Glass Houses

Here\’s some advice I have given teenage boys who are going toe-to-toe with their mothers about a health issue:
Don\’t go toe-to-toe with your mother; it\’s a no-win situation.  Either you are right, and you are looked at as a \”smarty-pants\” or you are wrong, and have given her a huge \”I told you so.\”  If, on the other hand, you keep quiet and listen to what she\’s saying, it\’s a win-win: either she\’s right and you learn something, or she\’s wrong, and you have been vindicated.

Fathers often pipe in that this applies to wives as well.  Mom\’s don\’t seem to disagree (for some mysterious reason).

While this may be sound relational advice, it also needs to be heeded by the medical community in its relationship to \”complimentary and alternative medicine\” or CAM.  I am not saying we shouldn\’t be angry and frustrated with the CAM purveyors who are harming and even killing people (such as the anti-vaccine movement).  I am not saying that we should embrace CAM and put it at anywhere near equal footing with our profession.  What I am saying is that in our enthusiasm to win the argument, we can undermine our own credibility.

The typical argument against CAM and for traditional medicine goes like this:

  • Traditional medicine is based on science.  This means that for something to be accepted, it must be tested by more than one study and shown to be valid.  It also means that any treatment or test can and should be challenged in its validity.  If it cannot stand up to scrutiny of thorough analysis, it shouldn\’t be accepted.
  • CAM, on the other hand, is largely based on anecdotal evidence.  When something gets enough science behind it, the argument goes, the therapy or test moves from the realm of CAM to that of traditional medicine.
  • Therefore, by definition, traditional medicine must be more trustworthy than CAM, since only treatments on the traditional medicine side are supported by science.

I think there is much validity to this argument – and it is one that I have used when arguing this subject.  But there is also a huge flaw in one of the assumptions.  The flaw is in the very first statement in the argument: \”Traditional medicine is based on science.\”  While this is, in my opinion, a true statement, the inference from this statement, that all traditional medicine practiced is based on solid scientific evidence, is false.  Very false.  Some of the medicine I practice is based on science, and all of it is open to question, but not all of it.  Much of what we do is based on very weak scientific evidence, some of it is even practiced in the face of contradicting data.

Here are some examples:

Fenofibrate – The drug Fenofibrate (Tricor, and others) is one of the most potent drugs to lower triglycerides.  Type 2 diabetics are particularly prone to having high triglycerides, and so are often put on this medication.  The elevation of triglycerides is of unclear significance (although very high levels do increase a person\’s risk of developing pancreatitis).  To address this problem, the ACCORD trial was performed to assess (among other things) the efficacy of the drug to lower the rate of heart disease.  After all, people don\’t die of triglycerides, they die from heart attacks. Here are the results (from NEJM):

Conclusions The combination of fenofibrate and simvastatin did not reduce the rate of fatal cardiovascular events, nonfatal myocardial infarction, or nonfatal stroke, as compared with simvastatin alone. These results do not support the routine use of combination therapy with fenofibrate and simvastatin to reduce cardiovascular risk in the majority of high-risk patients with type 2 diabetes.

But this medication continues to be aggressively pushed and widely prescribed.  When these results came out I expected to see the Tricor rep hanging her head, but instead she excitedly pointed out a sub-group analysis showed people on this medication had a lower risk of eye problems related to diabetes.

Colonoscopy – Clearly there is good evidence for colonoscopy, right?  Gary Schwitzer discusses this in a letter to Harry Smith, who is campaigning in favor of colonoscopy:

In this month\’s journal, Gastroenterology, is an article \”Colorectal Cancer Screening Guidelines: The Importance of Evidence and Transparency,\” by Dr. James Allison, Clinical Professor of Medicine Emeritus, University of California San Francisco.

As a network news operation, CBS should really be on top of this information, but I\’m going to bet no one in the network has read this, so I\’ll offer some excerpts:

\”The only screening test for colon cancer shown by randomized controlled trials to decrease colon cancer mortality and incidence is fecal occult blood testing (FOBT).\”

Did you know that? Did you consider doing a live promotion of the stool blood test? Granted, it might have been a little gross, but we did see your colonoscopy. And it appears that this kind of colonoscopy promotion is what helped make it the most popular colon cancer screening test, despite the evidence (or lack thereof).

Antibiotics – What do sinus infections, ear infections, conjuctivitis, and bronchitis have in common?  They all get better without antibiotics.  Studies have shown clearly that sinusitis does not do better when treated with antibiotics, yet this prescription is commonly given.  Ear infections are supposed to be treated with \”watchful waiting,\” where the parent treats the pain and only uses antibiotics if it does not get better.  The other two infections are 99% viral, so are not fixed at all with antibiotics.  Still, all of them are treated with antibiotics with great frequency.


Again, I am not saying that traditional medicine and CAM are equally valid.  What I am saying is that we overstate the scientific basis for traditional medicine.  It\’s not wrong to do things that aren\’t yet proven; often we end up using the best evidence available, which sometimes is sparse.  But giving the perception that traditional medicine is scientifically \”proven\” (there is no such thing as scientific proof, just support), is only setting us up to look really stupid when what we do is contradicted by clinical data and give ammunition to those who support truly unproven therapies.

The very nature of the practice of medicine makes it something that uses science, but often is not itself scientific.  Medical studies take a group of people and draw conclusions about certain interventions.  Medical practice takes those studies and tries to find which one applies to the person sitting on the other side of the room.  Often there are no studies, however, and we need to just do \”what makes sense.\”

What\’s my point?  We need to be careful in our attacks on CAM.  We need to be sure we don\’t give the impression that everything we do is scientific.  People will embrace other things because traditional medicine doesn\’t always work.  We should not over-promote unproven things (see also: mammography and PSA testing) and we should also be aware of the commercial motivation behind a lot of these recommendations.  To quote the researcher who \”invented\” PSA testing:

I never dreamed that my discovery four decades ago would lead to such a profit-driven public health disaster. The medical community must confront reality and stop the inappropriate use of P.S.A. screening. Doing so would save billions of dollars and rescue millions of men from unnecessary, debilitating treatments.

We are often operating on shaky ground.  There is no solid ground a lot of times, but our saying it is not shaky doesn\’t make it so.

9 thoughts on “Glass Houses”

  1. I definitely agree! However, I think you can go even further analyzing the science behind traditional medicine to find flaws and problems that make the science behind traditional medicine not as neat and tight as some practitioners would have us believe.
    For example, there was just a story in the NY times about how medications to lower blood pressure, increasing HDL, or modulating the postprandial glucose spike in diabetics didn't prevent them from having heart attacks.

    Similarly, there was story in the NY times about how salsalate was very helpful in blood glucose control

    As far as I can tell, the science behind these studies are solid. Yet how long will it take before practitioners follow this scientific advice? How long before they stop trying to aggressively treat diabetics' blood pressure and HDL? Clearly, the science behind medicine is constantly changing, but most physicians I know (as a physician-in-training, I've been exposed to quite a few) are years behind the research.

    Also, the science behind traditional medicine is often flawed and biased. Here I would refer you to Overdo$ed America, which is a brilliant expose of how drug companies have famously skewed their research to increase profits. For example, when a drug company (I believe Pfizer) tried to get SSRIs approved in the European market, they were required to submit all the research they had done on SSRIs, not just the studies that were published. What the European drug agencies found was an equivocal response to SSRIs when all the research was analyzed, not just the research published with the best results.

    So the process behind traditional medicine's science is wrought with flaws and biases. For example, who would pay, now that most research is privately funded by the companies who have something to gain by their success, for a 10 year trial of lifestyle modifications, or of herbs that have generations of anecdotal evidence? Not only is the first statement of the argument flawed, but the second statement, that when CAM gets enough research behind it, it becomes traditional medicine, is flawed as well. There are lots of CAM treatments that simply will not pay enough to merit the research necessary to “prove” their merit.

  2. Lisa Chippendale

    That is a very good explanation for why some otherwise very intelligent people often prefer CAM to traditional Western medical practice. There's another: for most people, first-hand observation trumps anything scientists say. That's why despite the fact that I'm usually very supportive of listening to the evidence, I remain very suspicious of the current gospel that antibiotics are always useless for the conditions you list above. I see them work. I am prone to sinus infections; they don't clear up until I start taking antibiotics, then they clear up quickly (and I always wait a couple days to see if it'll get better on its own). My kids get pink eye–within a day of getting the antibiotic eyedrops, they are drastically better. Ditto on severe ear infections (although yes, I have seen the mild ones clear up on their own) and bronchitis. I find it hard to believe that the fifteen or more times I have seen this phenomenon can all be ascribed to coincidental improvement.

  3. I'm glad you brought up the issue of antibiotics being over prescribed for upper respiratory infections. I'm wondering what a good guideline is for putting a patient with a UTI on an antibiotic. If the patient has a cold for 4 or 5 days and is getting worse in terms of congestion and coughing, is that an indicator that a secondarial bacterial infection might be an issue and antibiotics appropriate?

  4. some dude named steevo

    Thanks for the words of wisdom, this post made me think. However, I think the antibiotic argument is kind of like arguing with your mom…

  5. A UTI should always be treated per current recommendation. This is because of how quickly a kidney infection can turn into sepsis.

    I have a 7 day rule with coughs – that any cough (bad cough) lasting 7+ days probably warrants an course of treatment. Statistically it is way more likely these will be mycoplasma, or even more importantly, pertussis.

  6. I agree that personal observation is hard to deny. Yet that's our job as docs – to put our personal observation (that is 1000 times more observations) out there. I am personally not an antibiotic non-prescriber. The point of this post was to say that we all do some non-science, which makes arguing against CAM a little more hypocritical if it is done via a “science vs. non-science” perspective.

  7. I appreciate this post, as I'm researching the experience of elderly women living with arthritis, their communication with health care providers, and their use of CAM. A common theme is that people use all sorts of CAM and folk remedies when they are desperate for relief, or when friends or media convince them it's worthwhile. It's about empowerment and trial and error, not necessarily logic and discernment. Even when they can't say the treatments “work” for sure, or when they are doing something so ridiculous they hide it from their friends, they just have to do something.

    Meanwhile, most admit that they don't disclose their CAM use to their doctors, because it's something that their doctor has no control over, or they feel their doctors will poo poo it. When this is the case, crucial opportunities are missed for healthcare providers to discuss the risks and benefits of CAM and to address lifestyle issues that go beyond just prescribing a pill. Simply asking patients non-judgmentally about what other self-care or alternative strategies they are using shows that you care, and can foster a sense of empowerment and more open communication. It seems to me that many areas of CAM provide these psychological and sometimes spiritual benefits which the medical system no longer has room for, and that will never be captured in any randomized controlled trial.

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