Do you believe in magic in medicine?

Sometimes, between blogging, a demanding day (and night) job doing surgery and science, and everything else, I embarrass myself. Sure, sometimes I embarrass myself by saying something that, in retrospect, I wish I hadn’t. More often, I embarrass myself by letting things slide that I shouldn’t. For instance, when friends send me a prepublication copy of their books, I should damned well read them, don’t you think? So it was that Paul Offit sent me a copy of his latest book, which just hit the bookstores and online outlets this week, Do You Believe in Magic? The Sense and Nonsense of Alternative Medicine, and I haven’t finished it. Oh, I’ve read a good chunk of it, but it’s not a huge book (around 335 pages); so I should have finished it by now, particularly since it’s quite good. However, my personal laziness (or lack of ability to prioritize) aside, I’m glad to see that the book’s getting attention in a large media outlet, namely USA Today, in an article by Liz Szabo Book raises alarms about alternative medicine. There’s also a companion piece How to guard against a quack. One of the people interviewed in that article might seem a wee bit familiar to regular readers of this blog.

People interviewed aside, it always warms the cockles of my heart when a major media outlet writes a (mostly) skeptical article about alternative medicine. I credit that to Dr. Offit, whom I consider a friend even though I haven’t actually met him in person yet (although I have spoken on the phone with him about various issues a few times). It makes me wonder if I should write a book myself, although I’m not sure that the angle I’m interested in would be as marketable as how Dr. Offit did it; it might well be too wonkish and hardcore. Be that as it may, I congratulate Dr. Offit for his achievement. What I’ve read so far is really good. The USA Today article is also, by and large, skeptical. At least, it’s more skeptical than most. I must admit that it did irritate me that Szabo ended up finishing the article with a quote from the Queen of Quackademic Medicine—excuse me, I mean the director of the “integrative” medicine program” at Memorial Sloan-Kettering Cancer Center saying:

Yet Cassileth, author of The Complete Guide to Complementary Therapies in Cancer Care, says non-traditional approaches can have a place in medicine, when modern medicine has little to offer.

As opposed to “alternative,” Cassileth prefers the term “integrative” medicine, which subjects nonstandard therapies to scientific tests. At Memorial Sloan-Kettering, integrative health researchers focus on alleviating pain and other symptoms. But they would never claim that nontraditional therapies can cure cancer, she says.

For example, doctors have had promising early results using acupuncture to restore salivary gland function in patients who receive radiation to the head and neck. Without functioning salivary glands, these patients can’t talk or swallow.

While critics counter that acupuncture treatments are simply placebos, Cassileth says, “if there is a placebo effect that brings back salivation to these people who can’t eat or talk, who cares?”

In response to which I want to shout to the rooftops that “integrating” quackery with real medicine doesn’t improve medicine. It’s the same as Mark Crislip’s famous 34 word definition of “integrative medicine, “If you integrate fantasy with reality, you do not instantiate reality. If you mix cow pie with apple pie, it does not make the cow pie taste better; it makes the apple pie worse.”

Or, as I put it, if you integrate quackery with real medicine, you do not produce better medicine. Instead, you turn quackery into medicine and medicine into quackery to the point where the line between the two becomes difficult to distinguish even for physicians. That is exactly what is happening now in academia, and Barrie Cassileth is a key example. That’s why she (or, more frequently, a study of hers) has been a not infrequent topic of this blog.

The focus of the article, wisely, begins with unregulated supplements. Because of the infamous (and Orwellian-named) Dietary Supplement Health and Education Act (DSHEA) of 1994, a law that more or less deregulated the supplement industry. Well, not exactly. As I’ve explained many times before, what the DSHEA did was to regulate supplements as food and basically tie the FDA’s hands over health claims, just as long as they were sufficiently vague. Not acceptable are claims that supplements will treat or diagnose specific diseases or conditions. Acceptable is almost anything else, which has led to supplement manufacturers becoming increasingly creative with so-called “structure-function” claims, such as “boosts the immune system” or “promotes prostate health.” Also true is the portrait of the supplement industry as big business, a $34 billion a year industry with aggressive lobbyists and its own Dietary Supplement Caucus and powerful legislators in its corner, such as Orrin Hatch and Jason Chaffetz.

Also noted is how the federal government spends nearly a quarter of a billion dollars a year researching alternative medicine through the National Center for Complementary and Alternative Medicine (NCCAM) and the National Cancer Institute’s office with one of the most unfortunate acronyms ever, the Office of Cancer Complementary and Alternative Medicine (OCCAM). Unfortunately, when interviewed by Szabo, Josephine Briggs wastes no time in the “bait and switch” of alternative medicine, in which Tai Chi is not represented as being anything more than just light exercise:

Briggs notes that research conducted by her center and others shows real benefits to certain alternative therapies, which doctors describe as “complementary” if they are used in conjunction with conventional medicine. Last year, for example, The New England Journal of Medicine published a study showing that people with Parkinson’s disease can improve their balance and stability by practicing Tai Chi, an ancient Chinese exercise system. A study published last month in the Journal of the American Medical Association found that intensive-care patients on ventilators experienced less anxiety, and required fewer sedatives, if they could listen to their choice of music.

Since when is exercise “alternative”? Didn’t we also used to call things that make patients’ stays in the hospital more bearable “supportive care.” I’m talking about things like—yes—music, along with art (which is now “art therapy), and visits from pets (which is now “pet therapy”). In fact, if there’s an aspect of the story that I wished to see but didn’t, really, it’s an explanation of how such supportive therapies are being “rebranded,” along with various science-based modalities such as diet and exercise, as somehow “alternative.” I suppose it’s a hard thing to explain to the average newspaper reader who doesn’t follow the issue the way readers of this blog do.

Worse, a supporter of quackademic medicine even gets away with the old “most so-called ‘evidence-based medicine’ is not evidence-baed” gambit:

Only about one-third of alternative therapies have safety and efficacy data behind them, critics note. Yet conventional doctors don’t always follow the evidence, either, says Adriane Fugh-Berman, an associate professor of pharmacology at Georgetown University in Washington and author of a textbook on herbs and supplements. Only about one-quarter of therapies used in conventional medicine are “evidence-based,” she says.

Nonsense. Steve Novella explains why. Nonsense, says Edzard Ernst. Nonsense, said Robert Imrie and David Ramey. And nonsense say I.

At least the harms are mentioned. Some previous subjects of this blog show up, including the example of chelation therapy killing a five year old autistic boy named Tariq Abubakar Nadama in 2005. There’s the example of harmful quackery for Lyme disease. There’s the example of Steve Jobs, although, as much as I hate to disagree with Dr. Offit, I have to say that I disagree. As I’ve said before, the nine month delay most likely didn’t make a difference in whether Steve Jobs lived or died of his cancer, although the delay certainly didn’t help him. There’s a chapter in his book about Steve Jobs, and I think the “alternative medicine killed Jobs” angle is played up too much. Interestingly, it is actually Barrie Cassileth who says that Jobs “essentially committed suicide.” No, he did not. He might have inadvertently contributed to his death, but, given lead time bias and the indolent nature of Steve Jobs’ tumor, probably the “cat was already out of the bag” when he was first diagnosed. It’s very odd for me to be less harsh on alternative medicine than Barrie Cassileth.

On the other hand, leave it to Andrew Weil to say something truly dumb:

Andrew Weil, one of the USA’s best known advocates of holistic medicine, says he also favors closer regulation of supplements.

“I would love to see the FDA set up a division of natural therapeutic agents,” says Weil, director of the Arizona Center for Integrative Medicine at the University of Arizona,

There’s no need for such a division within the FDA. The FDA as currently constituted is perfectly capable of handling the regulation of supplements if only the DSHEA were repealed or amended to give it the power to do so. Too bad that the readers probably won’t recognize Weil’s blather for the self-serving, disingenuous propaganda that it is. Other previous topics of this blog who pop up in this article include Stanislaw Burzynski, Mehmet Oz, Joe Mercola, and—talk about a blast from the past!—Rashid Buttar (about whom I’ mibht have more to say later this week).

Overall, it’s a good, but flawed effort, and USA Today should be given kudos for having published it. I also like how in both articles, quacks were called quacks. Although there was a bit of “false balance” sneaking in, in the current climate, this article is probably about as good as it gets. That’s not damning with faint praise, because the Szabo hit all the right notes. I just wish they hadn’t been interspersed with too much of the wrong notes letting the quacks speak.