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Questioning the 'Guardians of Science'

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Friends recently brought to my attention a commentary in The Atlantic in which the following is said about me, purportedly related to a presentation I gave at Yale:

"... [He] listed a lot of things he'd tried and which failed to work. His conclusion was not that they should be abandoned, but that we needed a 'a more fluid concept of evidence.'"

Those same friends know me, of course, so they, along with anyone else who knows me, know this characterization to be incorrect.

The troubling thing is how easy it would have been for the author to know it, too. He either didn't know it, which means he is making very public assertions without even doing a rudimentary amount of homework; or he knew it and willfully misrepresented my position. Neither is to his credit.

My professional activities have turned me into a fairly public figure, so my life's work is an open book, at the disposal of anyone with Internet access. My publication record in the peer-reviewed literature is accessible to all in two simple steps: go to PubMed.gov, and type 'Katz DL' into the search box. Three steps, if clicking "go" counts.

What that record, along with my CV (which is also readily available online at davidkatzmd.com, among other places) shows is that the statement in The Atlantic is nonsense.

I have run a research lab for roughly 15 years, secured and managed approximately $30 million in research funding, and published more than 120 peer-reviewed papers. Among those papers are reports of studies in complementary and alternative medicine, the alleged threat to science the commentator in The Atlantic and other self-proclaimed "guardians of science," oppose.

But doing science is not, and cannot be, a threat to science. We have studied complementary and alternative medicine modalities with an open-mind, and unbiased methods. So, for instance, we have shown that massage therapy does indeed appear to be a very promising treatment for osteoarthritis. Our research in that area is ongoing.

But we have also shown that chromium supplementation does not appear to be effective in treating insulin resistance. In direct contradiction to the allegation in The Atlantic, the results of our own research along with the weight of evidence have, of course, prompted us to stop using chromium supplements for this purpose. We published evidence, at odds with our hopes, indicating that yoga is not effective adjuvant therapy for asthma. Why would anyone continue to use what doesn't work?

We have shown that meditation combined with massage improves quality of life in end-stage AIDS. We have shown that homeopathy does not effectively treat ADHD in children. We have studied intravenous nutrients for fibromyalgia, and are as yet uncertain about the therapeutic effect.

There is additional nonsense attributed to me. I allegedly believe in "mysterious forces." My actual belief? There are no mysterious forces; there are just forces that exist, such as osmolarity, gravity and electromagnetism. Some forces that exist we understand well; some we understand poorly; and some, no doubt, are as yet undiscovered and we don't understand them at all.

I also, allegedly, believe in spoon-bending. (My actual view, of course, is courtesy of the education I received in The Matrix: there is no spoon! The jury is still out on forks ...)

If the guardians contend that under the expansive rubrics of "CAM" and "integrative medicine" there is nonsense and charlatanism, they are of course correct. If because of that they contend that nothing legitimate can be done under those banners, they might look more closely at the glass walls of the houses of conventional medicine before throwing such stones.

The guardians contend that CAM is all about lies, and its practitioners all authorized, and inclined, to lie to their patients. But telling a patient "I will never stop trying to find something to make you feel better" is neither lie, nor false promise, nor source of false hope (if, indeed, one never does stop trying). The promise, and the hope, are then real.

I am by no means a CAM zealot. In fact, I never had any particular interest in being involved in CAM. I always have, however, had an abiding interest in helping my patients get better.

A commitment to patients should not attenuate one's devotion to science and evidence. But it does require -- wait for it! -- that notorious 'more fluid' concept of evidence! This, according to the guardians of science, puts us into the realm of what they call "woo." Does it really?

Of course not. Fluidity is simply the opposite of rigidity. A rigid view of evidence is that it works like a light switch: on/off, pure illumination versus utter darkness. Any true scientist would consider this sheer nonsense. Even the brilliance of Einstein's relativity theory is the subject of ongoing validations, decades after his death. Science itself is fluid, constantly flowing in accord with new and better theories, new and better evidence.

What, exactly, is this dangerous "fluidity" I espouse? Actually, it is represented by a construct we have published on a number of occasions, and which I have presented at an Institute of Medicine summit. I call the construct CARE, standing for "clinical applications of research evidence."

The CARE construct suggests that there are 5 domains important to any clinical decision: safety, efficacy, research, preference, and alternatives. The construct is best illuminated by looking at the two extremes of its range.

Imagine a therapy that is perfectly safe, highly effective, supported by unassailable research, is just what the patient wants, and that faces no competition from any other therapy that can do the same job. Are there any doubts about the prudence of this choice?

At the other end of the range is a treatment that is likely dangerous, probably ineffective, and lacking good evidence, about which the patient is ambivalent, and for which there are safer, more effective, better studied alternatives. Any questions what to do in this situation?

The far-more-common clinical scenario, however, is in between. Consider a therapy that appears to be safe. There are indications in the literature that it might be effective. There is some relevant research, but no definitive clinical trials. The patient has tried everything that is routinely recommended for their condition, and is not better- and wants to try "something else."  There is no something else to try that is safer or better substantiated than the therapy under consideration.

The CARE construct, along with an awareness that evidence is not limited to flavors of "iron clad" or "absent," suggests that a promising but uncertain therapy is, indeed, the reasonable next thing to try in a patient who has already tried more conventional therapies which have failed. Take this incremental step along the spectrum of evidence, and you are into the realm of integrative medicine -- no hucksterism or false promises required.

This is what I presented at Yale. This is what I practice. Apparently getting one's facts straight is not prerequisite to writing commentaries in The Atlantic.

I have long been in the cross hairs of the self-professed "guardians of science." They have seen to it that I have been feathered, if not tarred, in cyberspace. Why? I maintain that responsiveness to the needs of patients is as great an imperative in medicine as responsible use of science. This is the basis on which I have been charged with quackery, and my position is: if this is quackery, I would rather be a duck than a doctor. Hence, the feathering.

I am, in fact, a card-carrying member of the evidence-based medicine club, and always have been. Among my publications is a textbook on evidence-based medicine which, if I may say so myself, is pretty good. It is from this foundation that I confidently assert that responsible use of science and responsiveness to the needs of patients that tend to go on even when the evidence base runs thin are not irreconcilable.

The inducement for me to practice integrative medicine was very straight-forward, and involved no eye of newt or voodoo rituals. As a primary care internist over a span of years, I simply had some patients I could not make better. Their pain did not go away, their migraines did not resolve, the medications that should have mitigated their various and sundry risk factors for chronic disease evoked intolerable side effects instead; their syndromes remained undiagnosable. This limitation was not specific testimony to my own clinical deficiencies -- although I readily admit those, as any honest clinician must -- because all such patients were referred to expert sub-specialists. When such patients failed to get better, it wasn't just because I couldn't help them; it was despite the best that modern medicine could offer them.

So a simple dilemma presented itself: when the conventional treatments fail to help a patient, do you tell them "sorry, I tried" and leave them to their fate, or do you pledge to help them look beyond the conventional to try to find something that might work for them?

I chose the latter -- still the road less traveled, many years later -- and that, indeed, has made all the difference, most notably for the patients I have been able to help as a result. When the going in medicine gets tough, a clinician can tell their patient "tough luck," but that to me seems wrong. Instead, I believe we should tough it out by our patient's side, and help make decisions when the next logical thing to try is far from clear.

That's what we do in my practice, which is also a matter of public record. Those who choose to denigrate it from a distance are hereby extended an invitation to visit, and, with the patient's assent, to sit in as we do what we do. I will surrender myself immediately to the butterfly nets of the authorities if at any point they see an eye of newt change hands.

With that image fresh in my mind, I anticipate the guardians lifting lines from this very post to continue their case against me. I hope they have fun. Assuming they get the quote right in the first place (really, how hard is that?), the rest of us will know the importance of context.

Someone might be quoted as saying "I believe I can fly." That might mean the person has decompensated schizophrenia. It might mean they've used LSD. But it also might mean they are a steely-eyed ninja airline pilot who not only can fly, but can land a crippled airliner in the Hudson River without injuring anyone, too! I rest my case for context.

Writing this is, inevitably, apt to seem an act of self-defense, and like all self-defense, to appear defensive. But to be honest, the guardians of science have done me no discernible harm despite their best efforts, and years of unsubstantiated allegations. So while I suppose I am indulging in some self-defense, I am far more concerned with defending science. Because the self-proclaimed guardians of science are denigrating it, every day.

Some of them critique research, without conducting any. Others critique patient care, never having cared for a patient. With friends like these, the public surely needs no enemies.

They reach conclusions about where I (and presumably others) stand without the careful review of my track record a scientific accounting would require. I have actually "mapped" the evidence base underlying complementary and alternative therapies, inventing a method in the process which has been adopted by the World Health Organization. They reach conclusions about the nature of my clinical practice, never having visited my clinic, and thus defiling the principle of direct observation on which all good science is based.

Science is advanced by an open mind that seeks knowledge, while acknowledging its current limits. Science does not make assertions about what cannot be true, simply because evidence that it is true has not yet been generated. Science does not mistake absence of evidence for evidence of absence. Science itself is fluid.

Science does not make assertions about what must be true when the evidence for it is in flux. Science does not espouse absolute knowledge, and scientists dutifully resist the tendency to fall in love with their own preconceived notions. Science subjects itself to the scientific method, which sometimes validates what one wishes to be true, and other times refutes it. A scientist accepts the results, whether hoped for or otherwise.

The self-proclaimed guardians of science are, in actuality, peddlers of propaganda. They practice their craft with a blend of sanctimony and hypocrisy, and violate the scientific method to advance their own notoriety. They make routine use of the term "woo" because it can mean whatever they want it to mean -- a decidedly unscientific practice.

They "defend" science with an apparently blind faith, a selective approach to information, neglect of first-hand observation, lack of due diligence, and a religious fervor hinting at fanaticism.
As such, their defense of science is an insult to science. Applying religious fervor to science is, at best, oxymoronic -- give or take the "oxy.'"

Dr. David L. Katz; www.davidkatzmd.com
www.turnthetidefoundation.org

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