The flying carpet retort to "integrative medicine"

I didn't think I'd be discussing Dr. David Katz again so soon after the last time. In fact, when blog bud Mark Crislip (who clearly hates me and wants me to pop an aneurysm or have a heart attack, given how often he sends me links to articles as infuriating as this) sent me a link to Dr. Katz's latest article, "Cleaning the House of Medicine", published—where else?—in The Huffington Post, that home for "reputable" quack-friendly bloviation since 2005, when I first read the article, my first reaction was that Katz must surely be trolling supporters of science-based medicine. At first, I wasn't going to respond to him again. However, Katz's article represents a very common misconception about science-based medicine that is worth refuting. It is not my intention to be arguing back and forth with Dr. Katz every couple of weeks, but I did think it worth one more round. I think you'll understand why by the end of this post.

First, however, a brief recap is in order for readers who might not have been following the discussion over the last month or so. It all started a couple of weeks ago, when Jann Bellamy, in response to a special issue of the American Journal of Preventative Medicine edited by Katz and dedicated to making the case for integrative medicine in preventive medicine training, quite correctly discussed how "integrative medicine" is always all about the "potential." Indeed, after having spent considerable sums of federal grant money studying the "integration" of pseudoscience into medicine with respect to preventive care, the journal couldn't come up with any concrete examples how integrative medicine adds anything (other than quackery) to medicine. Dr. Katz, who is well-known in the world of quackademic medicine for his infamous 2008 speech in which he asserted that physicians need to use a "more fluid concept of evidence" in evaluating treatments, particularly "complementary and alternative medicine" (CAM), responded with another HuffPo article entitled "Science and Medicine, Fools and Fanatics: The 'Fluidity' of Woo". In lieu of reasonable, science-based arguments, Dr. Katz' article was little more than a rant that consisted mainly of outrage that mere mortals lacking his awesome academic credentials had had the temerity to question his awesomeness and dedication to science coupled with an accusation that we are just too rigid and simplistic in our thinking to understand the subtle complexities of how different standards of evidence must be applied to complex patients. Steve Novella and I both responded that we understand just fine, explained how doctors do this all the time without using quackery like naturopathy and homeopathy (both of which Katz has advocated), and pointed out his argumentum ad ignorantiam with respect to energy medicine.

There's where I thought it would end. Unfortunately, I was mistaken. Last Friday, Katz launched another broadside SBM supporters,\ couched in the form of an argument that medicine must "clean its own house" before worrying about his quackademic medicine. It's something I hear often enough that I thought it would be worth responding to, even if Dr. Katz was indeed trolling me.

Worry about what I think you should worry about

A frequent attack on SBM goes something like this: There are so many problems in medicine when it comes to the rigorous application of evidence to medical treatments, such as the distortion of evidence by big pharma, the overuse of various treatments, and the use of treatments without a good basis in evidence, that we really shouldn't worry so much about things like CAM or integrative medicine because there are far bigger fish to fry. In other words, worry and write about what I think you should worry and write about! If you don't, clearly I can discount you as ideologically blinded. Indeed, Katz makes exactly this argument near the end of his article, with the further implication that because we here at SBM focus mostly on integrative medicine and CAM it must be due to ideology, not science (or, of course, as implied elsewhere, because we are in the thrall of big pharma):

To the best of my knowledge, a rather boisterous group in cyberspace calling itself "science based medicine" is silent on all of this. They preferentially malign all alternatives to conventional medicine, implying that problems of evidence and its application lie entirely without, and not within. This, in turn, makes it clear that such protest is itself unconcerned with the underlying evidence, and born instead of ideological zealotry. If evidence matters, it matters equitably, and universally.

Of course, I agree (and I highly doubt that anyone known for supporting SBM and arguing against quackademic medicine would disagree) that evidence and science must matter equitably and universally. Indeed, over the years, I've lost track of how many times I (and other bloggers) have pointed out that we advocate applying a single science-based standard to all of medicine. Dr. Katz also clearly has only ever read criticql posts here about him, because he sets up a rather massive straw man argument by characterizing SBM supporters by claiming that we are saying that the problems of evidence and its application lie "entirely without, and not within." What? No, the problems with application of evidence are indeed within medicine. The reason I and others discuss CAM so frequently is because the reason it is becoming more "respectable" is not because it's being forced on medicine from without, but rather because certain, well-respected members of the medical profession (like Dr. Katz) are misapplying evidence from within, so to speak. After all, this is the physician who thinks naturopathy is a valid medical specialty and is willing to use homeopathy.

It was also at this point that I wanted to make like Ygritte in Game of Thrones and retort, "You know nothing Jon Snow David Katz." Clearly, Dr. Katz knows nothing (or next to nothing other than the occasional criticism of his statements) about what I and other bloggers advocate. He is also, as he so often does, positing a false dichotomy: That we must do what he thinks most important (clean up the house of medicine, defined by him to mean malign pharma influence, the inconsistent application of evidence, and the persistence of medical tests and interventions that are no longer supported by evidence) before we can do what we consider to be important (combat pseudoscience in medicine). There is no reason we can't do both, and, in fact, I do do both. He's just unhappy that I don't do just one. He's using one of the most irritating and disingenuous arguments of all: "You consider important what I consider important and act and write accordingly," or, as I call it with respect to blogging, "Why don't you blog about what I think you should blog about?"

Because I for the rigorous application of science to medicine, over the years we have written posts questioning all manner of "conventional" medical interventions. I'll start by mentioning just a few of my posts questioning various conventional medical interventions, such as vertebroplasty for osteoporotic compression fractures, which I referred to as "modern acupuncture." Then there's mammography, which has been a frequent topic on this blog ever since the USPSTF issued screening guidelines in 2009 that involved not starting screening until age 50 and then screening only every other year rather than every year and continuing to the publication last month of new guidelines by the American Cancer Society guidelines, which also backed off, albeit not as much, from starting mammographic screening at age 40. In the context of screening, I've discussed overdiagnosis in cancer screening and criticized a certain eminent radiologist who defends mammography at all costs, to the point where he wrote an e-mail complaining to me that reminded me of Dr. Katz's displeasure with us. I've discussed how surgical procedures are often adopted too rapidly, before there is adequate evidence that they are as good as or better than the procedures they supplant. That doesn't even count the times I discussed some downright abusive and criminal conventional doctors and spectacular failures of state medical boards.

I could go on, but got tired after finding just this much. You get the idea. Yes, we do write a lot about CAM and "integrative medicine." We make no apologies for that. If I'm sounding a little defensive, I make no apologies for that, either. Attacks based on ignorance of what I do irritate me. I write about plenty of other medical topics that have nothing to do with CAM. What they do have to do with is exactly what Dr. Katz accuses us of ignoring: Calling out areas of medicine where the application of scientific evidence is not so rigorous. He ought to love me for that, but he doesn't. I wonder why.

The flying carpet problem

Dr. Katz uses a recent systematic review published in JAMA Internal Medicine presenting evidence against certain medical practices that should be reconsidered in 2015 as his jumping off point:

A recent report in JAMA Internal Medicine highlights prevailing medical practices that should be "reconsidered" in 2015 based on the weight of evidence. The paper, appropriately, is written in the matter-of-fact style customary for the peer-reviewed literature. To some extent, that semblance of analytical calm belies the storm swirling between the lines of the report, and the mess it has long been making in the House of Medicine.

The authors, for instance, note that excessive zeal for cancer screening results in "unnecessary surgery and complications." As a statement, that is rather bland, and even when statistics are attached to show scale, as the authors do, it likely fails to evoke any deep impression. But consider any time you have been through surgery yourself, either as the patient, or as a family member. Unless you are the rare individual who has avoided the OR entirely, even by proxy, those occasions are likely indelible in your memory, and easy to recall.

Of course, this is nothing that we (myself in particular) haven't been discussing quite frankly on SBM since at least 2008. Just type the words "overdiagnosis" and "mammography" or "overdiagnosis" and "screening" into the search box of this. Heck, I even just recently co-authored an article in the New England Journal of Medicine discussing this very issue and how widespread mammographic screening programs appear not to have decreased the incidence of metastatic breast cancer at diagnosis. I note that this NEJM article came about because H. Gilbert Welch has read my blogs. Liking my posts on mammography, he invited me to co-author the article with him, and I jumped at the opportunity. In fact, I can't help pointing out to Dr. Katz that this NEJM article, as well as my Nature Reviews Cancer article about integrative oncology and Steve Novella's and my article on clinical trials of highly implausible treatments are extensions into the peer-reviewed medical literature of what we've been doing here at SBM since the beginning. We hope to do more.

But back to the study. Let's summarize its findings briefly. Basically, the authors, from Yale University, the University of Maryland, Johns Hopkins, and the Memorial-Sloan Kettering Cancer Center, did a structured review of studies published in 2014 selected for use of the following words in the title: overuse, overtreatment, overdiagnosis, inappropriate, and unnecessary. Results were limited to human studies and the English language and reviewed by the authors for relevance to overuse. The ten most relevant studies were selected, highlighted, and organized into the categories of overdiagnosis, overtreatment, and methods to avoid overuse. Here are the findings:

  1. There Is No Benefit to Screening for Asymptomatic Carotid Stenosis. The authors cited the USPSTF review that showed that screening for asymptomatic carotid artery stenosis leads to false-positive results. There is no evidence that it reduces stroke on the side where carotid blockage is found.
  2. Screening Pelvic Examinations Are Inaccurate in Asymptomatic Women and Are Associated With Harms That Exceed Clinical Benefits. The authors cite a review from the American College of Physicians that failed to demonstrate benefit of routine pelvic examinations in women who are asymptomatic.
  3. Head Computed Tomography Is Often Ordered but Is Rarely Helpful. If you've ever done trauma (as I did during residency and as a part-time trauma attending back in the late 1990s), you know that we order too many head CTs. The study cited didn't necessarily show that ordering the first CT is not indicated, but rather questioned the use of serial CTs, leading the authors to conclude that a second head CT scan "rarely affects patient management" and that "clinicians should be judicious in ordering multiple CT scans in the same patient," as only 4% of these CTs showed clinically significant findings that changed the medical or surgical management of the patient.
  4. Thyroid Cancer Is Massively Overdiagnosed, Leading to Concrete Harms. I discussed the overdiagnosis of thyroid cancer as part of a post about screening for cancer in general way back in 2008. Perhaps I should do an update focusing just on thyroid cancer overdiagnosis, which has many paralles with breast cancer overdiagnosis.
  5. There Is No Benefit to Paracetamol or Acetaminophen for Acute Low Back Pain. A large, double-blind, placebo-controlled clinical trial tells us so.
  6. Postoperative Opioid Use Continues Past the Postoperative Period. Basically, the authors cite a cohort study that showed that 3% of patients given a prescription for opioids after surgery are still taking them 90 days later. To be honest, I'm not sure I buy this one; undertreatment of pain appears to me to be more of a problem than overtreatment, at least in cancer patients.
  7. The Harms of Perioperative Aspirin Outweigh the Benefits in Patients Undergoing Noncardiac Surgery. The Perioperative Ischemic Evaluation-2 [POISE-2] trial tells us so.
  8. Renal Artery Revascularization for Renal Artery Stenosis Has No Clinical Benefit. There are several randomized trials that show that medical management does as well as stenting for blood pressure control and preventing deterioration of kidney function.
  9. Medications to Raise High-Density Lipoprotein Cholesterol Level Do Not Improve Cardiovascular Outcomes. A recent systematic review and meta-analysis supports this conclusion.

Another systematic review from earlier this year suggests that testing doesn't reassure patients; testosterone supplementation might harm patients (discussed here by me as a pharmaceutical company-invented diagnosis whose purpose is profit); inappropriate antibiotics use can cause C. difficile colitis (well, duh!); and that dramatic regional variations in surgical practice is driven largely by physicians.

So, yes, medicine has a lot of "housecleaning" to do. Here's the problem. His implication is that because medicine has problems with treatments that are not as rigorously evidence-based as they should be our focus on CAM is misguided and based on ideology rather than science. To this, I respond: Nonsense! I also like to quote Ben Goldacre at this point:

Similarly, just because big pharma misbehaves and conventional medicine practitioners don't always use the most rigorous evidence does not mean that, for example, homeopathy or energy medicine works, as Dr. Katz seems to believe they might. It's also worth pointing out at this point that the reason we tend to emphasize the pseudoscience that is much of CAM is because (1) there are plenty of others in medicine now calling out big pharma and insisting on more rigorous evidence and (2) CAM largely gets a free pass because the expertise needed to analyze CAM claims in light of science is not an expertise possessed by many physicians. In other words, SBM fills a gap in the movement to promote a more rigorous application of science to the practice of medicine. In addition, contrary to what Dr. Katz thinks, we at SBM can walk and chew gum at the same time. We can call out the pseudoscience of CAM and integrative medicine while we advocate for more rigorous science in all areas of conventional medicine.

Let's look at an example of how we do this.

In which I walk and chew gum at the same time

At this point, I feel as though I've flipped the script and, to an extent, changed roles with Dr. Katz. Last time, I criticized him for referring to his own medical authority (and awesome CV) over and over again in comparison, presumably, to us mere medical mortals who blog. Here, I am about to assert my authority on this issue, because, well, you know nothing, Dr. Katz, about what we here at SBM do aside from criticizing pseudoscience in medicine. Also, doing so serves the purpose of demonstrating that it is indeed possible to walk and chew gum at the same time, as hard as it seems for Dr. Katz to believe.

Near the end of his article, Dr. Katz pontificates:

Were I tasked with rebutting the very case I am making in this column, I would say: Well, the articles cited here are evidence that conventional medicine is policing itself, seeking ever more evidence and a higher standard. That is just what we would hope to see.

That is the best, and perhaps only argument for the defense, and might matter if it managed to thrive, but alas, it is stillborn. The simple fact is that the products of conventional medicine -- Big Pharma, Big Tech, and the associated patents -- are routinely promulgated, widely practiced, and massively reimbursed, often for years, before there is evidence to support them. Evidence to repudiate them comes after, and this despite our prime directive: first, do no harm. In stark contrast, the often kinder, gentler, but unpatented offerings of other domains are repudiated for years until or unless evidence comes in to exonerate them, and sometimes, even then.

In other words, the prevailing pattern is that "we" (i.e., conventional medicine) are innocent until proven guilty, but everyone else is guilty until proven innocent. No special olfactory acuity is required to discern how bad that smells.

One can't help but note that I discussed that bit of CAM allegedly "repudiated for years." Let's just say that Dr. Katz's take on the matter is…exaggerated.

And, yes, it is rather amusing that Dr. Katz writes so bitterly about medical practices that lack rigorous evidence using an article from a peer-reviewed journal that is about as mainstream as there is, JAMA Internal Medicine, pointing out that those very practices should be questioned in light of new evidence. Heck, I'll even concede that if Dr. Katz had written this article ten years ago, he would have had a point about medicine not being sufficiently vigorous at calling out and abandoning practices for which the scientific evidence is not sufficiently strong. Apparently, though, Dr. Katz is unaware that over the last several years there really has been a movement to do exactly what he says he wants done: To subject conventional medical practices to heavier scientific scrutiny and discard the ones that don't make the cut.

My example of this movement in medicine is an initiative from the Foundation of the American Board of Internal Medicine (ABIM) called Choosing Wisely, whose goal is to advance "a national dialogue on avoiding wasteful or unnecessary medical tests, treatments and procedures." It did this by working with Consumer Reports to challenge medical specialty societies in 2012 to come up with lists of medical practices that should be questioned in light of evidence. Thus far, over 70 medical specialty societies have done so. I like the Choosing Wisely initiative so much that I've written several posts about it, including one recent post pointing out how thus far Choosing Wisely hasn't had much of an effect on medical practice because changing entrenched practices is very hard.

In fact, I'll let Dr. Katz—and you—in on a little secret. (Actually, it's not really a secret, given that I've mentioned it before.) I spend a lot of my time doing exactly what Dr. Katz says we as physicians should be doing and working to improve the quality of care by making it more evidence-based. In fact, I am the co-director of a statewide collaborative quality initiative (CQI). We are 25-hospitals strong and looking to expand to more. Our mission is "to collect accurate data on women diagnosed with breast cancer in Michigan. We will collect demographic, diagnostic, treatment, and outcome data, and use this information to evaluate current standards of care and to initiate quality improvement efforts that will advance breast cancer treatments in order to improve patient outcomes."

Indeed, one of our quality initiatives is based on Choosing Wisely, specifically the American Society of Clinical Oncology (ASCO) guideline not to do advanced imaging (PET, CT, or bone scans) in patients with early stage breast cancer without symptoms suggestive of metastasis. The reason, of course, is that in this group of patients metastasis is so uncommon at the time of presentation that the false positives far outstrip the true positives, leading to the sorts of additional interventions that Dr. Katz is so concerned about, and rightly so.

Isn't this exactly what Dr. Katz says those of us criticizing him don't do in our ideological hatred of all things CAM? What, I ask, has Dr. Katz done to improve the quality of care in integrative medicine and make sure that what is actually being administered "on the ground" in the clinic (rather than in his ivory tower of academic CAM, where he seems oblivious to what naturopaths actually do, such as using homeopathy) is actually supported by science and evidence? I put my money (and career) where my mouth is when it comes to both conventional medicine and quackery, contrary to Dr. Katz's delusion otherwise.

Near the end, he sneeringly writes:

The cleanup will certainly not come courtesy of those calling themselves "science-based," who live within its glass walls, tossing stones outward. They produce nothing more useful than shards of glass.

It will come courtesy of those who concede, with suitable humility, that no single domain of influence has a monopoly on dirty boots. It will come courtesy of those who like a level playing field, and respect the potential for baby and bathwater in any given tub.

It will come courtesy of those who acknowledge that the blank in "_____ based medicine" has a long and rather unsavory list of applicants: profit; pharmaceutical; habit; preference; patent; turf; privilege; and status quo, to name a few. It is up to us to fill in that blank with a designation that is both desired, and deserved; both what we want, and what we actually do. That requires a much harder task than calling out the dirt on everyone else's boots. It requires a serious devotion to cleaning our own house.

Which is exactly what I am involved in doing. It is possible to walk and chew gum at the same time. What, I wonder, is Dr. Katz doing to make the actual medicine more science-based? In fact, I'll take it one step further. I have yet to see a single "CAM" organization or advocate like Dr. Katz take any serious, concrete steps to make their practice more science-based by abandoning treatments unsupported by evidence. The reason, of course, is that if they were to do that they would have to abandon most of the practices they want to "integrate" into medicine.

Dr. Katz's double standard

Dr. Katz's latest screed is very much of a piece with his previous screeds. Although I didn't want to at first, I ultimately considered it necessary to counter his criticism, even though I suspected Dr. Katz was trolling us, because his criticism is one that is directed all too frequently at those of us who criticize the infiltration of CAM into medicine and argue for science-based medicine. Basically, he is accusing me (and others, such as Steve Novella) of hypocrisy because we write so much about the pseudoscience and quackery that is being "integrated" into medicine in the specialty known as "integrative medicine" but, from his perspective, do not write about problems with the evidence base of conventional medicine. He is wrong on both counts, and I suspect that, even if 95% of the combined output of the offending blogs was about evidence and science deficiencies in conventional medicine and 5% about CAM pseudoscience and quackery, Dr. Katz would still focus like a laser beam on that 5%. As I've shown above, I do write about issues with evidence in conventional medicine—and not infrequently, either. Also, unlike Dr. Katz, outside of my blogging and other activism, I do far more to promote what Dr. Katz claims he wants to promote than Dr. Katz himself does.

As I and the other bloggers have said time and time again, the best medicine is medicine that has a firm basis in science. It doesn't matter whether we are referring to conventional, big pharma-produced drugs, surgery, or diagnostic tests or whether we are referring to anything that is considered "alternative," CAM, or "integrative medicine." We always advocate for a single, science-based standard of evidence for evaluating medical practices. Yes, I concentrate more on CAM and "integrative medicine." I make no apologies for that because I believe that I (and Steve Novella and company) fill a niche that is not well covered by those advocating a the more rigorous application of science to medical practice and also because most physicians are genuinely unaware of just how much pseudoscience has infiltrated—excuse me, been "integrated" into—conventional medicine. Moreover, This integration of quackery into medicine in the form of what we like to call "quackademic medicine" is in itself a double standard, allowing into medicine treatments that someone like Dr. Katz would never approve of if they had been developed by big pharma or medical device companies. Just look at his conspiracy mongering about "big food" and "big pharma" conspiring for big food to profit by making people sick and then to have big pharma profit by treating those sicknesses, if you don't believe me.

Dr. Katz is correct that "if evidence matters, it matters equitably, and universally." We don't argue with that at all. In fact, we not only agree with that statement, but we champion it in word and deed. If only Dr. Katz would do the same, instead of advocating a double standard whereby pseudoscience and quackery can be integrated into medicine using a standard of evidence that he would never accept for any other medical treatment.


More like this

Dr. David L. Katz is apparently unhappy with me. You remember Dr. Katz, don't you? If you don't, I'll remind you momentarily. If you do, you won't be surprised. Let me explain a bit first how Dr. Katz recently became aware of me again. A couple of weeks ago, I posted a short (for me) piece about…
Dr. David Katz is undoubtedly a heavy hitter in the brave new world of "integrative medicine," a specialty that seeks to "integrate" pseudoscience with science, nonsense, with sense, and quackery with real medicine. In fairness, that's not the way physicians like Dr. Katz see it. Rather, they see…
David Katz doesn't much like skeptics, particularly those of us who question the value of "integrative medicine." In fairness, I can't say that I much blame him. We have been very critical of his writings and talks over the years to my criticism of his statement advocating a "more fluid concept of…
If there's one lesson that I like to emphasize while laying down my near-daily dose of Insolence, both Respectful and not-so-Respectful, it's that practicing medicine and surgery is complicated. Part of the reason that it's complicated is that for many diseases our understanding is incomplete,…

The cleanup will certainly not come courtesy of those calling themselves “science-based,” who live within its glass walls, tossing stones outward. They produce nothing more useful than shards of glass.

It will come courtesy of those who concede, with suitable humility, that no single domain of influence has a monopoly on dirty boots. It will come courtesy of those who like a level playing field, and respect the potential for baby and bathwater in any given tub.

Dr. Katz needs to go to rehab for metaphor abuse.

It will come courtesy of those who concede, with suitable humility, that no single domain of influence has a monopoly on dirty boots.

Well, there is certainly a lot more to be done about cleaning "mainstream" health industry.*
As an example, as I understood it, the FDA is now asking for studies intended to be part of a drug approval process to be registered at start, in a public-available database, so there is less risk of someone doing 20 studies and showing only the single one clearing p=0.05.
We are still lacking such a provision en European regulatory policies.

OTOH, Dr Katz' writing samples read like they could be summarized as "No, you are!".

* where exactly mainstream ends and alt-med starts is left for another debate.

By Helianthus (not verified) on 19 Nov 2015 #permalink

David Katz infuriates me because he makes gestures toward genuine problems in the U. S, healthcare system, then derails the discussion by citing the wrong key exemplars, and the wrong causes, all in an attempt to backdoor justification for alt-med 'modalities' that don't actually address the specific issues he cites, much less the real loci of systemic failure in conventional practice, or their causes. He misdirects energy we need to fix things into making them worse.

I'll stir the sbm advocacy pot by agreeing that there would be more benefit to be gained by conventional medicine 'cleaning its own house' than by whacking at quacks. However, I want to take issue with what Katz and Dr. G. are mainly taking as the mess that needs cleaning: i.e. 'unsupportable standard forms of care'. To use the terms of Goldacre's metaphor, flaws in aircraft design (poor use of science in conventional care) aren't all thatbig a part of the mess that needs cleaning. It's more a case of bad airline management delaying scheduled maintenance, plotting crazy route patterns and unrealistic schedules, and over-working the crews. The 'design' issues are not trivial, and SBM is indeed to be lauded for addressing them. But, overall, weak science has only a minor role at best in the problems within mainstream care that help push consumers toward woo. I'd rephrase Goldacre's bon mot more like, 'just because badly run airlines leave you stranded doesn't mean magic carpets get you anywhere." The big mess in the house of conventional medicine is composed of bad administration and poor application of scientifically sound medical principles.

Science-based medical practice is hamstrung when over-scheduled PCPs MUST limit patient appointments to no ore than 15 minutes, when the system is so fragmented by specializations and hospital staff rotations that one provider has no idea what another knows about the patient, when the centralized regimes of insurance companies and medical groups provide physicians with no resources to 'treat the whole patient' as a human being in a valid and effective manner.

In the thread about this on SBM, Petticoat Philosopher hit the nail on the head: "doctors can give 'lifestyle' advice until they're blue in the face but it won't make it any more possible for some patients to comply with it." For now and the near future at least, identifying valid and effective means of treating 'the whole patient' will need a different standard of evidence than the bio-physical sciences rightfully demand, though 'fluid' has nothing to do with it. The more any bio-physical-scientifically-sound treatment relies on behavioral change by human subjects, the less a rigorous science of double-blind controlled experiments can gauge it's effectiveness. We're off the turf of medical science, and onto the terrain of clinical psychologists, social workers, educators, communication experts and the like. Good work in these fields is indeed evidence-based. It's just that this evidence isn't the conclusive, quantifiable stuff of the hard sciences. It's more the sort of evidence used academically by historians, field-work-based sociologists and cultural anthropooglists, semioticians... the humanities in general. It's as wrong to ignore or underestimate the complexity of the mind – to attend only to physiology or treat the mind as if it acts like a physiological disease or treatment – as is to imagine the mind can heal physiological disease via some mechanism of magical 'energy'. Science advocates rightly trumpet the record of successes in the 'hard' sciences. In contrast, attempts to model the study of what human beings do on the methods of the hard sciences have yielded virtually nothing but failure.

Anyway, in stirring this pot, I don't mean to suggest the contributors at SBM ought to be sacrificing their critiques of pseudo-science or bad conventional science in favor of advocacy for systemic reform of medical-delivery institutions. For one thing, that's not really their field of expertise. I'm not going to argue that there's anything wrong philosophically with the notion 'we should attend to the greater harm' – no doubt the world would be a better place if we all could find some way to do that. But people just don't work that way. We seem to be hard-wired to pay more attention to the issues defined by our more immediate spheres of everyday life. Thus, the critique that there are more important fish to fry applies to the vast majority of human concerns. Who among us is immune to calls to move our focus up the ladder to more crucial issues? Certainly not David Katz. If cleaning house in conventional medicine is more important than smacking back at quacks, it pales in significance to the problems that blare at us from the daily news pages – climate change; war; persistent racism, economic exploitation and inequality; police shootings; a dysfunctional education system; broken political systems... Donald Trump and Ben Carson being the leading presidential candidates of one of the two major parties in the most powerful nation on Earth... Just as we can almost always face criticism to go up the ladder of 'significance', we can almost always defend ourselves by looking down the same ladder. How could I criticize SBM for devoting time to attacking quackery while I spend any part of my time caring about what team wins football or basketball games, or why Hollywood movies suck?

As far as I'm concerned, anyone working to lessen significant harms experienced by real people is on the right side of the moral bell curve. Just because there may be worse wrongs than those inflicted by cancer quacks, what happened to Makayla Sault, for example, is just too wrong to expect an oncologist to substitute some other concern. Someone needs to stand against the victimization of the vulnerable by sCAMs, and if David Katz has a problem with that, as far as I'm concerned, he can go f*** himself. There are things to critique at SBM. The mission isn't one of them...

Katz is just full of substitution/deflection tricks. He writes:

the blank in "_____ based medicine" has a long and rather unsavory list of applicants: profit; pharmaceutical; habit; preference; patent; turf; privilege; and status quo.

That's true, of course, and the influence of many of those things have contributed mightily to the healthcare mess. But just because "applicants" come from certain broad categories doesn't mean any of them have actually secured the position. And Katz' use of terms is too general, whose profits, habits, preferences, privilege are involved? Which status quo? Katz, of course, backdoors the usual suspects to take the blame for evidentially weak standard practices, leaving out the institutional problems and the complex web of profits, habit, preference, turf, privilege and status quo behind the actual Big Problems in healthcare:

I am not conspiracy-theory minded, but it's hard to resist the macabre fantasy of Big Food and Big Pharma behind closed doors, concluding: It's a deal. We will profit from causing the disease, you can profit from treating it -- and everybody wins! Everybody except the public, that is.

Since he passes this off as "macabre fantasy" he doesn't have to offer any evidence that the questionable standard practices he cites ("excessive zeal for cancer screening", "overuse of CT imaging of the head", "a common tendency to over-prescribe narcotics for extended periods of time", "hormone replacement at menopause" etc.) are driven by the likes of Monsanto and Merck, or that they're such an important mess that cleaning them ought to be a top priority, much less that any of this is an argument for CAM in any way whatsoever. (Hey, Dr. Katz, where does YOUR funding come from, anyway?)

I have to resort to anecdotal evidence here, but I consider my medical experiences and those of the various otherwise-unconnected folks I come into contact with to be fairly typical. Its seems to me that almost everyone I know has experienced, as have I, some sort of conventional medicine horror story: missed diagnoses, misdiagnoses, wrong prescriptions, and, of course, 'your insurance doesn't cover that'. I was going to say that none of these disturbing tales involved anything like implementation of a treatment that lacked a proper basis in scientific evidence. But then I remembered one sketchy thing that happened to me, and I'll spare you the details and merely note that it so paled in comparison to the other stuff that it wasn't at all prominent in my mind...

Katz has the juice to address the real problems in health care, the failures having nothing to do with 'science' that leave people abandoned, hurt, dead, and he pours it all into pimping for 'Integrative Medicine'? I read his stuff – diet, prevention, popular quackery – and what he sounds like to me is naturpathy-lite. I just learned via the Google that he was "nominated for the position of U.S. Surgeon General in 2009 by the American College of Physicians, the American College of Preventive Medicine, and the Center for Science in the Public Interest, among others" (U.S. News and World Report). Who's writing this script – Ionesco? Jarry? Philip K. Dick?

I don't think Katz could win in a 5th grad science fair...but he could sure lull the judges to sleep with his long-winded hand waving as to why it's not just "science".

By Chris Hickie (not verified) on 19 Nov 2015 #permalink

The fluidity of woo. Ha ha ha.
Yeah, but he keeps pouring it on anyway.

Oddly enough, I heard about details of the JAMA article ( esp 1. and 2). from no-less a critic of SBM ( and all things reasonable) than Gary Null a few days ago @ In addition, SB doctors treat DCIS, he opined, even when not all cases progress to a more serious condition. So what should they do, oh Grand Master Woo**, give patients daily doses of vitamin C at 5000 to 20,000 mg per day? No wait, that's for people WITHOUT any discernable problem. Cancer patients might get 100,000 per day so halve the difference I suppose.

The fact that SBM is already discussing and studying these issues considerably deflates Katz's balloon. I think he just wants to carp about the imperfections of SBM when he himself advocates for NDs and homeopathy which are perfectly non-evidence based..

And don't worry Orac, you needn't fear aneurysms and heart attacks too much- after all, you regularly read AoA and have thus far, survived. Think of reading woo as an alternate cardio workout.

** who practices/ practises medicine without a license/ licence and any sense. We'll soon be hearing more about his latest venture enabled by woo-friendly practitioners in Texas.

By Denice Walter (not verified) on 19 Nov 2015 #permalink

Or has been commented before, "Get the mote out of your own eye, SBM, before you go mucking about with my beams!"

By Mephistopheles… (not verified) on 19 Nov 2015 #permalink

I don't think you need to make any defense. It's akin to having to defend fighting poverty in Haiti vs India just because India has more people. Regardless, I consider you fight one of mainstream medicine's issues every time you argue against the false science that is integrated medicine.

What CAM adds to the equation reminds me of pollution. If there are many established factories polluting a river, you don't fix the problem by creating co-ops that add pollution to the river as well. As a patient there is enough crap to wade through in doctor's offices - there is no need to add more to the pile.

By Not a Troll (not verified) on 19 Nov 2015 #permalink

Yes, Katz seems oblivious to all the quality assurance/improvement work in which evidence-based physicians participate on a routine basis.

"What, I ask, has Dr. Katz done to improve the quality of care in integrative medicine"

Good question. While citing mainstream medical studies that critique mainstream practices, I wonder if he could point us to comparable studies in which wooists partake in self-criticism? Or list the therapies which woo practitioners have discarded along the way because they were useless and/or harmful?

What quality initiatives do homeopaths participate in? Are reiki practitioners supporting comprehensive reviews of their work?

By Dangerous Bacon (not verified) on 19 Nov 2015 #permalink

I think that woo-sympathists provide data about SBM's shortcomings purely as a distraction -in other words:

"Don't look at us - THEY perpetuate all of these evils!"

An over-arching search for evidence subsuming BOTH woo and SBM is most likely far beyond their ken.

By Denice Walter (not verified) on 19 Nov 2015 #permalink

Dr. Katz reminds me of that one troll on here. What was his name? zebra?

Isn't what Dr. Katz is doing known as the tu quoque logical fallacy?

DB wonders if Katz could list quality initiatives among wooists, discarding things that were harmful. Well, acupuncturists used to stab their patients with big nasty shivs, which they eventually dumped in favor of tiny little needles, and now with accupressure and acutoothpicking they don't need any kind of body penetration at all to tweak the qi along the meridians. Since Big TCM wants in on 'Integrative Medicine', and needs some kind of science cover they can publish in paid supplements to Nature to get there, I wouldn't be surprised if new studies try to explain the results of sham acupuncture by revealing that hitting acupoints is no longer necessary because some quantum-physics thing has led to homo sapiens evolving to the point where our qi is dispersed everywhere on our bodies, not just along meridians. How else to explain the efficacy of TT and Reiki? It's all progress and refinement in acupuncture!!

But seriously, I'm guessing Katz' line is that "Integrative Medicine" will require self-criticism, quality initiatives and 'choosing wisely' for it's 'complementary modalities' once they're fully brought under the umbrella of legitimacy and somebody gives leading Integrative Medicine researchers like David Katz a boat-load of money to do the necessary 'studies' that will properly guide those efforts, you know, 'scientifically'. At least as verified by PubMed cites from the supposedly respectable journals that have already accepted 'acupuncture works!' studies so poorly controlled they make my head spin...

@Dangerous Bacon #8:

What quality initiatives do homeopaths participate in?

Well, they do their very best to not imperil the purity of lactose tablets.

By Rich Woods (not verified) on 19 Nov 2015 #permalink

Todd: I think you've managed to insult both Katz and zebra by comparing the two...

I assume your question about tu quoque was rhetorical. Katz actually goes beyond tu quoque as his claim is less 'you, too' than 'it's you, not me!'.

In any case tu quoque is what's called an "informal fallacy" meaning, well, it's not really a fallacy per se, but a rhetorical strategy that be used disingenuously in an attempt to undercut a valid argument. Tu quoque is also called 'appeal to hypocricy' which is perfectly germane if you're calling out someone who actually is a hypocrite. Like all ad hominem attacks, of which tu quoque is considered a subset, it doesn't disprove anything the person being attacked has said, but it doesn't claim to do that, only to question the integrity and credibility of the source, flagging the argument for further inquiry into potentional flim-flammery. It's not like Orac never drops some ad hominem on the quacks, but then they really are untrustworthy asshats.

If invoking tu quoque is done without justification, that's scummy, but not in and of itself fallacious, though it may be hung on some other enabling fallacy, such as a straw man version of the opponent.

Anyway, for heuristic purposes, the exchange here can be reduced to:
SBM: Katz advocates treatments that have no support in valid evidence.
Katz: No. You ignore the evidence against some conventional treatments, and I have evidence for everything. Because 'fluid'.

Now, I'd say the fluid in question is Dr. Katz pissing on rational standards of evidence. But that's just me, and the ACP hasn't nominated me for Surgeon General, I don't run a prestigious clinic at Yale, I'm not a 'health editor' for HuffPo, and I'm not a regular guest on The Dr. Oz Show and the Oprah Network. So what do I know?

Katz's insistence on SBM "cleaning its own house" puts me in mind of Uri Geller. "Look over there, while I bend the spoon with my hands over here."
The difference is that Geller pretended that his trickery was mystical, while the naturopaths and their kin take their mysticism and pretend it's science.
(PS: my spellchecker wanted me to replace "naturopaths" with "osteopaths". Even my browser has a sense of humor.)

By Old Rockin' Dave (not verified) on 19 Nov 2015 #permalink

Quoth Dr. Katz about SBM types:

They preferentially malign all alternatives to conventional medicine, implying that problems of evidence and its application lie entirely without, and not within.

.... uhhhh .... WHAT?!

By palindrom (not verified) on 19 Nov 2015 #permalink

@Sadmar (#13):
Well said!

By Derek Freyberg (not verified) on 19 Nov 2015 #permalink

So Katz's argument is that Medicine should be more like CAM and never acknowledge its faults, because if you don't admit them then they don't exist.

Talking of real medicine's more shameful cockups, who on Earth still licenses this quack as fit to practise?

Oh, and just to prove to Katz us nasty Earth-bound realists aren't completely anti-sCAM, let me propose the following all-natural integrative cure for that which currently ails him:

Complementary and Alternative Treatment for Burning Butthurt


1 large bucket of baking soda
1 large bucket of vinegar
1 large-capacity enema kit

Instructions for use:

Insert ingredients up the old bunghole, succuss vigorously, and look at the moon.

@ Old Rockin' Dave

PS: my spellchecker wanted me to replace “naturopaths” with “osteopaths”. Even my browser has a sense of humor.

Mine goes for "naturalists".
Closer but one diphthong away from "naturists". Which brings back to mind the story of the "Emperor's new clothes".
Our spellcheckers may be smarter than we think.

By Helianthus (not verified) on 20 Nov 2015 #permalink

Checking naturopaths in three different spellcheckers: 2 osteopaths and 1 neuropathology.

Strangely the neuropathology suggestion comes from what seems to be the best of the three spellcheckers.

By jrkrideau (not verified) on 20 Nov 2015 #permalink

I was amused to see Katz also posted a gushing review of his own book (presumably identical to the Huffpo one) on Amazon. It has been removed from but can still be seen at the UK site I linked to.

What kind of person writes the following about their own work?

I love a good epic adventure, and had a great deal of fun reading reVision- falling in love with several characters along the way. But I also finished with a sense of illumination from a deep source - and the gift of fewer shadows in my corners. The most opportune comparison may be to truly great wine. There are depths and complexities to reward those inclined to seek them. But there is also a great and simple pleasure, readily accessible to all.

By Krebiozen (not verified) on 22 Nov 2015 #permalink

On the U.K. Amazon site you can get Katz's "The Flavor Point Diet" for the remarkable price of £0.01.

Hurry before they're all gone!

By Dangerous Bacon (not verified) on 22 Nov 2015 #permalink

What kind of person writes the following about their own work?

When someone reveals that combination of conviction in his own genius, shameless self-promotion, contempt for criticism and blithe disregard for ideas of integrity, nothing coming out of his lab is of any value to anyone... any given research result might be valid, not made up to confirm a hypothesis, but you won't know until you replicate it yourself.

By herr doktor bimler (not verified) on 22 Nov 2015 #permalink

Dr. Katz goes on ,and on, about articles like the one JAMA advising against some current practices in the light of new evidence. This kind of advice appears every year. When does a homeopathic or other woo-woo journal ever advise against a current practice in the light of new evidence?NEVER. No matter how much evidence of the highest possible quality there is that something doesn't work, no corrections or changes are made. No advisory. EVER. Alternate practice has never made a mistake! This is the real meaning of Dr. Katz' "different criterion of evidence":NO evidence is ever needed because WE ARE ALWAYS RIGHT. This is his real standard of truth:It's true if I feel like it.

By DanielWainfleet (not verified) on 22 Nov 2015 #permalink

Some of this CAM and naturopathy bashing is a serious "diss"ervice to cancer patients. Both regular MDs and NDs alone, typically represent severely incomplete offerings for cancer treatment. Current cancer results for "regular medicine" alone are often nasty, brutish, short and expensive.

Nevertheless both groups, collectively, offer substantial resource pools, and literature, to draw upon. For those able and informed enough to improvise, these can provide complementary bases, to substantially improve both length and quality of life even in dire situations. One bashing or ignoring the other, deprives patients of combined technologies that likely could produce a much better result.

I don't think regular medicine has had a clue about how to personalize cancer treatment in a timely and cost effective way in my neck of the woods to deal with mCRC. "I shop a la carte a lot cheaper than thou" with better results.