Sunday, June 9, 2019

Hacks and Quacks

Sunday morning, and I'm just surfin' around on YouTube and what have you, and I ran across a video by GeneticallyModifiedSkeptic about how the quackbuster Sam Harris "beats quacks every time." Now I like this kid (real name: Drew McCoy). He's a young guy whose channel specializes in discussion of argument, belief, and reason, mostly centered on his own experience of moving from theism to atheism. He also explores the arguments of various proponents of contemporary intellectual positions like those of Jordan Peterson, religious cults, PragerU, and so on. So most of this broadly falls into the categories of general philosophy and epistemology--the "study of knowledge". His Facebook page lists one of his subspecialties as "debunks alternative medicine."

I emphasize that I like this guy, because I think he's smart and constructs his own arguments in a clear and accessible way. This blog post isn't meant to criticize him alone; rather his videos on alternative medicine--along with another bit of news I picked up on Google News this morning--inspired me to write about how we think about medicine, and why we think it.

The other bit of news comes form The Independent and concerns the sentencing for manslaughter the parents of a 7-year-old Italian boy, because his death was determined to be from the choice of homeopathic remedies for an ear infection, instead of giving him antibiotics.

This got me to thinking: what's really going on here?

Let's start with the Italian boy. I read the story. The homeopathic practitioner was said to have "underestimated the seriousness of the illness" when he persisted "despite recrudescence of the symptoms." In plain English, this means someone tried something that could have worked, and when it didn't and the kid got worse, the practitioner didn't punt to something else.

That doesn't have anything to do with homeopathy. Let me explain by analogy.

My mom was in a car accident. In the accident, her leg was pierced by an umbrella rib from a folded umbrella that was in the passenger-side door pocket. The wound got infected. She went to her doctor, who gave her an antibiotic. By the time she called me, the infection had gotten pretty bad and she told me "He gave me Keflex for a week, but that didn't clear it up so he gave me Keflex for another 10 days."

The infection was still a problem when I saw her, now more than 3 weeks into things. I lanced the wound, packed it, and changed the antibiotic to clindamycin. She was fully better in mere days.

Do antibiotics work? Of course they do, but there's this thing called "antibiotic resistance" and everyone knows about it, and why would you keep doing the same thing if it's not working?

So you can see that the real issue is clinical knowledge and clinical reasoning, not whether or not one should use antibiotics--or homeopathy, or essential oils, or prayer, or meditation, or whatever. Look, it's an axiom of clinical medicine that she might have gotten better with simple hot packs applied to the wound. Or...not, and so then we do something else. Get it?

McCoy does make one effective argument: why not just use something that has been proven to work? But that's not an epistemic question. It's still just a question of good clinical reasoning. And since he's not a clinician, I have to ask why he'd feel comfortable getting into an area that is so fraught with unknowns.

Take hypothyroidism, or low thyroid hormone levels. It's a mostly straightforward clinical problem, and the thing that cures it is T4 replacement therapy. I have not found any evidence that anything works as well as T4 for this problem. When people ask me if there's a homeopathic "cure" for hypothyroidism, I tell them "Take the drug. Think of it as food"--and technically it is, as the first treatments that effectively treated what was called "myxedema" (hypothyroidism) in the olden days was little hamburgers made out of cow thyroid gland.

Now take depression. Although there are some theories about the biological basis of depression, we really don't know what's going on. Furthermore, we don't have any good diagnostic instrument to measure depression. It's a black box. We know some general things. We know that many people improve on various antidepressants, but we can't predict which class of antidepressant will work in any given case, and we don't know what dose will work in any given case. And we don't know in any given case if antidepressants will work. I teach my students that prescribers can make general predictions: pure serotonin-focused drugs will often be somewhat sedating, so those drugs are a better first choice if the person has depression with anxiety or insomnia. Serotonin-norepinephrine focused drugs might be better if the depressed person lacks energy and sleeps too much. You get the idea.

I also teach my students that it takes time to see the effects of these drugs--regardless of category or class--and it takes time to find the right dosing. Side effects are many and often troublesome, and may lead to changing the drug as this becomes apparent. In the end, psychopharmacology is a bit of a crapshoot: it's educated guesses combined with active analysis of the ongoing case, with adjustments made ad lib based on results, or the lack thereof.

So to say that T4 works in cases of low thyroid is easy. To say antidepressants work for depression is a problem. That problem is complexity, and the difficulty I have with people who wish to "debunk alternative medicine" is that it ignores the complexity of clinical experience, clinical practice.

This is the issue I have with Harris, McCoy, or any of the many others like Edzard Ernst, David Gorsky and so on.

It is a fair intellectual exercise to experimentally inquire into the uses and effectiveness of various medical alternatives. Inquiring minds want to know--said the old ad tagline from the tabloid The National Enquirer! It is a fair exercise of political and economic policymaking to ask whether or not the costs of a thing justify public funding of its use. It is also fair to discuss the measurable harms to the public when people choose not to vaccinate. It's fair to express concern that people with low qualifications market products with broadly falsifiable claims in the hopes of bilking people out of their money while real medical problems go untreated. However, it is neither fair nor justified to spend one's time in a general enterprise "debunking" medical approaches one knows little about.

What I'll argue here today is related to something I've proposed a few previous times in this blog: These so-called skeptics have an agenda that isn't intellectual, it's psychological. I've written here before about the impulse these critics express as intellectual rectitude. It's the same "I'm right, you're wrong" attitude that affords them with a sense of superiority...or sublimates their woundedness at the harms they've seen when people make choices that don't line up with a logical positivist, materialist worldview. In the former case, it's just smug people behaving badly. In the latter case--usually among practicing doctors and nurses--it's despondency among clinicians who hate to lose patients to what sometimes prove to be bad choices.

But there's another side to this, and that side can probably be found all over South-central Pennsylvania, when some of my patients go back to see their doctors and tell them that I gave them some little white pellets and their __(fill-in-the-blank)__ got better, and stayed better. But you don't hear many doctors saying "Hmm, that's interesting. I wonder what happened there?" They shrug. Some may say something vaguely affirmative (which is at least good bedside manner!), or they may actively argue that the choice made was a poor one, and try to persuade the patient to do otherwise.

McCoy has a sharp mind and lots of promise as an interlocutor online. He--and others like him--falter when they stray into areas beyond topics like whether or not tax dollars should pay for things that have scant proof in the medical literature, or if the value of mass immunization to society exceeds its minimal harms to individuals. When he and others simplistically paint "alternative" medical approaches with a broad epistemic brush, their arguments crash on the realities of clinical experience, and the mysteries of human health and disease.

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