Respect my authoritah on “integrative medicine”!

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 evidence” more than once, to my pointing out that his arguments frequently boil down to a false dichotomy of either abandoning science or abandoning patients.

Last week, my friend Jann Bellamy discussed an unfortunate special supplement of the American Journal of Preventative Medicine (AJPM) entitled Integrative Medicine in Preventive Medicine Education. This supplement included articles summarizing the results of project called IMPriME (Integrative Medicine in Preventive Medicine Education), funded by the Health Resources and Services Administration (HRSA), to advance the inclusion of “integrative medicine” in Preventive Medicine residency programs. Not surprisingly, this project was led by Dr. Katz. Jann used this special issue as a jumping off point to show, quite correctly, how, when it comes to so-called “integrative medicine,” it is always about the “potential,” which has always been elusive and has never been realized. Unfortunately, the elusiveness of the amazing potential attributed to “integrative medicine” (formerly referred to as “complementary and alternative medicine” or “CAM”) has done almost nothing to dampen the ardor of its cheerleaders for “integrating” as much woo as they can into medicine, which is why a major journal would allow someone like David Katz to edit a special issue dedicated to articles discussing IMPriME’s findings.

It appears that Dr. Katz is most displeased with Jann, to the point that he felt the need to lash out at her and all skeptics who question his greatness. To express his displeasure, he has rattled off a little rant over at his usual non-academic hangout and quack-friendly Internet outlet, The Huffington Post. There, he castigates us with a post entitled Science and Medicine, Fools and Fanatics: The ‘Fluidity’ of Woo. Yes, right off the bat, it’s the same old strategy, to paint advocates of “integrative medicine” as the “reasonable” ones while those of us who object to integrating prescientific quackery into medicine are clearly the “fanatics” (or, if you prefer, the fools). In it, as usual, Dr. Katz lays down some real howlers in defense of his integration of woo with medicine.

Respect my authoritah! I’m a real scientist, dammit!

Many species of animals (humans included) engage in various agonistic behaviors. One form of such behavior is known as threat display and consists of the animal doing something to show its strength or make it look larger and more dangerous in order to intimidate potential opponents and thereby win without having to fight. For example, when threatened the frilled-neck lizard engages in an impressive display in which it raises its body, gapes its mouth to expose a bright-colored yellow lining, and spreads out its frill showing bright orange and red scales. It’s a reaction used to assert territory, intimidate predators, and impress females. Male gorillas howl and beat their chests to accomplish the same goals. The way Dr. Katz starts his article reminds me very much of an academic equivalent to the display of the frilled-neck lizard in the way he puffs himself up and tries to assert his academic dominance over us by showing us his science bona fides. Substitute the pages of one’s CV for the impressiveness of the neck frills, and you get the idea.

Boasting how he was a “logical choice” to lead IMPriME and clutching his pearls mightily at the very thought that mere peons like us would have the temerity to criticize such an initiative led by such a bold visionary as himself, much less l’il ol’ us, Dr. Katz sarcastically noted, “Predictably, no sooner had the electrons announcing this settled into the Medline index, than the clique calling itself ‘Science-based Medicine’ weighed in, with customary disparagements,” before puffing up the frill on his neck thusly:

That this suggestion [of a more “fluid concept of evidence”] was parlayed into allegations of quackery, or flirtations with it, has always amused me when it hasn’t annoyed me, and struck me as absurd in every way. For one thing, I make for quite a bad quack. I have run a federally-funded clinical research lab for nearly two decades. My colleagues and I have contributed nearly 200 peer-reviewed papers to the literature, some few of which demonstrate the utility of certain “alternative” medicine modalities, some few of which suggest the futility of others. Along the way, our efforts spawned a novel technique, called evidence mapping, later adopted by the World Health Organization for other applications, which showed the variability of evidence underlying the domain of so-called “complementary and alternative” medicine.

My passion for science is rather an open book, as are my musings on what “holistic” medicine is, and should be. Speaking of books, I have authored one textbook exclusively about evidence-based medicine and its relationships with both research methods, and clinical decisions; and multiple editions, in the company of colleagues, of an epidemiology text much devoted to that same domain. I will protest no further in that regard.

Lately, Dr. Katz seems to begin his rebuttals to any criticism of his advocacy for integrating quackery with medicine this way, with an appeal to authority—his authority. Yes, Dr. Katz. We get it. You’re freakin’ awesome! You’re so much more a real scientist than any of us because of your couple hundred publications, your federal grants, and your “passion” for science. (Or so you say.) In contrast, what have I to offer, a mere peon with only one federal grant at present for a preliminary study and a fraction of the number of publications? Heck, I’m not even a full professor yet (although, barring any unforeseen glitches in the process, that situation should be rectified by spring). All I can offer are science, critical thinking, and snark, in that order. Fortunately, for arguments as bad as David Katz’s, they are more than enough. After all, it is the quality of evidence, science, and argument that matters. That’s why I rarely dwell long (if I mention them much at all) on my own qualifications, even when I’m writing about topics that fall under the purview of my specialty that I might reasonable be considered to be an expert in, such as screening mammography. As I’ve said before, doing so is just…unseemly to me. In my experience, it’s almost always an indication that the arguments to come will be weak. Even if the experience that leads me to that rule of thumb is mostly confirmation bias, Dr. Katz’s article does nothing to counter that experience.

Besides, given the rise of quackademic medicine, defined as the infiltration of quackery into academic medical research and practice, coupled with the existence of the National Center for Complementary and Integrative Health (NCCIH), formerly known as the National Center for Complementary and Alternative Medicine (NCCAM, a much nicer abbreviation), having federal grants and publishing a couple of hundred papers are no guarantee of being quackery-free.

Basically, here Dr. Katz is telling us, like Cartman on South Park, to respect his authoritah. Don’t get me wrong. I do respect academic authority. I’m just not overawed by it. I also don’t think it’s wrong to appeal to the authority of someone like Paul Offit on vaccines as a shorthand for having to go through all the evidence. What I respect far more than authority, however, are science, critical thinking, and compelling arguments. It bothers me little or not at all that I’m frequently attacked for not having being a “real” expert in scientific disciplines I discuss, and it’s usually not even other physicians doing it but lay people with no training in those disciplines themselves. In other words, David Katz needs to spend more time burnishing his arguments and less whining about upstarts who dare criticize his genius.

Starting with a reasonable premise and then using it to justify pseudoscience

To be fair, Dr. Katz does make a couple of reasonable points. The problem is that, as he has done so often in the past, he takes those points and drives right off the cliff of woo with them. For instance, Katz’s infamous 2008 quote about resorting to a “more fluid concept of evidence” would have sounded a whole lot less quacky if he hadn’t yoked it to a patient anecdote in which he took the advice of naturopaths and referred the patient to them, where he was treated with homeopathy, The One Quackery To Rule Them All, using the anecdote to illustrate why he thinks physicians must be willing to use that more “fluid concept.” It would also be less objectionable if he didn’t also construct a false dichotomy wherein if a physician is not willing to consider pseudoscience like homeopathy when he reaches the end of what science-based medicine can do for a patient, then he is “abandoning” the patient.

Referencing one of the articles he wrote for the AJPM supplement he edited, Dr. Katz argues:

Moving on to the “fluidity” that has proven such a diverting target for the slings and arrows of my science-based colleagues, what did I mean? Well, that, too, is a matter of the published record — previously, and again in the new compilation in AJPM. Colleagues and I proposed, based on years of wrestling with complex patients, many of whom, urgent medical needs still insufficiently addressed, had tried and exhausted all of the well-supported, conventional treatments, that evidence traversed 5 key considerations. Those include: what is known about a treatment’s safety; what is known about a treatment’s efficacy; how well those first two are known (i.e., the clarity of evidence); the patient’s preferences; and, importantly, the availability of other, untried treatments for the condition in question.

It’s hard to argue with too much of this; that is, up to a point. This is the sort of thing that science-based medicine does all the time, particularly with rare conditions for which gathering “gold standard” randomized clinical trial evidence for treatments is difficult or even nearly impossible. It’s also the sort of thing science-based medicine does all the time with pretty much every patient for which science-based treatments might be lacking or far less than ideal. It is not Katz’s contention here about the “fluidity” of science that is the problem. Clinicians who wrestle with complex patients on a daily basis are more than familiar with such questions, to the point that Katz’s argument above is basically trivial. Besides, it’s not the point above that we object to; it’s how it’s used to justify “integrating” quackery like homeopathy into science-based medicine.

For instance, Katz then writes:

One need not be a clinician, wrestling with especially challenging patients or otherwise, to see the relevant spectrum of decisions. Whenever a treatment option is unsafe, ineffective, unclearly supported by evidence, unpreferred by the patient, and/or surrounded by other, ostensibly better treatments for the same condition — it is time to move on, be that treatment a product of tree leaf, or test tube.

Who could disagree with this? Certainly not me. Well, not quite. Here’s one problem. Katz clearly doesn’t move on when a treatment is clearly unsupported by the evidence; e.g., homeopathy. Here is a physician who, as I keep harping on, used the “fluidity of evidence” as the justification for sending a patient to naturopathic quacks and letting them treat him with The One Quackery To Rule Them All. Here is a man who is quite comfortable working with naturopaths, whose specialty is a cornucopia of mutually contradicting pseudosciences and quackery.

Also, notice the last two conditions, if the treatment is “unpreferred by the patient, and/or surrounded by other, ostensibly better treatments for the same condition,” then it’s time to move on. As I’ve said time and time again, a competent adult can choose or refuse any treatment he or she wants, but if a patient refuses a validated science-based treatment modality it is not a valid justification for a physician to use quackery. Similarly, the lack of “ostensibly better treatments” for a condition is also not an excuse to invoke quackery. Yet that is exactly what Katz does, although he denies it to high heaven. For instance, look at this table from the article he references (click to embiggen):

Again, this sounds superficially reasonable. The problem comes in how CAM/integrative medicine enthusiasts define the word “possible” under the Efficacy column and the word “unclear” under the Science column. Once again, the science for homeopathy is not “unclear,” nor is its efficacy “possible.” For instance, later in the paper, Katz argues:

Recent outcomes research on models (or “whole systems”) of integrative care^{32, 33, 34, 35, 116, 117, 118} demonstrate promise and innovation, as well as potential cost savings,^{8, 119} despite a lack of large-scale funding^{160, 161} and methodologic challenges.^{162, 163, 164}

I note that most of the “whole systems” references cited by Katz refer to naturopathy and traditional Chinese medicine. As before, I point out that naturopathy is not only a cornucopia of quackery but that homeopathy is part of naturopathic training to the point of being included on the naturopathy licensing examination (NPLEX), and that what we now refer to as “traditional Chinese medicine” is the result of a rather cynical retconning of Chinese folk medicine by Chairman Mao Zedong in the 1950s. Indeed, 150 years ago, acupuncture was indistinguishable from bloodletting.

In which Dr. Katz lights a straw man about medical plausibility on fire

As you can see above, if your criteria for determining whether the science is “unclear” or the efficacy of a treatment is “uncertain” are lax enough, you can use Dr. Katz’s criteria to justify trying almost anything on a patient. Faith healing, anyone? Reiki? Well, it turns out that Dr. Katz does not accept that energy healing modalities are incredibly implausible. In what has to be the most embarrassing passage in the entire article (at least I’d be embarrassed if I had written it), Katz declares:

What is most fascinating and relevant about [E.O.] Wilson’s account is not the technology that is now revealing to us realities to which we were insensate before: colors we could not see; sounds we could not hear; energy fields we could not feel. What is most compelling is that all of these ARE perceivable to biology, just not OUR biology. There are animals that see colors we can’t; animals that hear sounds we can’t; and animals that feel one another’s electromagnetic fields. This, of course, is not woo; it is established biological fact.

The sounds, the colors, and the fields exist; and biologies other than our own can access them. Given, then, the range of human aptitude — from Helen Keller to the Rain Man; Michelangelo to Mozart; Edison to Einstein — are we truly prepared to say that no human being could possibly perceive the energy field produced by our bodies? Are we prepared to know in the absence of evidence that no such person endowed with a heightened sensitivity blunted in the rest of us, could interact with the energy field produced by a body in close proximity?

My radical version of alleged woo is captured in my answer to these questions: no. I simply don’t know what we don’t know. No one else does, either. No one else, that is, save fools and fanatics.

This is a straw man so massive that the heat derived from burning it could be used to generate electricity for the world for decades, much like Katz’s hot air boasting about his credentials. No one says that it’s impossible that a human being might be able to perceive energy fields. We say that it is incredibly improbable based on what we know about the basic sciences of biology, physics, and chemistry. It’s the same reason that I never quite say that it’s absolutely impossible that, for example, radio waves from cell phones might influence the development of cancer. I just know, based on cancer biology, chemistry, and physics, that it is so incredibly implausible that radio waves cause cancer, of the brain or breast or other organ, that it is reasonable, barring new evidence, to provisionally treat it as impossible. It is then up to believers like Katz—and, make no mistake, he is a believer in CAM, his protestations of being all about the science notwithstanding—to provide the evidence that a phenomenon like humans who can detect and manipulate other humans energy fields actually exists. It would also help if they could actually demonstrate that a human energy field, of the sort claimed to be manipulated by energy healers and TCM practitioners, actually exists, which they can’t. Given that, for example, for homeopathy to be true huge swaths of conventionally understood physics and chemistry would have to be radically rewritten, there would be many Nobel Prizes involved in such a discovery. The same is true of energy healing. Why hasn’t the evidence been found? Could it be because this phenomenon doesn’t occur?

At this point, it is obligatory, and rightfully so, to show that the hypothesis that a human being can detect another human’s “energy field” is rather trivial to falsify, so trivial that even a 12-year-old girl can do it.

Science doesn’t know everything, and skeptics criticizing woo are akin to the Spanish Inquisition

Circling back to Jann’s article that so riled Dr. Katz up in the first place, I note that her central idea was that, because so much of CAM and “integrative medicine” is based on pseudoscience and quackery, there is little or no evidence of its efficacy for the indications claimed, which leaves its apologists nothing but pointing to the “potential” of CAM. Flowing naturally from that central idea is the observation that that “potential” has never been realized—and almost certainly will never be realized—because there’s no “there” there. CAM is all either pseudoscience or the co-opting and rebranding of perfectly science-based disciplines like pharmacognosy or “nutrition” as being somehow “alternative,” so whatever “potential” CAM might have would come from such rebranded treatments as being CAM rather than medicine. Even then, the results have been disappointing, claims that the recent Nobel Prize in Medicine somehow “validates” traditional Chinese medicine notwithstanding.

So what someone who declares himself “passionate about science” to do when science doesn’t support his view on medicine? Easy! Pull the “science doesn’t know everything” gambit (a.k.a. an appeal to future knowledge or an appeal to future vindication) by comparing yourself to great scientists of the past whose discoveries overthrew old scientific paradigms:

That the proposition — the fluid nature of evidence, and more importantly science, should be respected — is contentious in the first place is, frankly, bizarre. I trust I am reliably conjoined to my science-based confrères (they are, in fact, male predominated so far as I know, and whatever that implies) in noting that the greatest of scientific minds — Einstein and Hawking and Newton; Darwin and Dawkins; Copernicus and Galileo and Herschel — were exceptionally devoted to the fluidity of science. They have, and in some cases still do, challenge the conventional understanding. They respect what we know, and how we know it, but humbly concede the potential for it to change as new evidence accrues.

This is, of course, another massive straw man. Perhaps Dr. Katz could point me to a passage—any passage!—in the entire nearly eight year history of this blog that could be construed as saying that science isn’t fluid or that there are findings in science that are absolute and not subject to change. I can’t find it. However, there are some parts of science that are—shall we say?—more fluid than others. Out near the “cutting edge” of science, findings and understandings are very fluid; back towards the core, less so. In other words, it’s a lot less likely that central laws, such as the three laws of thermodynamics, will be overthrown than it is that more recent and tenuous findings will be. Science is not a monolith. Besides, major paradigm shifts build on the old; they seldom completely replace it. My favorite example of this is how the theory of relativity supplanted Newton’s laws. Of course, it didn’t really supplant Newton’s laws, but rather improved on them. Newton’s laws are, in fact, still used for most calculations of motion used in aeronautical engineering because relativistic corrections are not necessary until velocities reach a fraction of the speed of light sufficiently large to exceed the precision required for a task. Basically, at most speeds that humans can observe and use, the theory of relativity reduces to Newton’s laws. That’s how science works.

Unfortunately, for something like energy healing or homeopathy, both of which Katz has advocated, new science much more revolutionary than the theory of relativity replacing Newton’s laws would be required to make them plausible. Barring that, Katz’s likening CAM investigators to Einstein, Hawking, Copernicus, et al is risible at best. Apparently, Katz views himself and his fellow integrative medicine enthusiasts as scientific groundbreakers who are unappreciated. I’m reminded of what Carl Sagan once said: “The fact that some geniuses were laughed at does not imply that all who are laughed at are geniuses. They laughed at Columbus, they laughed at Fulton, they laughed at the Wright brothers. But they also laughed at Bozo the Clown.” I’m surprised at this point that Dr. Katz was able to restrain himself from using Arthur Schopenhauer’s dubious quote about how “all truth passes through three stages.”

Of course, it’s not enough to appeal to “science doesn’t know everything” and imply that someday Katz and his fellow CAM enthusiasts will be viewed as scientific pioneers (a.k.a. the fallacy of future vindication). They must also paint their critics as close-minded and dogmatic, and what better way to do that then to write:

No one ever expects the Spanish Inquisition. Monty Python said it; it must be true.

And perhaps there is real wisdom in it. Perhaps the Spanish Inquisition is intrinsically shielded from all anticipation, because it is so improbable, even paradoxical. In this lamentable, historical episode, people were tortured and martyred for the heresy of their absolute faith in unknowable things, by people with absolute faith in unknowable things.

That’s why nobody expects the Spanish Inquisition. The martyrs and their murderers were too much alike, subject to differing versions of comparable hooey.

We have the inherent fluidity of scientific evidence to thank for every Nobel Prize in science. We have fluid thinking to thank for the innovations of Copernicus and Galileo; Darwin and Newton; Einstein, Edison, and Jobs. We have ideological rigidity to thank for the Crusades, the Salem Witch Hunts, 9/11, and the Spanish Inquisition. This is not a difficult comparison.

Yep, to Dr. Katz, we here at SBM and our fellow medical skeptics elsewhere are the equivalent of the Crusades, Salem Witch Hunts, 9/11, and the Spanish Inquisition. I’m surprised he didn’t mention the Holocaust as well or maybe Josef Stalin’s or Pol Pot’s atrocities. (Come on, Dr. Katz, do it! Compare us to Hitler! You know you want to! You know you want to so badly!) In any case, it’s true that this is not a “difficult” comparison to make. It’s all too simple, in fact! Actually, it’s so simple that it’s simple-minded. The ham-fisted way Katz explains the comparison also inadvertently conflates science and religious belief. After all, Katz refers to people being “tortured and martyred for the heresy of their absolute faith in unknowable things, by people with absolute faith in unknowable things.” In other words, both the persecuted and the persecutors believed in things that had no evidence and couldn’t be proven. Is Katz implying that all those scientists he lists underwent adversity for their faith in something unknowable? Likely not, but it sure sounds that way from what he wrote.

It’s sloppy thinking and writing, followed by even more sloppy thinking when Katz compares a scientific finding using poliovirus to treat cancer to homeopathy because it’s “using a toxin to treat a toxin.” No, it’s nothing at all like homeopathy. Cancer is not a “toxin,” nor is poliovirus. The engineered poliovirus does, however, release a toxin that kills cancer cells when it is in them.

I really have a hard time believing an actual physician made such a ridiculous analogy. Who’s the fool and fanatic here?

If you believe Katz, it’s us:

We need no help from fanatics to know there is hucksterism in the world, or bathwater in the tub. A common dose of common sense will suffice. The same measure will serve to renounce the counsel of fools to overlook the baby in the tub, or the possibility of somewhat surprising new truths in the fullness of time. We are most likely to find the advantages of wisdom in the realm of nuance and doubt; of open-minded skepticism; of caution, and hopeful curiosity.

The guardians will be there all along, telling us what is possible, and what isn’t — until it turns out it is. At which point, they will revise their fluid definition of woo, and pretend it never happened.

Oops. It looks as though I spoke too soon about Katz not invoking Schopenhauer, because that sure does sound like a paraphrasing of the ridiculous quote attributed to him about truth being “violently opposed” and then becoming “self-evident.”

Whenever someone like Dr. Katz invokes the “science doesn’t know anything” gambit, I like to quote Dara O’Briain:

For instance, around 1:50: “Science knows it doesn’t know everything. Otherwise it’d stop.” and “Just because science doesn’t know everything doesn’t mean you can fill in the gaps with whatever fairy tale most appeals to you.”

This particular O’Briain quote reminds me of Jann’s post again. In it, she quotes Katz’s definition of “integrative medicine” from his AJPM article, which I’ll expand:

Integrative medicine, a concept developed over the past few decades, refers to the fusion—by various means, and to varying degrees—of conventional medical practice and some of the practices that fall under the complementary and alternative medicine (CAM) rubric.

Doesn’t this sound like he’s filling in the gaps in medicine with whatever fairy story appeals to him? It does to me.

Jann also notes that if it is true that integrative medicine = SBM + CAM, then what’s left of integrative medicine if CAM is left out. Medicine. Or, more specifically, conventional medicine plus whatever science-based medicine CAM has “rebranded” and co-opted as being somehow “alternative.” Either way, it’s not as though woo-prone doctors and scientists like Dr. Katz haven’t been searching for evidence validating CAM therapies for a long time now. By and large, they haven’t found it, which has reduced them to making the sorts of appeals to future vindication and future knowledge that David Katz has invoked in his rebuttal and comparing their critics to the architects of Crusades, the Salem Witch Hunts, 9/11, and the Spanish Inquisition. I’m reminded of a suitably themed Geico commercial. It’s what you do when you believe in something but don’t have science on your side to support that belief.

Concluding this discussion, as part of the Spanish Inquisition, I sentence Dr. Katz to the comfy chair for his crimes against science and logic:

At least it might make him a little less angry at skeptics. Nahhh. Who’m I kidding?