Covering Alternative Medicine---Another perspective

In a piece on this site, journalist Jane Allen gives some useful advice about covering alternative medicine, but there are some gaps that are are hard for a non-medical professional to recognize (and frankly, for many medical professionals as well). She quite rightly urges skepticism, but when looking into ideologic and muddled topic of alternative medicine, skepticism needs to be turned up to "11". A major complaint that doctors have about health coverage is not the objectivity, earnestness, or research abilities of the reporter but the lack of some of the fundamental knowledge of the subject.

"Alternative medicine" can mean many things and the National Centers for Complementary and Alternative Medicine (NCCAM) provides a good starting point. Whan many skeptics have pointed out over the years however is that there really is no "alternative" to medicine; only that which is proven to work, and that which is not. This is one of the bases for ethical medical practice. Medicine is full of compelling stories---we physicians hear them every day. But, knowledge of what does and does not work cannot be based on a good story. The histories we record each day help guide us in treating individuals using interventions tested on larger groups. The randomized-controlled trial (RCT) is often seen as the "gold standard" for testing medical interventions, but there are a two primary limitations to this view. First, not all interventions can be examined using an RCT due to ethical and technical concerns. Second, an RCT is often blind to the idea of "plausibility". This leaves us open to what Dr. Harriet Hall has termed "Tooth Fairy Science": we can generate statistically significant data about the average price of an incisor, the average time between tooth loss and monetary gain, and other such factors, but none of these numbers tells us whether the Tooth Fairy in fact exists.

If in reporting on health the goal is to inform as well as tell a good story, an informed skepticism is necessary. Supporters of alternative medicine are often gripped by a religious-like zeal and may be somewhat deficient in skepticism. Doctors and scientists are trained to be skeptics (a training that ometimes wears off) and usually start from the premise of "I don't believe it, show me the data". Ms. Allen's excellent article lays out some of the problems:

The task of sorting it all out becomes all the harder because evidence for health claims in non-traditional medicine often does not rise to the gold-standard -- randomized, controlled clinical trials (those in which participants are randomly assigned either to an experimental group or to a comparison group) published in major peer-reviewed journals.

"There isn't the same depth of research, and there never will be," says Hardy, medical director of the Simms/Mann-UCLA Center for Integrative Oncology, who has long studied herbs and dietary supplements and often recommends them to appropriate patients. She says safety margins for herbal remedies, especially those used for thousands of years, are better than for prescription drugs. "It's very uncommon that any herb with traditional knowledge behind it will be as toxic as a new drug."

Claims about alternative, complementary and integrative medicine often are built on anecdotal evidence. But that's not the same as demonstrating their effectiveness through rigorous science....

When she's trying to evaluate such claims of an alternative remedy's effectiveness, Hardy wants study authors or those making the claims to provide multiple cases of good responses. She also wants to see a rationale for the treatment that is either consistent with the principles of alternative medicine practices, such as traditional Chinese medicine, or explainable through principles of Western medicine.

This credulous claim by a supporter of alternative medicine deserves careful parsing. There is no reason that any claim made by alternative medicine cannot be subjected to the same scrutiny as any other intervention. In fact, it's done regularly. An NCCAM-funded study of Saw Palmetto, for example, found insufficient evidence to recommend its use. This wasn't a set of anecdotes but a randomized-controlled trial, just the sort of "gold standard" that Hardy claims "there never will be" in researching herbs.

Her next claim that "any herb with traditional knowledge behind it" is unlikely to be as toxic as a new drug" is a non sequitur. Safety is only one factor to consider in evaluating an intervention---the other, of course, is efficacy. Something with no physiologic effects at all will not be toxic, by definition. Something with significant physiologic effects can always have potential toxicities. Another way of framing it is that there is no such thing as "side effects"---only effects, some desired, some not.

The final disturbing point made by Hardy is that claims should be evaluated via anecdotes that are seen through the lense of alternative medicine principles. This is a terrible idea. The evaluation of a medical intervention must rest on its safety and efficacy and its scientific plausibility. Calling something "alternative" does not render it immune from scientific investigation.

Ms Allen goes on to discuss areas in which alternative medicine may be most useful, but unfortunately appears to have fallen for the seductive propaganda of alternative medicine's boosters.

Integrative medicine is particularly useful in treating chronic diseases like diabetes, coronary artery disease and pain, which are all can be influenced by such lifestyle factors, such as diet and exercise. With the aging of the Baby Boomers, integrative approaches are likely to generate rafts of stories in coming years. It's already happening: just think about how often you hear that regular exercise and a diet rich in antioxidant- packed fruits and vegetables and plant-based proteins (rather than proteins high in saturated fats) may prevent cancer and heart disease.

Lifestyle factors such as diet and exercise are not the exlusive domain of alternative medicine---they are an important tool in the medicine internists like me practice every day. Attempts to co-opt these tools are usually done out of ignorance or deception. (Also, claims about anti-oxidant rich diets have been largely unsupported by the literature).

As a medical professional, I can only imagine the difficulties inherent in covering such a complicated field. Some important rules though should be kept in mind: don't trust your own knowledge or instincts as they are an inconstant guide; don't trust sources with significant investment in an alternative therapy unless the greater part of the data supports their claims (PubMed is your friend, as are competeing sources); and subject all claims to the Tooth Fairy test---would accepting a claim mean having to overturn the entirety of our understanding of biology, physics, and chemistry.

Journalists take their duties seriously, but doctors perhaps more so, at least on a moment-to-moment basis, but we have similar abilities to help or harm large numbers of people.Protecting the public requires a deep but compassionate skepticism.