a refresher course on the invalid arguments used by altmed boosters. The Turf Battle Fallacy and Pharma Shill Gambit are classics for a number of reasons. The most amusing thing about these gambits is their hypocrisy. The alternative medicine movement is essentially a collection of businesses selling unproven supplements and interventions (not “therapies”, as Steven Novella aptly observes).

Of course, that’s an incomplete analysis. Altmed is also a religion, with zealous adherents. The arguments made by these adherents are never about the data, but about beliefs. When asked for data, they often resort to two more of my favorite gambits: moving the goalposts, and the argumentum ex culo. I’m going make an example out of a recent commenter, not because I have anything against him, but because he’s just that hilarious.

Our commenter, in defending alternative medicine (but giving few specific examples) states that:

In mentioning diet, I was referring to Pal’s own admission that he does not normally bring up diet with his diabetes patients.

I mention this as being ex culo as I have written frequently about lifestyle modification, which is not in any way “alternative”, but a normal part of medical practice. I have many times written that advising lifestyle modification is often insufficient. For example (since Nathan gives none):

The truth is that diabetes can, and often is, well-controlled by medicine alone. This isn’t because real doctors prefer it that way; it is because many diabetics cannot adhere to diet and exercise programs, and many diabetics do not have enough pancreatic beta cell function left to avoid medications.

When called out on his pulling a “fact” out of the vacuum, he backpedals—and the picks up his goalposts and starts to run:

Pal: I may have inferred wrongly from what you wrote earlier.

Dietary adjustments that effectively treat illnesses are rarely mentioned by physicians, in my experience, and are routinely downplayed. If your experience differs, I’m interested to hear about it. Do you ask H. simplex patients about their diet?

“In my experience” is of course a placeholder for, “wait, my rectum is still full of unsupported assertions.” Dietary modification is the mainstay for the treatment of many common diseases: coronary heart disease, hypertension, sleep apnea, obesity, type II diabetes, hyperlipidemia, just to name a few. It is not “downplayed” but real doctors recognize that real patients should not be punished for their inability to make significant enough lifestyle changes.

I had trouble deciding if the final phrase was truly a “moving of the goalposts” or simply an idiotic non sequitur. I concluded that it is both. In my eyes it is a non sequitur because it literally does not follow. It makes no sense. It is devoid of reason. To Nathan, however (who, we should remember, is simply giving us typical examples to work with) he has raised the bar. Now that he sees that I may actually use dietary advice in my practice, his response is, “yeah, but did you do it for this other disease? Huh? Didya?”

This simultaneous running away with the goalposts and birthing ideas ex culo leads to some disturbing imagery, but more important is that it reveals the poor thinking habits of those who would critique the need for medicine to be based on science. There is no “alternative” to medicine. There is simply that which can be shown to work, and that which cannot. The humane application of what we know is the art of medicine. The humane application of alternative medicine is quackery with a smile.

Comments

#1 bexley
May 11, 2010

Great post – although from the title I thought this was going to be about colonic irrigation.
#2 Kate from Iowa
May 11, 2010

Yeah, Bexley, I thought it was going to be about kids. Maybe I just had wierd brothers.

I was wondering about the H.simplex comment myself, Pal.
#3 Rogue Epidemiologist
May 11, 2010

I’m going to guess that the commenter is hinting at the use of lysine supplements to control herpes outbreaks.
#4 Nathan Myers
May 11, 2010

There are no goalposts. There is no bar. The simple and correct answer would have been “no, I don’t ask my HSV patients about their diet”. Instead, you demonstrated my point (“dietary adjustments are … routinely downplayed”) by downplaying: “I also don’t ask people with eczema what their favorite color is.”

Nobody here is criticizing the need for medicine to be based on science. Suggestions otherwise are manifestly ex culo.

The connection between HSV outbreaks and lysine and arginine in the diet has been known and well documented decades. If in fact you are not applying that knowledge because it is too “alternative” for you, then you are indulging in your own flavor of quackery, not essentially different from those you rail at.

Conservative estimates put the number of deaths from treatments administered by or under the orders of board-certified physicians in the U.S. at tens of thousands per year. There’s no estimate available for deaths from lack of appropriate treatment, and none of failed treatments that do not result in fatalities, but they must be at least as large. Practitioners who insist they already have all the answers must be a big part of the problem.
#5 PalMD
May 11, 2010

Would you care to give some useful citations to back up your assertions, because I’ve scoured the literature and found little of interest about clinical connections between specific amino acids and HSV in humans.
#6 Nathan Myers
May 11, 2010

Scouring in culo, now? Don’t you know any research librarians who can help you?

I have just noticed your aberrant and frankly weird definition of “alternative”, in the other thread: “… no supporting evidence, or are promoted despite that lack of evidence.” What would you call a treatment for which there is evidence of its effectiveness, but which has not been submitted for FDA approval because there is no way to extract enough revenue from it?
#7 nsib
May 12, 2010

Egads, Nathan, are you simply incapable of arguing honestly?

Scouring in culo, now? Don’t you know any research librarians who can help you?

Why keep your sources hidden? Are you afraid that they won’t withstand scrutiny?

What would you call a treatment for which there is evidence of its effectiveness, but which has not been submitted for FDA approval because there is no way to extract enough revenue from it?

I’d call this “begging the question.” With a strawman argument thrown in for good measure. Not FDA approved != “no supporting evidence.”
#8 CanadianChick
May 12, 2010

Nathan honey, there’s ALWAYS “enough money to be made from it” if the science proves itself and it fills a vacant niche. If lysine was proven by REAL scientific standards to be effective against herpes, there would be a fast-acting sustained release version of it on the pharmacists shelves ASAP.

Besides which, do the companies that CURRENTLY sell lysine capsules do it to lose money?? Of course not – So OBVIOUSLY there IS profit to be made…although if “Big Pharma” did produce the hypothetical FA/SR capsule you’d probably refuse it on “principle”, wouldn’t you?*

*shhh…no one tell him that the more reputable supplement companies ARE often owned by “Big Pharma”, ‘k?? It’s not nice to make someone’s little head explode if you’re not there to help clean up the mess it makes
#9 Nathan Myers
May 12, 2010

nsib: [Ignoring the trolling.] Yes, “not FDA approved” is not the same as “no supporting evidence”. That was precisely my point: “with supporting evidence, but not FDA approved” is what normal people call “alternative medicine”. Anybody obliged to invent wacky definitions for words to make a point is on thin ice indeed.

CC: [Ignoring the trolling.] Do you really not understand that the price obtainable for patented treatments can be much higher than for generics?
#10 bexley
May 12, 2010

nathan come on where are your sources for your assertions on HSV? you’ve been asked already and all you’ve done is obfusticate. You must have some evidence or you wouldn’t have said anything, right?
#11 CanadianChick
May 12, 2010

Nathan, honey – are you really so ignorant of how “Big Pharma” actually works?

For someone who claims to know so much, your ignorance is amusing.

I’ll give you a hint – go back to my post. Read it again, focussing on the descriptors of my hypothetical lysine capsule. Don’t worry about reading with your lips moving, I’ll be polite and look away.

Now, see the part that would make the drug patentable?

If you don’t, that’s OK – I don’t think anyone’s expectations of you will be disappointed…
#12 Mu
May 12, 2010

Even if the supplement turned FDA approved medication is not patentable, it’s brand-able. They still sell Tylenol and Aspirin for double the price than the generic and make good money of it.
#13 nsib
May 12, 2010

Nathan,

That was precisely my point: “with supporting evidence, but not FDA approved” is what normal people call “alternative medicine”.

Is it now? Well then, I would love to see your evidence for homeopathy and reiki.
#14 JoeB
May 12, 2010

My evidence? You should be able to find my evidence.
#15 Terrie
May 12, 2010

That was precisely my point: “with supporting evidence, but not FDA approved” is what normal people call “alternative medicine”.

I guess I’m not normal, because I’ve never used that definition in my life.
#16 Dianne
May 12, 2010

That was precisely my point: “with supporting evidence, but not FDA approved” is what normal people call “alternative medicine”.

I guess homeopathy isn’t alternative medicine, since there’s not a shred of evidence supporting its efficacy and a good deal of evidence (for example, basic physics and chemistry) against it. Who knew?
#17 Kelly
May 12, 2010

MLIS background here, working currently working in IA within health research. I am very familiar with PubMed.
I put through a *very* simple search of all of the cataloged literature and received *one* old literature review in German. (1960s) More complex searches did not find anything more, and in some cases eliminated this one result:
http://www.ncbi.nlm.nih.gov/pubmed?term=%22Herpes%20Simplex%22Mesh%20AND%20%22Diet%20Therapy%22Mesh&cmd=DetailsSearch

If any of you have access to archives of this journal and can read German, it would be great if you could share the results. Somehow, I doubt very much that they will satisfy Nathan.

Essentially, there is no proven dietary intervention for any strain of HSV.
#18 Tsu Dho Nimh
May 12, 2010

birthing ideas ex culo

I have to remember that phrase. It could be useful.
#19 Nathan Myers
May 12, 2010

Dianne: No, homeopathy isn’t alternative medicine, it’s just proven quackery. Homeopathy is unusual in that not only is there no evidence that it works, there’s plenty of sound evidence that it doesn’t. There are good reasons to have two different terms. If you lump everything together into mush, all you have is mush.

Kelly: So, your “very simple” search omitting any mention of any amino acids didn’t turn up anything interesting. I’m no MLIS, but my very simple search “herpes and lysine and arginine” turned up plenty. Maybe you should consider work in a different field?
#20 PalMD
May 12, 2010

Nathan, i pubmed’d the hell outta that one yesterday and found little of relevance.

Googling is another matter, but of course, U. Google isn’t exactly science.
#21 fhorn2
May 12, 2010

Minor divergence: I just want to thank you, PalMD, for your blog. It is a relief to read logical, skeptical discourse that refutes current fallacies about science and medicine. Keep it up.
#22 Nathan Myers
May 12, 2010

So, you “pubmed’d the hell outta” it and didn’t find what I found in a single, trivial search. Does that indicate incompetence or bias? I’ll bet on bias.
#23 PalMD
May 12, 2010

You gonna share your cites or keep typing ex culo?
#24 Nathan Myers
May 12, 2010

I posted the search string that produced plenty of results on the first try. A competent research librarian could surely tease out lots more.

Which of us, again, is supposed to be the health care professional who cares about his patients’ welfare? When a patient walks in with blisters crusted all over her mouth, would it be so degrading to you to ask if she maybe munched a big bowl of peanuts or something like, that weekend?
#25 Stephanie Z
May 13, 2010

Nathan, I think it might have more to do with the fact that Pal did more than count the number of results (22) that search string brought up. Of those, one is a small study stating there is no connection between the lysine content of diets and frequency of outbreaks. Two are small studies showing some effect of supplementation (which is not diet). The rest have nothing to do with ingestion of lysine. That is not “plenty.”
#26 gaiainc
May 13, 2010

I should be asleep but I’m finding Nathan’s tone annoying. I went to PubMed, put in the search string “herpes and lysine and arginine”, and got 22 studies. Of those 3 or 4 were done in human subjects. One basically said based on 16 subjects that there is variability in howuch lysine and arginine are in American diets (though it seems to favor lysine rich foods). Another in ?26 subjects showed lysine supplementation may prevent herpes simplex labialis reccurrence which was echoed by another study with maybe 16 people (haven’t figured how to type on one screen on my smartphone and look at a different webpage without losing my spot on typing). Yeah. I’m not finding this to be a lot or compelling.

I have learned why Bathan brought up peanuts, though given most of my patients, I’d rather encourage them to a more arginine diet than a lysine one. Oh, wait. That’s what I do already. Also, Nathan, PalMD never said that diet is downplayed. He said real physicians deal with real patients who can’t or won’t or some combination thereof make the necessary lifestyle changes for their health. We can discuss why that is, but I’d tread very softly in saying physicians don’t discuss lifestyle changes. I saw 10 patients this afternoon. The 3 yo with parvovirus didn’t need lifestyle advice nor did my 2 month-old. The rest including the 27 year-old in for a colposcopy, got something if not the whole visit about diet, exercise, lifestyle change. If you don’t think I’m doing it right you are welcomed to come to my clinic and do that counseling. Have fun.
#27 nsib
May 13, 2010

>_< Nathan, your definition of "alternative medicine" covers everything from appendectomies to rehydration. That's hardly what "normal people" think.

Also,

When a patient walks in with blisters crusted all over her mouth, would it be so degrading to you to ask if she maybe munched a big bowl of peanuts or something like, that weekend?

what the hell is up with all these strawmen?
#28 nsib
May 13, 2010

Hmm. The last sentence shouldn’t be in blockquotes. That’s what I get for not previewing…

P.S. It seems that HTML and east asian emoticons don’t mix
#29 Calli Arcale
May 13, 2010

Wow. Not content to go “no true Scotsman”, Nathan has gone “no normal person” on his definition of alternative medicine. Anyone who has a different definition, even if they be the entire human race minus Nathan, can thus be dismissed by him with one fell swoop, as they are therefore not normal people.

Truly, that is an impressive degree of arrogance.

Most people really do consider these things to be alternative medicine: homeopathy, reiki, chiropractic, naturopathy, aromatherapy, iridology, prayer, meditation, hypnosis, herbalism, acupuncture, acupressure, orthomolecular medicine, purging, colon cleanses, etc. They have varying degrees of evidence behind them, but the main thing they share in common is that they are not accepted by the medical mainstream. The average person defines alternative medicine very loosely as “an alternative to what my MD can give me”, so if something is not accepted by the medical mainstream, it probably can safely be described as alternative medicine.

Don’t like that definition? Tough. Natural language is almost impossible to subjugate to the will of any one person; it will mean what the general public thinks it means.
#30 Dianne
May 13, 2010

That was precisely my point: “with supporting evidence, but not FDA approved” is what normal people call “alternative medicine”.

Just to jump on Nathan some more for this statement: Bevacizumab (avastin) is FDA approved for a number of cancers, but not for head and neck cancer. Yet if you look up bevacizumab and head and neck cancer in Medline, you’ll find that there is supporting evidence for the claim that it is at least modestly effective in head and neck cancers. So this high priced, patented, totally artificial engineered drug not even vaguely found in nature, traditional to no society except 21st century first world countries is “alternative medicine” by Nathan’s definition.
#31 Nathan Myers
May 13, 2010

Latecomers to the party can be forgiven for missing the context. Our accommodating host had pretended that his definition of “alternative” was to “have no supporting evidence”. I say “pretended” because he, like Calli and me and everyone else, actually uses the word to refer to many treatments which are backed by evidence, some of which are well supported by any standard. It’s a rhetorical trick to lump every treatment he personally doesn’t favor with those that have been demonstrated valueless or harmful.

Dianne: Yes, avastin for neck cancer, off-label, is alternative. What’s your point? I note you haven’t answered my questions from the other thread, yet. What is so wrong with trying ginger to see if it prevents queasiness when you go sailing?

gaiainc: I take your annoyance seriously, but, again, context matters. I don’t pretend to be a research librarian. When a supposed research librarian posts and announces she can’t find something that I find in ten seconds, it says nothing about me, but volumes about her. Likewise, I don’t pretend to be a health care professional, but when somebody who is proudly proclaims ignorance of information of immediate value to his patients that even I know about, it says very little about me, and a great deal about him.

He didn’t have to tell us he downplays diet. He downplayed it right in front of us, while we watched, right after he insisted that he didn’t.

Obviously arginine is not a problem for your patients who haven’t got HSV holed up in their trigeminal ganglion nuclei, and there must be reasons why Seventh Day Adventists live seven years longer than the rest of us. That’s not a valid reason to keep herpes sufferers ignorant of dietary details they could use to make their lives better.
#32 Vicki
May 14, 2010

Nathan–

No, the FDA isn’t going to be investigating ginger. They don’t need to. It’s already approved as a food.

That may mean you can’t get your insurance company to pay for it, but that’s not primarily a medical issue. They won’t pay for shoes, even though walking is good for my health. I still buy shoes, I still walk, my doctor still approves and says so.
#33 nsib
May 14, 2010

Nathan,

I say “pretended” because he, like Calli and me and everyone else, actually uses the word to refer to many treatments which are backed by evidence, some of which are well supported by any standard.

Do you have even a single example of this?
#34 Calli Arcale
May 20, 2010

Nathan: why do you say we all use the words “alternative medicine” the same way after asserting a ridiculously restrictive definition? Also, speak for yourself — I find that few treatments promoted as alternative medicine are well supported by evidence. Some have a bit of evidence, though, such as ginger for nausea, though not really enough to guide clinical practice. FDA approval, meanwhile, is not a good separation between alternative and mainstream; a great many things are neither FDA approved (because they are neither foods, drugs, or medical devices) yet are considered mainstream medicine. Surgical interventions leap instantly to mind; FDA may regulate the drugs and some of the devices, but they don’t regulate the actual procedure. Yet who would seriously consider an appendectomy to be alternative medicine?

Myself, I find the term to be mostly a marketing device akin to “natural foods”, primarily applied by its own promoters as a way of framing customer expectations. This probably explains its vagueness.