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UPDATE 4/27/2011: Here’s the online video of Dr. Novella’s appearance on The Dr. Oz Show:

  1. Controversial Medicine: Alternative Health, Part 1
  2. Controversial Medicine: Alternative Health, Part 2
  3. Controversial Medicine: Alternative Health, Part 3

Welcome, Dr. Oz viewers!

As managing editor of the Science-Based Medicine (SBM) blog, I am writing this post because our founder and exective editor Dr. Steven Novella was invited to be on The Doctor Oz Show. Later today, the episode in which he will appear will air in most of your local markets, and we wanted to make sure that any Dr. Oz viewer who sees the segment and as a result is intrigued (or angered) enough to wonder what it is that we are all about will have a convenient “primer,” so to speak, on the problem with Dr. Oz from a science-based perspective. In other words, who are these obnoxious upstart bloggers who are so critical of Dr. Oz are and, far more importantly, exactly why are we so critical? What is science-based medicine, anyway?

On to some of the answers!

Who is Steve Novella?

First of all, who is Dr. Steven P. Novella, the man who had the chutzpah to go into the proverbial lions’ den of Oz? An Assistant Professor of Neurology at the Yale School of Medicine and founder and president of the New England Skeptical Society, in his spare time Dr. Novella is also the host of the popular science and skepticism podcast, The Skeptics’ Guide to the Universe, as well as a blogger at his own personal blog, NeuroLogica Blog, and other related blogs, including The Rogues’ Gallery and SkepticBlog. A fellow of the Committee for Skeptical Inquiry and Chairman of the Board for the Institute for Science in Medicine, Steve was most recently named a Senior Fellow of the James Randi Educational Foundation (JREF) and director of its new Science-Based Medicine Project. As a result of this most recent appointment, SBM will be collaborating more closely with the JREF on projects related to science in medicine. As you can see, Dr. Novella’s activism on behalf of skepticism and SBM is extensive and varied. That’s why we can think of no better person to have appeared with Dr. Oz to try to explain what it is we at SBM find objectionable about how he covers many medical topics on his show.

What is science-based medicine?

Many readers have likely heard the term “evidence-based medicine” (EBM). It’s a (relatively) new buzzword designed ostensibly to describe medicine that is based on solid evidence, in contrast to much medicine practiced in the past that may or may not have been based on solid evidence. Indeed, I sometimes jokingly refer to some forms of medicine, particularly from more than a few decades ago, as “dogma-based” medicine or “tradition-based” medicine. We at SBM, however, have noted a problem with EBM. Specifically, EBM elevates clinical trial data to the highest level of its “hierarchy of evidence,” in particular, randomized, double blind clinical trial data. Under normal circumstances, where new treatments are developed “organically” from basic science and clinical observations, through preclinical experimentation (biochemistry, in vitro work, cell culture, and animal models), all the way to clinical trials, it is correct to rank randomized clinical trials as the “gold standard” of scientific evidence for or against a particular therapy. After all, many are the therapies and drugs that look promising in preclinical investigations, only to fail when tested in humans, many more than the therapies and drugs that succeed and prove their worth. Here’s the problem with EBM. While EBM works well for science-based medical interventions, it has a distressing tendency to break down when applied to medical interventions that are, from a basic scientific standpoint, highly improbable. And I’m not just talking mildly improbable, either, but interventions that are incredibly improbable.

To try to explain, my favorite example of this phenomenon is homeopathy. Homeopathy, you see, is improbable. Really improbable. You just won’t believe how hugely, mindbogglingly improbable it is. (Apologies to Douglas Adams.) Basically, homeopathy postulates two “laws,” the law of similars and the law of infinitesimals. The law of similars states that “like cures like”; for example, something that causes itching (poison ivy, for instance) can be used to cure itching. The law of infinitesimals then states that the more you dilute a remedy, the stronger it gets. It also postulates that the remedy is “potentized” by vigorous shaking between each dilution. A typical homeopathic remedy is diluted 30C, each “C” being a 100-fold dilution, which makes 30C a mixture that’s been diluted 100-fold thirty times. This results in a 1060-fold dilution, a one with sixty zeroes after it (by comparison, a trillion is represented by a one with twelve zeroes after it). To understand the significance of this, you need to know that a unit that chemists use to measure quantities of chemicals is the mole. One mole is roughly 6 x 1023 molecules. (One mole of table sugar, sucrose, for instance, weighs approximately 342 grams, which is less than 14 oz.) What this means is that typical homeopathic remedies are diluted way, way, way beyond the point where not a single molecule of original remedy remains. Indeed, some homeopathic remedies go up to 200C, which is a 10400-fold dilution. By comparison, the number of molecules in the known universe is estimated to be between 1078 and 1082. Clearly, for homeopathy to work, huge swaths of what we know about chemistry, physics, and biology would have to be not just wrong, but spectacularly wrong. It’s about as close to being impossible as can be imagined in modern science. Yet Dr. Oz promoted homeopathy on his show not long ago, and millions still swear by it.

Why?

Given that homeopathy is nothing more than water, one reason is nonspecific placebo effects. Combine placebo effects with the fact that, by design based on the way we calculate whether the results of a clinical trial are statistically “significant,” at least 5% of clinical trial results will be false positives; i.e., give a “positive” result when the treatment really doesn’t work. This is true for drugs as well as implausible remedies like homeopathy. In fact, it’s considerably higher than a 5% chance of a false positive, because the 5% number is more theoretical than anything else. It applies only when a clinical trial is perfectly designed and perfectly carried out, and there’s no such thing as a perfect clinical trial. Unfortunately, EBM does not take into account the extreme implausibility of a treatment like, for example, homeopathy, reiki, therapeutic touch, or many other “energy healing” methods. Clinical trials are all that matter, and the flaws in clinical trials can lead to the appearance that such remedies have an effect. SBM, in marked contrast, is evidence-based medicine that takes scientific plausibility into account. Because all the ins and outs of SBM could take up a book, we’ve written up a primer describing the concept of SBM, along with a bunch of links for those interested in learning more about it. Personally, I suggest starting with four posts:

The bottom line is that we at SBM reject the whole concept of “alternative health” in the title of Dr. Oz’s segment featuring Steve Novella. “Alternative medicine” represents a false dichotomy. Indeed, I frequently repeat an old joke that asks: What do you call alternative medicine that has been scientifically proven to work?

The answer: Medicine.

That’s because alternative medicine by definition is medicine that either hasn’t been scientifically proven to work or has been scientifically proven not to work, while “integrative medicine” is nothing more than “integrating” unproven “alternative” medicine with medicine scientifically proven to work.

Which finally brings us back to Dr. Oz.

The trouble with Dr. Oz

I can’t speak for the rest of the bloggers here at SBM, but up until about a year ago, I really didn’t have that much of a problem with Dr. Oz. I really didn’t. Admittedly, he did annoy me a bit with his tendency towards credulity towards certain forms of dubious medicine, such as reiki (which, when you come right down to it, is faith healing based on Eastern mysticism rather than Christianity). Also admittedly, I found Dr. Oz’s on-air persona to be a bit on the cheesy side. However, for the most part, before he got his own show and even early on after he got his own show, most of Dr. Oz’s health advice was at least semi-reasonable, much of it even science-based. As time went on, however, we did notice that, more and more, Dr. Oz seemed to want to “go with the flow” and “give the people what they want.” Why? we wondered. Dr. Val Jones, formerly a regular blogger for SBM, thought she knew the answer:

I told him [a business colleague] that I was contributing to a blog called Science-Based Medicine in an effort to combat some of the medical quackery that is being promoted online. He looked at me and said I’d never be a success with that message. He said that people like Oprah and Mehmet Oz were successful because they “went with the flow” and gave people what they wanted.

“Most people don’t want to think critically about things – they want to hear about miracle cures, self-help, and vitamins. They already have the media they ‘deserve.’ You’ll never appeal to a mass audience with your skeptical message.”

Even if that’s true, we view it as our mission to try to change that and encourage as many people as we can reach to learn to think critically about medicine.

So why would Steve agree to be on Dr. Oz’s show? It was a difficult decision, actually. Even in our wildest dreams we had no idea that our criticisms were even being noticed by Dr. Oz or his producers, much less having any effect. So, on the one hand, we were grateful to Dr. Oz’s producers for inviting our representative on the show. On the other hand there was very little time for Steve to make a decision, much less prepare, and, given Dr. Oz’s history, Steve and the rest of us were all—understandably, I believe—wary about how he might end up being portrayed. In the end, given that the mission of this blog is to promote science in medicine and medicine based on good science, we agreed that this invitation was an opportunity that we had to seize, even knowing the risk that Steve might be portrayed unfavorably. Even though, as I write this, I haven’t seen the episode yet, I have seen the preview. What I see is that my fears weren’t unfounded. The very title (“Controversial medicine: Why your doctor is afraid of alternative health”) is clearly slanted against the SBM point of view. Worse, even in just the brief promo clip presented, Dr. Oz:

  • Challenges Steve by asking, “Why do you not want me to talk about these therapies on the show?” This is a distortion of our position. Nothing could be further from the truth to claim that we don’t want Dr. Oz to talk about these therapies. What we don’t wnat him to do is to promote them as efficacious when they are not. What we want is a skeptical, science-based assessment of them. Despite the claim by Dr. Oz and his producers that we are “afraid” of alternative health, in actuality we crave an open dialogue based on science, both preclinical and clinical trials, not marketing hype, pseudoscientific claims, and testimonials.
  • Says it’s “very dismissive” of Steve to challenge these therapies as not working. This is the infamous “don’t be close-minded” gambit. Of course, the problem with being too open-minded is that your brains might fall out.

No wonder our readers are pessimistic at how Steve will be portrayed in the episode, and no wonder I took umbrage at being called “afraid” of alternative medicine.

Still, that Dr. Oz apparently was sufficiently stung by our criticisms over the last several months that he felt the need to have Dr. Novella on his show tells me that there may well be more hope than is readily obvious. My optimism aside, though, it’s impossible for us to deny that at huge part of the reason that Dr. Oz’s show is so successful is, no doubt, because he does “go with the flow,” serving up for the most part lightweight, fluffy, uplifting entertainment which sometimes contains good medical information. In this, he clearly learned at the feet of the Master, his mentor and the person who got him started as a media doctor, Oprah Winfrey, who has come under considerable criticism herself for promoting pseudoscience and New Age mystical beliefs. He’s also apparently learned at the feet of Oprah how to gin up a controversy, as his promo for Steve’s appearance shows.

Most disturbingly, though, of late Dr. Oz has been also promoting pseudoscience and what can only be described, in my opinion, as quackery. The snake oil that Dr. Oz has promoted over the last several months includes Dr. Joe Mercola, one of the biggest promoters of “alternative” health, whom Dr. Oz first had on his show about a year ago and then defiantly defended in a return appearance in early 2011. Then, in a rapid one-two punch, Dr. Oz had an ayurvedic yogi named Cameron Alborzian, who promoted highly dubious medicine, including “tongue diagnosis,” to be followed a few days later by something I would never, even in my most cynical assessment of Dr. Oz, expected, namely the appearance of faith healer Issam Nemeh on his show. Worse, Dr. Oz showed zero signs of skepticism. Unfortunately, Dr. Oz wasn’t done. In rapid succession next Dr. Oz endorsed a diet that he once eschewed as quackery and then, to top it all off, invited psychic John Edward onto his show, asking Is talking to the dead a new kind of therapy? This latter episode so shocked me that I basically said, “Stick a fork in him, Dr. Oz is done when it comes to SBM.”

Dr. Oz’s descent was complete, and that is now the trouble with Dr. Oz and much of the reason why in 2011 the James Randi Educational Foundation awarded him the The Media Pigasus Award for the second year in a row. I fear he very well may three-peat in 2012. The only thing that might save him is listening to his critics, but I fear that is unlikely. We’ll see.

Further reading about Dr. Oz

I hope you, our regular readers, will comment on Dr. Novella’s appearance, both here and in Dr. Novella’s post about his experience, the latter of which will be posted this evening after he gets a chance to see how the segment turned out after editing. I also invite Dr. Oz viewers to join in. Just register a user name and password here. In the meantime, here is a collection of critical posts and articles about Dr. Oz. Also, don’t forget to dive into the discussion forums at Dr. Oz’s website after the episode with Steve airs in your area.

From Science-Based Medicine:

From other sources:

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