In case you hadn’t noticed, snake oil is alive and thriving under the shield of alternative medicine. As the Baby Boomers approach retirement age and develop health problems, we can expect an even greater boom of quackery, pseudoscience, and misinformation. Even the most critically thinking scientist may think less critically when he’s sick. This column will examine questionable health claims using rigorous science and reason.
Alternative Medicine is a Misnomer
There is really no such thing as alternative medicine. There can be alternatives in medicine (penicillin vs. erythromycin) but there is no valid alternative to medicine. Either a treatment works, or it doesn’t. As soon as science shows that a treatment works, it becomes a part of scientific medicine and is no longer considered “alternative.” Treatments called “alternative” may be:
(1) Effective but not yet properly tested.
(2) Effective only as a placebo.
(3) Ineffective, but not yet proved ineffective.
(4) Proved ineffective.
(5) Obvious quackery that no one is going to waste time testing.
We can keep an open mind about (1) (2) and (3) without letting our brains fall out. We are justified in rejecting (4) and (5) unless new evidence overwhelms the old.
Complementary Medicine is Too Fuzzy
Complementary medicine includes anything added to standard medical treatment to make people feel better without having any objective effect on the course of a disease. Penn Jillette (the big, loud half of Penn and Teller) says that if all you want is to feel better, heroin will do quite nicely. Massages feel good; I’d feel better with a maid to do all my housework; my daughter would walk all over the mall on a broken foot if you gave her a $10,000 one-day shopping spree. Medical insurance should not be paying for maids and shopping sprees. Should it pay for massages? Where do you draw the line?
Where Do I Stand?
I don’t recommend complementary and alternative medicine; but if a patient wants to try it, I am not “against” it. I’ll say, “There’s no scientific evidence that X works, but some people do think X has helped them, and if you want to try it, I’ll work with you and continue to monitor your condition.” I think patients have the right to try anything they want to try, as long as they are doing it with informed consent. What I object to is misinformation. If a chiropractor says he’s going to try a manipulation that has seemed to help other patients with pain like yours, I have no problem with that. If he says you have a bone out of place and he’s going to put it back, and you need regular maintenance treatments for the rest of your life to keep it there, I get real unhappy.
Confusion About Glucosamine and Chondroitin
I’ll just call them G and C so I won’t have to keep spelling them. For many years now, these substances have been recommended for osteoarthritis of the knee. There were some supporting studies, but they were not conclusive. The alternative medicine folks claimed G and C really worked, but since there was no money in it for Big Pharma, the necessary studies had not been done. Finally, the National Center for Complementary and Alternative Medicine (NCCAM) at the National Institutes of Health let the advocates of G and C design their dream study to prove once and for all that it worked. The original plan was to measure an objective endpoint: joint space narrowing; somehow they ended up measuring subjective symptom relief. The study was published in The New England Journal of Medicine (arguably the most prestigious medical journal in the world) and the conclusions were reported in my local newspaper: G and C worked no better than placebo.
In a rational world, this would have inclined most people to reject G and C, especially since the rationale for their effectiveness conflicts with some basic physiological principles. According to Dr. Wallace Sampson, one 300 mg capsule of glucosamine is approximately 1/1000th to 1/10,000th of the available glucosamine, most of which is produced by the body. He says, “Glucosamine is not an essential nutrient like a vitamin or an essential amino acid, for which small amounts make a large difference. How much difference could that small additional amount make? If glucosamine or chondroitin worked, this would be a medical first and worthy of a Nobel. It probably cannot work.”
Alas, this is not a rational world. The next day my newspaper said, “G and C Effective for Arthritis Pain.” No, this wasn’t another study; it was the same one. Different people read the same study and came to opposite conclusions. How could this be?
I read the full report to find out. They tested groups of patients on C, G, C and G together, placebo, and a nonsteroidal anti-inflammatory drug (NSAID). The NSAID worked fastest and best. None of the drugs worked significantly better than placebo. However, when you organized the data by subgroups, there was one subgroup (those with moderate to severe pain) who did better with G and C than with placebo. With all those subgroups, you might expect one to show a false positive result by chance. Was this result real, or was it an example of “data mining” where you twist the data every which way until you torture it into conforming to your expectations?
The authors pointed out that their study was not designed to differentiate between such subgroups, so no recommendations for clinical practice could be made on the basis of this data unless it was confirmed by further investigation. There were a couple of strange things about it. I can’t think of any other treatment that works for severe pain when it doesn’t work for milder pain. And in previous studies supporting G and C the combination was no more effective than either drug by itself; this time only the combination worked. The authors also pointed out that G and C are classified as diet supplements and are not required to meet federal standards; so that patients can’t be sure of getting a pure product or the proper dosage.
So we have a properly done scientific study that evidence-based doctors can quote to show that G and C are no better than placebo and that true believers can quote to show that G and C are better than placebo. Take your pick.
The Golden Ducky Award
Senator Proxmire awards the Golden Fleece, James Randi awards the Pigasus, and the Annals of Improbable Research award the Ig Nobel prize. I propose another award for outstanding silliness in medicine. We could call it Outstandingly Silly Health Information and Treatments, but the acronym might be offensive. We could call it DUQ – Dumbest Unbelievable Quackery. But let’s be more subtle and call it the Golden Ducky – that brings to mind a childish yellow rubber ducky in the bathtub as well as the sound that a duck makes. Of course the award itself will be imaginary, just like the ideas it commemorates.
I just read that a group of ducks can be called a “flush.” That seems appropriate. A whole flush of Golden Duckies go to Seattle chiropractor Johanna Hoeller, to her patients, and to the Washington State Chiropractic Quality Assurance Commission. Hoeller has invented no-touch chiropractic. She can be seen in action on a video on her website at http://www.psbl.com/hoeller/index.htm. She grasps her wrist with her other hand and produces snap-crackle-pop Rice Krispie sounds in her own wrist, holding it about an inch away from the patient’s skin surface. When the popping stops, the patient’s neck is supposedly realigned. I guess she has to keep not touching to maintain the alignment, because one patient said she’s been treating him for 7 years. The best part: she doesn’t even know what she’s doing! After watching herself not touching the patient on video, she acts amazed and comments, “My whole thing is that I’m touching.”
What’s wrong with this? Everything. In the first place, the whole idea of chiropractic (as opposed to the spinal manipulation therapy used by evidence-based practitioners) is based on a mythical “subluxation.” In the second place, she claims to be using the N.U.C.C.A. method, a “hole-in-one” technique in which the top neck vertebra is adjusted and that supposedly makes all the rest of the spinal vertebrae fall into line like good little soldiers – an idea which even most chiropractors reject. And she takes unnecessary x-rays. And she is either deliberately lying or she can’t distinguish reality from imagination.
I reported her to the Chiropractic QA Commission for (1) pretending to do a procedure, (2) billing patients for a procedure she has not done, and (3) being frankly delusional. They watched the video, decided she really touched the patient and was only pretending not to on the video, and dismissed my complaint on the basis of a short telephone conversation with each other. They said what she is doing is legal. I wrote the State Secretary of Health and asked if I could legally pretend to take out someone’s appendix or an imaginary tumor and charge them for it. If so, I can foresee a lucrative career ahead of me. I convinced them to reopen the case, but I won’t hold my breath. I don’t think they care what chiropractors do as long as they don’t get caught defrauding insurance companies or having sex with their patients. It’s up to us emptors to caveat.
For reliable information about other questionable health claims, visit www.quackwatch.org.
This article was originally published as a SkepDoc column in Skeptic magazine.