Infiltrative Pseudoscience

It’s always nice to see anti-quackery efforts in mainstream medical and science journals. We need much more of it. At times it can seem as if SBM advocates are a lone voice and the bulk of our profession are unaware shruggies about the threat of pseudoscience infiltrating our profession.

A recent article in The Surgeon by Ben Li, Thomas L. Forbes, and John Byrne was a rare and welcome sanity check pushing back against the recent fad of nonsense in health care. Their title, “Integrative medicine or infiltrative pseudoscience?” coins a nice term I will probably start using. That is exactly what so-called alternative medicine is – an infiltration of pseudoscience into the medical profession and health care industries.

The article will appear pretty basic for regular SBM readers, but that is OK. It is a good introduction to the problem, and anything that stokes a broader conversation is a good thing. They outline the risks of infiltrative pseudoscience:

The use of CAM may cause harm to patients through interactions with evidence-based medications or if patients choose to forego evidence-based care. CAM may also put financial strain on patients as most CAM expenditures are paid out-of-pocket.

Some CAM treatments are not inert. They can therefore cause direct harm, or may have interactions with evidence-based treatments that cause direct harm. Usually, for those who have not thought deeply about this topic, potential direct harm is the only concern that comes to mind when considering the potential downside of using pseudoscientific treatments. This is only the tip of the iceberg, however.

With a little thought people will also usually realize that even harmless treatments may delay or replace effective medicine, and this too is a source of harm. While this may seem obvious, there is also some objective data to support this conclusion. As David Gorski recently noted, a 2017 study of cancer patients found that using CAM cancer treatments was associated with a higher death rate. This likely was mostly due to delayed or refused standard treatment.

The authors also note the potential financial harm, which I think is more extensive than even we realize. Once a desperate patient is in the clutches of an alternative practitioner, promising side-effect free “natural” cures for serious ailments, it is not unusual for the mark to pay tens or even hundreds of thousands of dollars. Sometimes the patient or their family has to raise funds from friends, family, coworkers, and others to pay these high costs, spreading the harm around.

Since insurance companies are not involved, it may be difficult to carefully track these payments, which is partly why they are likely underestimated.

The authors also hit upon another harm, often missed because it is downstream and indirect:

Recently, there has been controversy surrounding the leaders of several CAM centres based at a highly respected academic medical institution, as they publicly expressed anti-vaccination views. These controversies demonstrate the non-evidence-based philosophies that run deep within CAM that are contrary to the evidence-based care that academic medical institutions should provide.

This, to me, is the real existential threat of CAM. Perhaps recent political events have made us generally more aware of how fragile our institutions can be. They really do depend on a culture of dedication to the underlying principles. If you erode that culture, no institution will save us from ourselves.

Our medical profession is premised on a dedication to science and evidence, arguably dating back formally to the Flexner report of 1910. But this dedication to science in medicine only exists so much as the individual people in the profession understand and are dedicated to a reasonable scientific basis for what we do. There needs to be a culture of science and standards.

The worst thing about CAM is that it erodes that culture. It is, in fact, a direct attack on that culture. CAM proponents seek to undermine the standard of care, to confuse how science works and the relationship between evidence and practice. They want to change the rules of evidence, to water down regulations or carve out exceptions, and to promote false ideas. For example, they have managed to convince much of the public that placebos are effective medicine, despite the fact that their very definition includes that they are not effective.

Expressing anti-vaccine views is just one tiny symptom of this deeper problem. It was good for drawing attention to the problem, but we should not think anti-vaccine views are the extent of the problem.

CAM also erodes the public understanding of science in medicine and public trust in medical science. This is arguably part of a broader cultural phenomenon of lack of trust in experts in general. I do wonder how much of the “death of expertise” was driven by the alternative medicine movement. It certainly contributed to this phenomenon.

I would also add to the list of potential harm of pseudoscience in medicine, redirecting limited resources away from more promising treatments and research. The very existence of the NCCIH (National Center for Complementary and Integrative Health) proves this point. The reason for this center is to provide funding for research into treatments that could not justify funding with proper science. As a result billions of dollars have been arguably wasted without resulting in a single new treatment, or diminishing the use of CAM by proving it doesn’t work. This is a small percentage of the overall NIH budget, but still that is billions of dollars of wasted medical research.

How many health care dollars have been wasted on demonstrably worthless treatments? What about paying for the harm of relying on those worthless treatments? How many patients have been diverted from actually promising clinical trials, and how many researchers have wasted their precious career time chasing fantasies?

I think it is clear, from the many articles we have published here on the topic, that if anything the medical profession needs to push for more science-based practices, higher standards in medical research and reporting, and better understanding of medical research. There is actually broad recognition that this is true. But simultaneously we are allowing a subculture of CAM that is pushing for the exact opposite, and too many of our colleagues don’t see the risk of this situation.

At the end of the day, our first professional duty is to our patients. The authors recognize this too:

Although there are financial incentives for institutions to provide CAM, it is important to recognize that this legitimizes CAM and may cause harm to patients. The poor regulation of CAM allows for the continued distribution of products and services that have not been rigorously tested for safety and efficacy.

That pretty much hits it on the head – don’t fall for short-term financial gain by selling snake oil. We have a duty to our patients to protect them from harm. This does partly stem from proper regulation, but that is not all. We need to affirm our profession’s dedication to a solid scientific basis for our practice. That means an abject rejection of everything that CAM stands for.

If you don’t think that CAM is the enemy of science in medicine, then you don’t understand CAM and its proponents. Don’t be fooled by their marketing. They want a return to the pre-scientific days when health gurus could sell any snake oil they want at exorbitant prices, with any hyped claims that they want, without going through all that tedious science.

They want to get rich at the expense of the public health and the health of our patients, and we are failing our patients and our professional duty unless we fight against CAM as vigorously as possible.