 It's Sunday, July 18th, and this is For Good Reason. Welcome to For Good Reason, I'm DJ Grothy. For Good Reason is the radio show and the podcast produced in association with the James Randy Educational Foundation, an international non-profit whose mission is to advance critical thinking and we focus on the paranormal, pseudoscience, and the supernatural. With the incessant push of herbal remedies and alternative medical therapies, this is stuff like acupuncture, maybe aromatherapy, magnet therapy, healing touch, homeopathy, Reiki, all of that sort of stuff, how can consumers, consumers of medical technology of medicine find objective scientific information about these therapies? People can not only waste their money, they can endanger their health. My guest today on For Good Reason, Dr. David Gorsky, he's an expert on this sort of stuff. He is a surgical oncologist at the Barbara Anne Carmanos Cancer Institute specializing in breast cancer surgery, where he also serves as the American College of Surgeons Committee on Cancer Liaison Physician, as well as an associate professor of surgery and member of the faculty of the graduate program in cancer biology at Wayne State University. He blogs on skepticism and science-based medicine at science-basedmedicine.org and also at the very popular science blog, which can be found at respectfulinsolence.net. Welcome to For Good Reason, Dr. David Gorsky. Well, I'm glad to be here. Thank you for inviting me. David, more and more people are using complementary and alternative medicine, or is that just something that we're telling ourselves? Do the numbers actually show that the usage of this stuff is up? It's actually very hard to tell. Obviously, proponents of complementary and alternative medicine, which we like to abbreviate as CAM, because it's a mouthful to say the whole term, like to claim that it is, but it's not at all clear. You also have to remember that a lot of things that get lumped into the CAM category are not exactly CAM. Stuff like massage therapy, which I love a good massage, but am I engaging in woo-woo when I get one? Well, it sort of depends on what the massage therapist claims. I mean, if you're just getting a good massage to feel good, no. If the massage therapist claims that he's somehow channeling the energy of the universe into your muscles, well, then I would have to say, yeah, probably. I mean, Kimball Atwood, who's one of our regulars at Science-Based Medicine, actually put it pretty well when he said that for things like massage therapy, he's not entirely sure that you actually even need to do clinical trials unless you're actually making a therapeutic claim. I mean, if you're just going for massage just because it feels good, hey, more power to you. That's fine. People have known this for millennia. So that's not so much an issue. I feel the same way about aromatherapy. I'll sound like super gay when I say this, but I love taking bubble baths with lavender, right? And I guess I'm engaging in aromatherapy with all my lavender oils, right? Well, are you trying to cure anything other than bad smells? Yeah, I take exception to that. Well, everybody smells bad after a workout. Come on. Yeah, but I think the notion with lavender or some of these other scents, these fragrances, some people, I guess, make strong claims, but other people just like how it smells, right? The olfactory lobes, it's the strongest kind of sense that we have and it puts you in a good mood. Is that a supernatural claim? Is that even a medical claim? I guess that's debatable. Using, for instance, something like aromatherapy for that, I'm not sure that's even really a medical claim. It makes you feel better, but does it actually correct any condition or cure any disease or keep you healthy? You know, who knows? But the CAM persons or the people who like to promote CAM do tend to draft medical claims onto these things that really aren't medical modalities. Another example though, an example that I like to use of how what should be science-based medicine gets co-opted for CAM is exercise and diet. Somehow exercise and diet have become associated with CAM. Now, you could argue that perhaps conventional, quote-unquote, conventional medical doctors may or may not have provided or made enough emphasis on lifestyle interventions for various diseases and conditions. That's debatable, but there is nothing about exercise or diet that should be woo-woo, if you know what I mean. It's basically something that can be studied by science. It's something where we know certain interventions may decrease your risk of cancer, decrease your risk of heart disease, et cetera. I would actually take issue with some of the claims that conventional doctors, for want of a better word, don't emphasize these things. I don't consider myself that large. It's true I'm larger than I've ever been, but I'm by no means obese. However, when I took up with a new primary care doctor after moving to Detroit, what is the first thing she pushed on me? She was like, you're a little bit overweight. You could stand to lose 10 or 15 pounds, especially since your blood pressure is a little high, et cetera, et cetera. These were the first things she suggested, not medication. That might just be a difference in doctors though. That's anecdotal evidence. That's not how I want it. I know. You're right. I've been to some doctors who are, I'd almost consider eager to prescribe something. Other doctors, you have to do a fast-talking sales pitch to get any drug from. I guess we'll leave that topic aside. If we're getting into whether or not the numbers are as big as people say, let's backtrack and actually define the terms complimentary and alternative medicine. I've heard some skeptics refer to it as SCAM, so-called complimentary and alternative medicine scam, in other words. Do you think that's useful when we're trying to communicate about these issues or is it automatically kind of polarizing? There is a real problem with the nomenclature. Although other people have said it, perhaps Richard Dawkins summed it up the best in his special. I believe it was in enemies of reason where he pointed out that there's no such thing as alternative medicine. In my mind, I kind of view it this way. There are three kinds of medicine. There's medicine that's been scientifically validated to work as safe and effective. There's medicine that has not been scientifically validated to work as safe and effective. Then there's medicine that has actually had science shown it not to work or to be dangerous or something like that. And wouldn't you consider those last two categories not to be medicine at all? Well, exactly what the saying goes, once a therapy is shown to be effective through science, it ceases to be alternative and becomes simply medicine. And I'm obviously not the first person to have said that, but I like to use that particular quote. Well, let me ask you directly. Do you like the scam designation? In other words, I get the point of SCAM calling it scam. I understand that that's a way to say that it's not real and it doesn't really work. It's just so-called alternative medicine. But do you think that designation is useful? You know, it sort of depends on my mood, I think sometimes. I have used the term myself, although I usually don't actually abbreviate it scam. I will say so-called scam or so-called complementary and alternative medicine. And I think it's useful to point that out. I'm not so sure it's useful to call it a scam in that many of the people who use scam or integrative medicine, if you want to call it that, they believe it works. So they're not actually deceiving anyone other than themselves. But on the other hand, you could argue they're deceiving others when they promote it, but at the same time, they do believe. So I'm ambivalent about that term. I don't really criticize anyone who uses it. I'd be foolish if I did in a way because, for instance, Mark Cryslip seems to like to use it on our science-based medicine blog. But at the other hand, it makes me a little uneasy. David, I don't want to spend all of our time together just defining terms, but I note that we've talked these minutes so far and we still haven't really defined what complementary and alternative medicine is. And then you just used another term integrative medicine. Is that the same stuff? Basically, yes. It actually helps to go back to the history a little bit. This stuff used to be called alternative medicine. And when its practitioners wanted to achieve some sort of respectability, they realized that being considered alternative was not necessarily so good. So they came up with the term complementary and alternative medicine. In other words, it's supposed to complement quote unquote, Western medicine. Now I hate that term, but that's something we might be able to go into later. But as opposed to replacing it or being an alternative to Western medicine, it's supposed to be alongside Western medicine. Right. And then later on, more recently, they decided that they would like to integrate it into scientific medicine. So in other words, they would integrate Reiki, Acupuncture, whatever with the conventional science-based medicine. Or right now, in many hospitals, you'll find nurses doing therapeutic touch or what used to be called healing touch with no evidence backing it. But that's fully integrated into kind of full throttle Western medical institutions. Right. And the way I like to look at it is basically, for the most part, because most of these modalities are either unproven or clearly don't work, is that you're actually integrating pseudoscience with science, and I fail to see the advantage to that. It's actually rather difficult sometimes to define exactly what CAM is. If you look at, for instance, the way the National Center for Complimentary and Alternative Medicine defines it, they define it as systems that have either not been validated or that derive from other traditions besides the tradition that has resulted in science-based medicine. And they actually go into several different types of CAM, different medical systems based on different concepts other than science. Or just say traditions or indigenous peoples or something. The kinds of interventions that you as a skeptic might resist, don't they actually come from some of these folk traditions? And that's where we got things like quinine or digitalis. So we don't want to throw the baby out with the bathwater, do we? No, no. I mean, some interventions, for instance, herbal medicine is another category that should not really be considered CAM. That is actually natural product pharmacology. The difference is that CAM practitioners will make these rather vague and difficult or sometimes even difficult to test or sometimes even untestable claims that somehow the whole of the herb is better than what pharmacologists do, which is to find the active ingredient and purify it and make a drug out of it. I mean, herbal medicines are drugs. So the difference is, as opposed to pharmaceutical drugs, is that herbal medicines are impure drugs with variable quality and quantity of active ingredient and variable impurity. So obviously some of the drugs that we still use today come from various natural products. Digitalis, as you said, comes from Foxglove, as I recall. Aspirin was ultimately derived from a modified product that was isolated from Willow Bark. I'll give you chemotherapy example, which isn't really a CAM therapy or doesn't really have tradition, but some of the drugs we use today, a lot of the drugs we use today, come from natural products. The chemotherapy agent, Taxol, which is used against a wide variety of malignancies comes from the bark of the Pacific U tree. And until they develop the way to synthesize it, it was a problem getting enough of it without endangering the Pacific U tree. So CAM practitioners, boosters of alternative medicine, they say, aha, that's evidence that science should be more open-minded because this stuff actually works. And they're trying to include natural products pharmacology, as you said, into the broader category of complementary and alternative medicine. In fact, they say, you know, doctors, when they resist herbal remedies or something, they basically are just doing it because CAM and herbal remedies and all that, it's cutting in on their action, like big pharmaceutical companies, big pharma, as it's called, resist the herbal supplement movement, they say, because it's a million-dollar industry, and it's bad for Big Pharma's bottom line. But in fact, doesn't Big Pharma own the herbal supplement companies, right? Oh, that's true in many cases. And in fact, the supplement companies themselves, whether they're owned by Big Pharma or not, are significant economic forces. In fact, Utah, in the United States, Utah is a major center for supplement manufacturers. In fact, Utah Senator Orrin Hatch is a big protector of his state's industry, which in one big industry in Utah is the manufacturer of supplements. And in fact, earlier this year, when Senator John McCain and another senator whose name escapes me proposed a modification to the Food and Drug Act designed to tighten up regulations on supplements, Senator Hatch basically went to war. And ultimately, John McCain backed down because when the whole Tea Party movement started putting pressure on him, he couldn't afford to be seen as pushing a lot of government regulation. So it's actually these supplement manufacturers, although true, they're not as big as pharmaceutical companies. Even the ones that are not owned by pharmaceutical companies can have considerable political clout. So even if they're not billion-dollar Big Pharma transnational corporations, they're not the little mom-and-pop, you know, the David against the Goliath of Big Pharma. They are big companies themselves. Correct. Many of them are pretty respectable-sized companies. And then some of them are foreign companies. For instance, there is a French company that sells a homeopathic remedy for the flu and various other conditions, guaran, I believe, is its name. And it's actually pretty big business now. Is it as big a business as pharmaceutical companies? No. But it by no means, like you said, it's by no means little mom-and-pop stores or little mom-and-pop operation. Because I think that's actually, this is just my guess, but it seems to be some of the appeal of the outsiders who are into CAM and not science-based medicine. It's kind of a suspicion of the powerful doctor elite or the powerful pharmaceutical elite. It's this kind of us and them mentality where the little guy wants to support the little guy. At least my friends who are into alt-med, or I have exactly one friend who's into alt-med, so to be clear, that seems to be the gospel he preaches a lot. It's not just about the fact claims, almost the faith claims of the power of these interventions, but it's also this social critique against hierarchy and corporatism and profit and all of that stuff. Oh, without a doubt. In fact, there's a name for it. It's called the help freedom movement. And who doesn't want to have freedom, right? A rather libertarian viewpoint of, well, I don't want the damn government telling me what to do with my health. And I can understand that to a point except that health freedom to me frequently ends up meaning, when I look at it, freedom for quacks to do whatever they want without that pesky government interference. So, let me ask just pointedly, what's the harm if we're talking about this kind of social critique infusing a lot of the CAM movement? There are all kinds of people who are against the government or even against the corporation. They could be far left or far right. They meet somewhere. And is it up to the doctors, the class of our society with divested financial interests to defend their territory? That's also the criticism of you skeptics who go out attacking these alternatives. That is, the what's the harm argument sort of depends. Part of the problem is that some of these things will are frequently associated with people forgoing or delaying known effective science-based therapies. That's one potential harm. Another potential harm that I bring up, a lot of CAM is associated with, for instance, the anti-vaccine movement, which could be, you know, we could talk about that for another whole hour, but anti-vaccine movement endangers public health by driving down vaccination rates and thereby hurting or decreasing herd immunity to certain diseases. So, there's another potential harm. Okay, a lot of these CAM therapies, for instance, homeopathy, clearly do nothing. Homeopathy, as I like to say, is water. So, you say, well, what's the harm? I mean, part of the problem, and this comes down to somewhat of a value judgment. For instance, if what you're seeing, due to a CAM therapy, is a placebo effect, then some will say, well, what's the harm? It's a placebo effect that's not doing any harm. Part of the problem is to get that placebo effect, you in essence have to deceive the patient, or you're telling the patient something that is not true, that this stuff or whatever it is that you're giving them or doing is actually benefiting them in some way. Now, there's been an argument over the last 50 years in medicine, as far as paternalism. The funny thing is... That the doctor knows best that stuff. The doctor knows best. I mean, 50 or, you know, 50, 75 years ago, you could actually prescribe placebos as a physician, and physicians did. However, over the last 50 years or so, we've developed the medical model into a bit more of a collaborative model where it isn't the doctor always knows best, and the patient is supposed to have some autonomy. And that's somewhat market-driven, right? Because now the patient is considered a consumer of healthcare who has choices and has a voice. I think part of it may be market-driven, but I think part of it was going on before the rise of market-driven medicine. Whatever the cause, though, we don't really consider it proper medical practice or even entirely ethical to take on a totally paternalistic relationship with the patient. And I always find it rather ironic that what is, you know, that CAM supporters will rail against conventional doctors for being paternalistic, dictatorial, whatever you want to call it. And in order for their nostrils to work, you actually kind of need the paternalistic model where, you know, you tell the patient, this is what's good for you. And in fact, a lot of CAM practitioners do essentially that. David, I'm really glad you talked about this in terms of being a value judgment. So scientific skepticism or, let's say, science-based medicine activism, if you'll allow me to have that category. You know, doctors like you who don't just quietly do their doctoring, you know, at their hospital, but they speak out and the public interests try to educate people. There are some scientific skeptics who say you should not say anything unless it's supported by evidence. In other words, don't advance a point of view. Don't talk about the ethics of one thing or another. Surely don't talk about harm unless there are units of harm that you can measure. What I'm getting at right now is kind of distinctions and skepticism between some people saying, oh, it's completely kosher for doctors to say, homeopathy doesn't work and here's our evidence, but it would be inappropriate for a doctor to say, homeopathy doesn't work, but it doesn't harm you either. But the reason I'm against it is because you're lying to yourself and that's my beef. Do you understand the distinction I'm making here? Like it seems you're riled up because of the deception stuff, the value judgment, and some scientific skeptics would say that's verboten. Well, here's the problem. All medicine involves some degree of value judgment. And in fact, science-based medicine is no different. Science can tell us that treatment X doesn't work or treatment Y works or treatment Z works better than treatment A. But it can't always tell us which of these treatments would necessarily be the right treatment for this patient. Other factors sometimes come in. I'll give you an example from my specialty. As you know, I primarily treat breast cancer and I am a breast surgeon. We know from studies that doing a lumpectomy followed by radiation therapy produces equivalent survival to doing a mastectomy. Now, some women may choose mastectomy over lumpectomy for reasons that we may or may not agree with, but that fit their view of the world or their lifestyle. Is that a wrong decision? Of course not. However, I admit that I usually try to guide women who are candidates towards breast conserving therapy in the form of a lumpectomy, but if a woman like that chooses a mastectomy, who am I to say that she's wrong? If someone chooses homeopathy even though it doesn't work as long as it's not harming them, who are you to say that they're wrong to do so? In other words, you're no longer saying it's wrong to believe that untrue thing and here's the evidence. You're actually saying I judge that behavior as wrong morally and I think you shouldn't do it even though there's no harm in taking that homeopathy. In my example in breast cancer, both treatments we know to be equivalent. Homeopathy we know does not work. Now, I firmly believe that a competent adult has the right to do with his or her body, whatever he or she wants. If a competent adult decides that he wants to choose homeopathy, I will do my best with evidence, reason, etc. to try to talk him or her out of it, but if in the end that's what he decides, I don't have much that I can really say about it even though I know that opting for homeopathy is in essence opting for no real treatment. However, someone who gives a homeopathic remedy for whatever reason, if they believe in it or not and most homeopaths do, I think, believe in homeopathy, that's a different kettle of fish because it's basically deceiving the patient into thinking that an ineffective therapy works. Now, whether you believe in it or not... That's not a get out of jail free card. Whether you believe in it or not, I don't know that it makes such a difference other than in terms of whether you're being a fraud or not. The result is the same. A patient with a disease that might be potentially treatable with science-based medicine is being led down a path where he's taking ineffective therapy. So, you save your eye not for the consumers of CAM, but for the practitioners who peddle what you think is quackery, right? And it's not just because that is a kind of competitive business for your bottom line, but because of this harm. And the harm doesn't have to be in taking a poison that diminishes the patient's health, but it could be just in the patient choosing not to go to a real doctor. Those are charged words, but you know what I mean? Or just the patient believing nonsense, which is harmful in and of itself, some skeptics argue. Yes, that's more or less it. Whether believing in nonsense in and of itself is necessarily harmful, the end result can lead to harm for, as I pointed out, either delay in treatment or taking an effective treatment. I once wrote about a woman whose case I saw presented at a tumor board four or five years ago who basically showed up in her doctor's office with a breast lump, which was biopsied using a needle biopsy technique and shown to be a breast cancer. The surgeon recommended lumpectomy, sentinel node, you know, the standard of care, which would have produced about a 90% chance of her surviving five years and maybe, you know, an 85% chance of living 10 years. And beyond, in other words, you know, an 80 plus percent chance of being fine, of being quote unquote cured, although cancer doctors tend not to like, not to like to use that word. She opted not to and instead went to a variety of alt med practitioners for lack of a better word. And then two or three years later, she came back and this thing was now huge and starting to eat through her skin and had probably metastasized. She had lost her window of opportunity to quote unquote cure for cancer and now had a very high probability of dying of her disease. You know, it's hard not to get upset about hearing such stories. But that kind of upset feeling that you have is a kind of moral indignation. It's not just a scientist in a lab looking at evidence. It's an activist. It's a human being saying something is wrong. And of course, I see nothing wrong with that. Look, I was asking you some leading questions. That's where I was headed. You know, I wanted you on record as to whether or not the scientific skeptic should only be talking evidence or should also be talking right and wrong. And to that, I would say their medicine is not just science. We distinguish science based medicine from pure science. Medicine can never be a pure science because so many other factors come into the mix, including, you know, patient values, how the patient feels about various things, the patient's moral value system. Science based medicine is not about making medicine a pure science, which it can't really be. It's about basing what we do when we treat patients in what science tells us. So, as I said, science can tell us what works, what doesn't, what the chances are that a treatment will work, what the potential complications are, what the potential risks are. And together, the science based practitioner and the patient should be able to come up with a collaborative decision on the best course of action. And this decision may not be the same for every patient. So, it's a bit of a fallacy to view practitioners of science based medicine as saying that everything should be based on pure science. That's not what we're saying. What we're saying is that science should inform what we recommend to patients. We should not recommend to patients treatments that science tells us do not work or are not validated or, you know, in other words, most complementary and alternative medicine falls into one of those two categories. And because most CAM falls into one of those two categories and has the potential to cause harm, it's antithetical to the project of western or science based medicine, which has as its founding, I know this is even debated by some, but, you know, the premium known no serrate first do no harm the, the Hippocratic Oath, that sort of underlying philosophical or moral commitment informs all of the other stuff happening in medicine or should at least, right? Ideally, yes, it should. You know, our first duty is, of course, to do no harm whenever possible. However, it's true that we don't always succeed at that. But the idea is that we should strive that at the very least our treatments do not harm the patient. Again, what tells us what might be potentially harmful and what isn't? Science based medicine, the science that looks at the studies, we can weigh risk versus benefits in a rational science based manner and then help the patient decide which course of action would be the best for that individual patient. David, science based medicines role in medicine. That's a little confusing. Let me take it this way. Not every medical doctor is like you. I mean, they might even be steeped in science based medicine. They might not believe in complementary and alternative medicine interventions, right? But they're not out there trying to educate the public. They're not what we would call skeptics or scientific skeptics. They're not pushing that. And so my last question is why is that? What is, is it something about you that makes you want to rail against the quacks or is it something about the quacks that demands that you do? That's a difficult question. Val Jones who blogs occasionally for us coined a really good term for the vast majority of physicians when it comes to CAM and unscientific practices. She called them shruggies. Basically, the reaction is they shrug their shoulders when they hear about this stuff. It's kind of like it's not, you know, what do you want me to do about it? It's not my business, that sort of thing. And they kind of look the other way. Even though many of them will, as you say, realize that this stuff is nonsense without a basis in science. So the question, I guess, is what makes me not a shruggy and I think it's an outgrowth of my skepticism actually. I did not actually start being a proponent of science-based medicine. Oddly enough, I think my journey towards becoming a skeptic began about 12 years ago when I started to confront online Holocaust denial of all things. And then eventually, I started to become interested in skepticism and the skeptic movement. And then I discovered various online forums where alternative medicine was debated and alternative medicine proponents would promote their point of view. And I started reading this stuff and I couldn't believe a lot of it. There was, for instance, a news group called miss.health.alternative where I sort of, where I guess you could say I cut my skeptical teeth as far as science-based medicine goes. And I guess over time, as I read more of this stuff, I couldn't believe it. And then I started looking into it more. And it just got me fired up, mad. I don't know what you want to call it. And eventually, I became more and more active. And then about six years ago, I started respectful insulin and it sort of ballooned from there. But again, you're talking now about your emotional response, almost your moral or your ethical reaction to the peddlers of nonsense out there. And so it's not just about evidence, because as you say, the doctor, other doctors will look at the evidence and say, well, I'm a science-based medicine guy, but they're not activists about it. So with that, David, we've only just scratched the surface. I'd love to have you back so we can explore the topic of why more doctors aren't skeptics in the skeptics movement and many of the other things we touched on today. Thank you very much for joining me on For Good Reason. Well, thank you. I'd love to be back. Thanks for listening to this episode of For Good Reason. To get involved with an online conversation about today's show, join the discussion at ForGoodReason.org. Views expressed on the show aren't necessarily the views of the James Randi Educational Foundation. Questions and comments on today's show can be sent to infoatforgoodreason.org. For Good Reason is produced by Thomas Donnelly and recorded from St. Louis, Missouri. For Good Reason's music is composed for us by Emmy Award-nominated Gary Stockdale. Christina Stevens contributed to today's show. I'm your host, DJ Growthy.