My pseudonymous colleague Orac makes it part of his mission to lampoon "alternative medicine" wherever he encounters it, so this may well piss him off: For the last several weeks, I've been taking a daily dose of pseudoscience. Why? I blame the medical establishment, but you're going to have to click below the fold to find out why.
As I've mentioned here several times, back in January, I started having very bad heartburn more or less constantly. After a couple of visits to my doctor, I was referred to a gastroenterologist, who scheduled an endoscopy, and then proclaimed that I have "gastro-esophogeal reflux disease," or "GERD."
What does that mean? It means that I have very bad heartburn a lot. Why? Good question. I'd love to hear a good answer. It's apparently just one of those things. Take some pills, and it'll go away, or maybe it won't. Tough to say, really.
This is, as you might imagine, intensely frustrating, probably more so for someone who is a scientist by training. Even in a complicated system like the human body, I expect events to have identifiable causes, and the notion that I could go from having no real stomach problems to having very bad heartburn all the time essentially overnight without there being an identifiable cause is just maddening. Still more annoying is the fact that the gastroenterologists aren't particularly interested in trying to identify a cause-- it's just one of those things, shut up and take the pills.
The core problem here is that "GERD" is a description not a diagnosis. Well, it's a little more than that-- they can explain the mechanism by which acid gets out of the stomach and causes heartburn-- but it doesn't provide the sort of information about causality that is the common connotation of "diagnosis." There really ought to be another word for this sort of thing, where they clump together a group of common symptoms, assign an acronym, and call it a day.
There probably is some sort of specific cause. Or, rather, some collection of causes, since it's not clear that "GERD" really is one thing, rather than a collection of generally similar conditions. The advice they gave about diet and behavior was really hit-or-miss (more miss than hit, really), and the literature is loaded with "may"'s, which suggests that there are different things going on. Heartburn may or may not be triggered by food containing garlic, and the "may" and "may not" groups of people probably have slightly different things going on. But figuring out exactly what's going on is too complicated, so they get lumped together in a single condition.
(I should note that, in the grand scheme of things, this is not a terribly important condition. It's not debilitating, just very, very annoying. If somebody's going to sink a lot of effort into teasing out fine biochemical distinctions between similar but related conditions, I'd rather they do it for cancer or AIDS-- I'll live until they get around to GERD.)
This is the sort of situation that leads very easily to pseudoscience. A good chunk of the advice I got from actual doctors was little better than folk medicine, anyway, so why not try other things? In particular, a lot of people swear by eating yogurt as a heartburn cure, attributing the benefits to the bacteria. Now, I personally find yogurt disgusting, but they sell the bacteria in capsule form, so why not?
Does it work? Enh. I've felt pretty good the last several weeks, but things had started to improve before I started taking the pseudoscience pills. Is there a causal relationship between my relative lack of heartburn and the pills? Tough to say, really. They didn't make things worse, though, and I already paid for the bottle, so I'll keep taking them for a while longer.
The real issue here is the difference between acute and chronic conditions. Modern medicine does a really good job with acute conditions, things that have an obvious and immediate cause that can be treated directly. Those successes lead people to expect something similar for all medical problems, but there are a large number of chronic conditions that modern medicine just isn't equipped to deal with at the moment. In addition to the recent heartburn thing, I've had intermittent back trouble for years (owing to bad posture and playing rugby in college), and there's not a lot that can be done for that, either.
Given a chronic condition that's sufficiently annoying, and a medical response that amounts to a great big shrug, it's natural for people to end up trying other things. And some of those things are bound to work for at least some of the people who try them, whether because of some actual beneficial property of the treatment applied or through the magic of the placebo effect. Which is how you end up with Ph.D. scientists taking non-FDA-approved capsules for stomach problems (which, I might add, were recommended to me my several other people with Ph.D.'s). It might work, and probably won't hurt, so why not?
Does this mean that I think Orac is a Bad Person for bashing on "alties"? No, because there's a point where advocacy of "alternative" therapies crosses the line from "why not?" to "dangerous fraud." It's roughly the same as the line between "acute" and "chronic" as I used the terms above. If you've got stomach problems for some unidentifiable reason, there's nothing wrong with trying a few folk remedies in tandem with conventional treatment (I'm not sure the Nexium is really doing much good, but I'll keep taking it, too). If you've got stomach problems because you've got cancer, skipping chemotherapy in favor of vitamin C pills is foolish. Telling other people that vitamin pills will cure cancer is irresponsible, and telling them that they should skip chemotherapy in favor of vitamins is criminal.
But I can't help having some sympathy for people with chronic conditions who reach out for other sources of relief.
(I wound up writing this post now because of a spot of excitement last week, in which Kate suffered bad stomach cramps and diarrhea, badly enough to require a late-night run to the emergency room. She's better now, and the preliminary diagnosis is "colitis," which means "inflammation of the colon leading to bad stomach cramps and diarrhea." What causes that? Good question. It's apparently just one of those things...)
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My wife has lupus. Er, no, wait, the marker for lupus only showed up in one blood test, but not subesequent ones, and the joint inflammation never went away. So, maybe it's rheumatoid arthritis, except that the blood markers aren't there, and it doesn't seem to cause joint deformation. Well, she's got psoriasis, and some people with psoriasis get inflammatory arthritis, too, right? So, we'll just call it psoriatic arthritis for the moment. How shall we treat it? Well, it turns out that hydroxychloroquine, which treats malaria, makes a lot of inflamatory arthritis better. Why? No one knows, and of course even though it helps with the joint inflammation, it makes the skin rash from psoriasis much worse. All makes perfect sense, right? Give her something for the rash, mark the treatment as successful, and on to the next patient.
Modern medicine seems to understand just about nothing about autoimmune diseases.
From a med-chem perspective, I'd call the idea of bacteria for GERD "unproven", rather than "woo".
Now, if you were putting magnets on your stomach or taking homeopathic distilled water or something, that would be a different story. No one's ever gotten those things to work under any kind of controlled test (that I'm aware of) and there's no proposed mechanism for them that doesn't devolve into hand-waving.
But gut flora can have a demonstrated (though as yet poorly understood) effect on gastrointestinal health. Whether this affects GERD, which is rather upstream of where most bacteria can hang out, or whether the bacteria you're taking are the right kind to affect it, I don't know. But it's not prima facie loony, and I wouldn't consider clinical research on the subject to be a waste of money.
Ugh this is all so true. I was diagnosed with colitis, they prescribed medication that didnt help. Then more. Then some more that actually made my problem worse. Then a blood test, no IBD markers. New diagnosis, IBS. Not much we can do for you, good luck with that.
So what do I do? Walk the woo border. I take a ton of citrucel a day, it significantly helps. What next? Acidophilus? Peppermint pills? What works? no one knows. It's all guesswork. But i haven no other options.
Read the literature you get with the drugs (especially if your pharmacist doesn't pull the really technical one for his use before dispensing) for drugs for any number of conditions: GERD, depression, insomnia, restless leg syndrome (famously described by someone I've willfully forgotten as the inability to keep one's legs still and more bad manners than a medical condition; having suffered from not only the sleep disruption but odd, twisting, somewhere-between-tickling-numbness-and-a-charley-horse sensations that make me want to dig my leg muscles out with a combat knife, I really wanted to give the guy a swift kick somewhere sensitive), etc. and so on. In fact, the first drug I was prescribed for RLS was a minimal dose of a drug for Parkinson's disease that not only isn't medical science confident how it works on RLS, it doesn't even have a "believed to" statement about its effects on Parkinson's! I'm not saying it doesn't work--trust me, like my GERD medicine, it's very clear when I forget to take it--but medicine still has that aura of perfectibility that so many people transferred from religion to science (and came away sorely disappointed when progress wasn't automatic and painless, when doubt remained and when their perfection wasn't confirmed) and, reasonable or not, I'd expect someone would have to write something about what happens before selling the drug!
"There really ought to be another word for this sort of thing, where they clump together a group of common symptoms, assign an acronym, and call it a day."
I think this is roughly the meaning of "syndrome".
This is interesting to me, because I'm a retired physican (after I got my undergraduate degree in physics), because I used to have heartburn when I was overweight, and because ordinarily you're so good at analyzing things, Chad, but here your analysis is terrible, with overgeneralizations and rationalizations that may make sense to you, but that doesn't make them true. Is it because this is personal? Consider these:
"the notion that I could go from having no real stomach problems to having very bad heartburn all the time essentially overnight without there being an identifiable cause is just maddening."
Ah, the youth have no idea what they're in for. They almost do intellectually, but not emotionally.
"There probably is some sort of specific cause."
So why isn't that your stomach acid gets into your esophagus when you lie down a sufficient cause? It's an utterly mechanical problem, one I'm surprised a physicist isn't seeing as such, the end result being a matter of how much acid you have in your stomach, how tight your gastro-esophageal junction is staying, your body's posture, and how much irritation your esophageal lining can take before you feel pain. Bacteria probably have no place in that, though that's what everyone used to think about ulcer disease. Then it turned out that holes in one's stomach or duodenal lining were often the result of a specific infection, and cleared up if that infection were cured. Hallelujah! A magic bullet! But not everything goes away with a bullet, no matter what kind of ammunition people sell to suckers. It's like PT Barnum will live eternally seeling things to help people's fears and frustrations.
"but it doesn't provide the sort of information about causality that is the common connotation of 'diagnosis.'"
- Says who? Most causes of cancers and organ dysfunction are just as multifactorial. This is such sour grapes.
You're obviously someone who has been successful with relying on your intellect to get by in life. So I imagine that's why you make a sweeping indictment of medicine when it comes to chronic conditions, based on your disappointment that your doctors aren't telling you what you want to hear. I think there should be a special health plan for those of us who want to understand so much, staffed by doctors who will patiently go through what medicine really does know that patients can use for emotional support, if not physical palliation. It would be costly. Even then I'm sure most patients would decide things on their own, to be their own doctor to some degree. People are free to do that.
So how much weight have you been willing to lose to get rid of your heartburn? Maybe it will take something worse to motivate you to be as healthy as you can be. Heartburn wasn't enough to do that for me, but eventually more comes along. Most of us are disabled before we die. It teaches many of us lessons, and one lesson is that it's not all the fault of those guys who were supposed to keep me feeling 30 forever.
So how much weight have you been willing to lose to get rid of your heartburn?
Well, I lost fifty pounds between the beginning of January and the end of May, and it only got worse. In fact, I didn't start having problems until after I started trying to lose weight for other reasons. I think I'm done with that experiment...
My weight has been more or less steady since May (I'll probably post the graph at some point), but the heartburn didn't significantly improve until mid-July. So weight loss wasn't the key, but thanks.
"So weight loss wasn't the key, but thanks."
But that's a difference between medicine and physics. In physics one can make more substantial inferences about changing a variable and seeing that little happens quickly.
In medicine, any good doctor who has the time to tell you will tell you that of course weight is important for heartburn. It's an unavoidable factor in the mechanics of what pushes stomach acid up into the esophagus. Like arthritis, like a lot of things, once there is inflammation someplace, a patient will have persistent symptoms even when the mechanical stresses on the symptomatic area have lessened. Once the irritation has died down, taking months for many conditions, then the tissue is not so sensitive.
I'd bet you that you'll have less heartburn over the next 10 years if you're around your ideal weight than if you're heavy. Of course there's no way to do that experiment. Even if you have a twin who wants to pick either condition you don't, that's not a large enough number of subjects to measure an outcome, unlike a physics experiment where you can measure and control everything.
Everyone can be their own doctor, but I don't think there's a human being alive who can be rational in that, no matter how hard they try. It's not that we're ignorant. It's that we're biased and biased in subtle ways. So it helps to listen to people whose biases are different.
Chad,
Do you know how to swallow air? (It's a techique I learned in grade school in order to be able to produce horrendus belches when desired.)
I find that if I swallow a bit of air when I'm getting a bit of heartburn, it almost immediately makes things feel better. Maybe it's just a pocket of air at the top of the stomach keeping the acid from hitting the esophagus, but it does seem to help a bit.
You might give it a try (and even if it is woo, it's unlikely to be detrimental).
Man, just be glad that you don't have consumption.
In medicine, any good doctor...
Want an easy way to tell a crappy doctor from a possibly-useful one, in these days of "obesity epidemics"? The bad ones think that being fat causes everything, and losing weight will cure everything.
Find yourself a doctor whose first response isn't "lose the flab, porkroll", and you might just have found one whose diagnoses weren't handed to him/her along with a sparkly pen and an invitation to a swanky "conference".
Derek Lowe:
From a med-chem perspective, I'd call the idea of bacteria for GERD "unproven", rather than "woo".
Now, if you were putting magnets on your stomach or taking homeopathic distilled water or something, that would be a different story. No one's ever gotten those things to work under any kind of controlled test (that I'm aware of) and there's no proposed mechanism for them that doesn't devolve into hand-waving.
I wouldn't really call the bacteria thing "woo" either, though it stops short of scientific. I think the basic path is the same, though. I'm not going to start swallowing magnets or drinking homeopathic water because, well, I know something about basic physics, but someone with less scientific background might well find those things plausible. At least enough for the placebo effect to work.
DavidD: I suspect that we're actually in violent agreement about the facts, and just differ in the interpretation we put on them. I agree that there are multiple contributing factors that are not well distinguished, and that accounts for why different people have different results. The difference is that you're comfortable with "it's complicated" as a diagnosis, but I feel that the diagnosis is underdetermined.
I got a little snippy about the weight thing because as far as I'm concerned, trying to lose weight was where the whole thing started. I had already dropped a good ten pounds when I started having heartburn, and the next forty-odd didn't do a bit of good. I was happy when I was fat; or at least my stomach wasn't giving me trouble.
But it's gotten to the point where I bore myself talking about the details of my stomach problems, so I'm not going to keep going on about it. The main point here is more about the psychology of people presented with this sort of frustrating diagnosis (my "GERD" or Kate's "colitis") than about the specifics of my case.
It's called GORD over here. There's a fair bit of evidence-based information about. Try googling cochrane gord or prodigy gord to get started. Probably not a lot of help but informed pain is a lot more interesting than, er, ordinary pain.
Had a grim laugh at DavidD's comments about ageing. Ha, these kids don't know anything do they!
Just wanted to chime in and agree with Derek-probiotics are definitely not "woo", although I don't know of any solid proof of their efficacy. Since they are essentially food, there's no testing required for sales, and of course, advertising is what it is. Many people have anecdotes, and some labs have worked on studies to show that ingestion of probiotics alters the flora (the bugs in your gut). Obviously there's lots of hype, but unlike a lot of alt med, this stuff actually has solid bacteriology to support the hypothesis.