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Confessions of a Quack

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In thecomments section, someone (thanks, whoever you are) mentioned a book about Holistic Harry and I tracked it down and read it. The title is. It is fiction but is apparently semi-autobiographical; the author is Steven Bratman, MD, who coined the term “orthorexia” to denote an unhealthy obsession with eating healthy food. Holistic Harry is an MD who practices alternative medicine under the guise of “integrative medicine.” He develops an understanding of the importance of double-blind studies, realizes that what he has been doing is nonsense, loses his alternative medicine beliefs, but finds that it’s impossible to just quit. The book entertained me, made me laugh out loud, and gave me more insight into the thought processes and motivations of alternative medicine patients and providers. I think anyone who reads theblog would find it enlightening. The book is available free on the Internet

The anecdotes in the book go a long way towards answering two questions that come up frequently on the Science-Based Medicine blog:

Are alternative medicine practitioners or quacks sincere? Do they really believe in what they are doing and saying, or are they deliberately misleading patients? Why do patients fall for their nonsense and keep coming back even when they’re not getting better?

The Look

A patient gave Holistic Harry The Look. “The Look was an affectionate, misty expression that said, ‘You’re every patient’s dream, a wonderful, amazing doctor, a gift from God, a true healer of the sick.’” What had he done to deserve The Look? He had prescribed butterbur because he’d recently read a study that found it effective for migraines. But the patient didn’t have migraines. And she had developed severe diarrhea and vomiting, along with a litany of other weird symptoms. She “knew it was just one of those healing crisis things” so she kept taking it and now she feels better than she has in years.

He knew she had probably coincidentally come down with stomach flu on the same day she started taking the herb. But it was always possible she had some unique metabolic defect that made butterbur a miracle cure for her; and maybe he had finally hit on the right placebo for her, or she had finally reached a state of readiness to respond to placebo.

He wanted to stop the butterbur and send the patient to a neurologist. So he told her the butterbur had flushed out her triple heater meridian, spilling into Pingala Nadi, flooding her Agnya chakra and setting off a Herxheimer-like reaction. It had completed its job, and taking more at this point might over-flush her meridians. He knew she expected him to give her something else, so he said he would prescribe a great many herbs to support the next phase; but some of the herbs were pretty strong, so he wanted her to see a neurologist first, to make sure the circulation in her brain was up to the task.

When she left the office, he thought “I can’t keep this up another day. I’ll go out of my mind.” But then he thought about his financial obligations and living expenses and realized if he didn’t keep it up, he’d go broke.

He is deeply conflicted, because he thinks if he confronted patients with the facts as he now understands them, he would be hurting them, taking away their treasured beliefs and withdrawing the placebos they had come to depend on. On one level he knows his gobbledygook explanations and ineffective treatments are not really helping the patient, but on another level he still feels he is helping them in some way. At any rate, they believe he is helping them.

He felt betrayed

…he felt betrayed. Betrayed by all those alternative medicine authorities who spoke as if they knew what they were talking about when they didn’t know a thing. He’d trusted them for so many years, only to find out that they’d misled him on almost every point. How often had he read a citation of fact in an alternative medicine book and traced down the origin, to find that the first book was only quoting another book, which in turn was quoting yet another, and so on? When he finally reached the origin of the statement of fact he found that it was either a mere opinion propounded by a 19th century crank, or if an actual fact, one that had been twisted or even reversed by the subsequent game of telephone. Alternative medicine wasn’t just bad science: it was terrible journalism too.

He felt betrayed by his patients, too:

They were always couching their questions in such a way as to assume his agreement with alternative medicine theories or techniques he regarded as pure drivel. “What’s the best way to detoxify my liver? Which is more purifying, lemon or lime? How can I remove the damp heat from my spleen? What’s the best way to realign my DNA?” It was too much work to explain that the basis for their questions had no basis in reality. All he wanted to do was take them by the collar and bounce them out into the street.

A colleague diagnoses one of Harry’s long-time patients with Candida. Harry excuses his own failure to diagnose it thusly:

when I first started with Mrs. Bates, years ago, she had too many layers of disease overlying her Systemic Candidiasis for me to see it. It was necessary to clear away the top layers before the Candida problem could show itself… Once you get rid of her Candida, which will probably take a year or so, then you’ll be able to look for the next layer below that. And so on. You can keep on clearing her out at deeper levels probably forever.

His colleague doesn’t recognize his tone of sarcasm, and responds “That’s so wonderful. This is what real healing is about. It’s so much my dream.”

A colleague treats a patient for years for frequent bladder infections; but she still has them. The colleague blames the patient: she hasn’t completely cut wheat out of her diet.

That was the great thing about practicing alternative medicine: it provided sufficiently difficult rules that you could always blame your patients when they didn’t improve… From a legal, rational point of view, of course, she should lose her license. She was a quack and a fraud. But she was such a sincere fraud, and she meant nothing but well. [Harry] didn’t want it to happen to her.

About people who think they have found The Truth:

Much is given to those whom life has spared critical thinking skills.

The virtue of lying

When Ashley tells people that acupuncture balances the body’s energy, at least she’s believes it. We’re lying consciously. Doesn’t that put us in the wrong?” “Not at all. In medicine, lying is a virtue. It powers the placebo effect. [Patients] project their desires onto us, and those desires are real. They dream us into being as holy healers. We’re their work of art. Look, Harry, our patients want to have it all: treatments that are as effective as those of scientific medicine, but also soft, humane and gentle. Ancient wisdom magically free from ancient superstition. Reliability without the trouble of research. It isn’t possible, but they want it anyway. So why not pretend to give it to them? If they believe, then it will be real. People have a ceremonial need for doctors. What we say to our patients is a kind of liturgy. Whether it’s factually true or not is beside the point. All the bullshit alternative medicine is just ritual magic. And it works. Doctors have to do what they think is best for their patients. If you know in your heart that a patient needs chelation therapy, you should do chelation therapy. Even if he didn’t believe that Feldenkrais actually cured back or neck pain, surely people would benefit from Melanie’s kind touch. They’d feel better for seeing her, comforted by her kind presence if nothing else. That alone was worth her fee. And Feldenkrais certainly taught a kind of grace and balance. He’d heard a few testimonials so remarkable that moved even his skeptical heart. What if for some people, the magical reputation of Gerson acted as a particularly powerful placebo, and actually did help the cancer? It was at least possible. Facts don’t feed the soul. It’s better to live in a world where healing wisdom exists. If it doesn’t, someone has to make it up. It’s far better to lie. What we are doing is a holy thing.

Funny anecdotes

One of Harry’s friends sells subliminal healing tapes. He eventually realizes that the laws of physics and the signal-to-noise ratio of audiotapes ensured that the subliminal messages on his products were physically inaudible. On the next tape, he leaves off the subliminals. That tape beats all previous sales records.

Someone is selling “Homeopathic Healing Sounds.” Apparently, consumers were supposed to turn down the volume until they couldn’t hear anything, in order to receive soothing inaudible subsonic vibrations.”

When a colleague recognizes a Quackbuster masquerading as a patient, she reports “I gave him that speech about how we only use treatments that are supported by scientific evidence. Like detoxification. I think it confused him.”

As Harry starts to wise up, he comes up with a perfect answer to a patient.

Patient: Your body uses aspartate to make energy, doesn’t it?

Holistic Harry (thinking to himself): Well, yes, and cars use spark plugs to run their motors, but if you dump ground up spark plugs into the gas tank, the car won’t run better.

This is a great analogy that I will remember and use. It applies to so many alternative medicine claims, and to the “structure and function” claims allowed for dietary supplements under DSHEA .

From quack to evaluator

When Harry writes a book, he sprinkles in scientific studies to give the appearance that his recommendations make sense. Then he proceeds to make up testimonials. “The AMA, the American Dietetic Association and the American Heart Association jointly condemned the EightFoldWayDiet, and in consequence the book sales tripled.”

When he is investigated by the Medical Board, he hopes they will take away his license and make the decision for him so he can stop practicing quackery. But his friend tells him, “Sweetie, you’re not going to lose your license. You couldn’t bribe the Board to take it away from you, not for a million dollars.”

His dilemma is resolved when the Board suggests he retire from practice and head a commission to evaluate the scientific evidence for alternative medicine. He knows that when science digs deep into alternative medicine it mostly finds elaborate placebos, but the beauty of the solution for him was that he could tell the truth and it wouldn’t hurt anyone.

The Appendix

The book ends with an Appendix explaining double-blind studies.

Although most people have heard of double-blind studies, few recognize their true significance. It’s not that double-blind studies are hard to understand; rather, their consequences are difficult to accept. Why? Because double- blind studies tell us that we can’t trust our direct personal experience. This isn’t easy to swallow. It’s nonetheless true.

He goes on to explain confounding factors, the placebo effect, observer bias, regression to the mean, statistical illusions, and many other essential concepts familiar to readers of the Science-Based Medicine blog.

Alternative medicine contains a few modestly effective individual treatments, but its grand schemes of healing most likely possess no more truth than other pre-scientific approaches to understanding the physical universe. In Harry’s words, the body is a biochemical machine, alas, not a spiritual entity composed of subtle energies, and one can’t get very far without a microscope.

The endnotes to the Appendix are not just references, they are as informative as the text. For instance, there is a detailed account of the history of studies on hormone replacement therapy. In another endnote he tells us,

St. John’s wort (used for depression) is said to “support healthy mood.” It does not have any such general effect. It treats major depression of mild-to-moderate severity, a far more limited action. A supplement company complying with the rules of the FDA is therefore violating the false advertising rules of the FTC.

Conclusion: Worth reading

Fiction can sometimes be more illuminating than nonfiction. Do quacks believe in what they are doing? Some do, some don’t. If they don’t believe, their patients believe for them. After reading this book I have a better understanding of what motivates alternative medicine practitioners and their patients, how they think, and how placebo medicine is practiced. It’s a good read, with a villain (the Quackbuster), not one but two love interests, a dramatic tension that is eventually resolved, and a lot of funny incidents along the way. The Appendix is well worth reading as a stand-alone essay; it explains what Science-Based Medicine is all about.