Quactitioners II – The mystery of medical history

The Jobbing Doctor has an excellent quote on his blog:

One reason why medical history is not much taught in medical schools is that so much of it is an embarrassment – Lewis Thomas (1992)

Thomas put his finger firmly on one of the problems with the debate between scientific medicine and alternative medicine: scientific medicine’s reluctance to face the fact that in the bad old days doctors were as ignorant and dangerous as anyone else. This is counterbalanced by the fact that alternative practitioners are reluctant to accept that modern evidence-based medicine is safe. Established orthodoxy has moved on and the rebels haven’t, and this is causing wires to be crossed.

It would assist the argument enormously if medicine owned up to its embarrassing history, and then disowned it, staking its claim to be the truly revolutionary movement and the real alternative to the dangerous practices of the past.

You’ve seen the full version of this grid before. However that was a 20th and 21st century version. This version shows the situation in the 19th century when there was little science, and practice was based on observation and experience rather than trials.

Despite this, medics and sceptics frequently talk and write as if there have always been two separate paths – scientific medicine (good), and alternative medicine (bad), and I’m not convinced of this.

18th and early 19th century doctors were a dangerous bunch, as ignorant and hopeful as the herbalists and homoeopaths but with a fondness for powerful drugs, and frequently with an arrogant attitude. They killed millions of new mothers by giving them “child-bed fever” because they didn’t know that infection can be communicated by touch. They’d treat just about anything by drawing blood. Their favourite medicine was calomel which induced vomiting and acted as a laxative because it’s toxic. Their patients became addicted to opium in the form of laudanum. (When a showed a draft of this to a young doctor he pointed out that his predecessors used to massage women to orgasm to cure “hysteria”. It’s not called “doctors and nurses” for nothing). Dodgy sexual practices aside, it was no wonder that Samuel Hahnemann and Edward Bach devised gentler alternatives, even if the reason these alternatives did no harm was because they did no good.

So, if doctors were as ignorant as other practitioners in the 18th and early 19th centuries, what has changed? And what hasn’t?

The big change of course is that medicine now works. It cures diseases and in the main it doesn’t kill people. We now benefit from antibiotics, immunisation and increased standards of public health, not to mention treatments for everything from athlete’s foot to cancer. And all as a result of acute observation, empirical testing, double-blind clinical trials, and a widely-published and peer-reviewed evidence-base. The roll-call of conditions which are a thing of the past is awesome, and medicine has done away with these in the last 100 years or so.

By contrast, not much has changed in the practice of alternative therapies. This is partly because “traditional” is “good”, and partly because clinical trials are expensive and will either show that the interventions are not very effective (herbalism) or not effective at all (homoeopathy). Ben Goldacre rightly criticises homoeopaths for their lack of self-criticism and for treating their founder’s approach as dogma, and they most certainly aren’t the only ones. He contrasts this complacency and stasis with the continuous questioning of the scientific approach and the constantly moving medical frontier.

Another thing that hasn’t changed is the rhetoric of the alternativists. They still talk about medicine as if its practices were as dangerous and untested as they were in the 18th and 19th centuries. There are a whole bunch of reasons for this, including the difficulties the lay person has with medical science because of the poor quality of science education in our schools, the challenges in creating and interpreting drug trials (listen to R4′s excellent edition of More or Less on the subject), and the confusion that understandably arises about where and why to draw the line between things science can be certain about and things it can’t. Oh, and demonising doctors is good for business, of course.

But has the rhetoric of the doctors changed either? The science has, and the outcomes of the science most certainly have, but has the rhetoric? (I genuinely don’t know).

I’m asking because, as I said right at the beginning of this piece, if modern medicine admitted its murky past, it would make it much easier for us all to point out that the alternative practitioners are still living in it.

Quactitioners I – Sincerely WooWoo

Ben Goldacre’s recent Radio 4 programme seeks to place current food faddists (I assume he’s thinking of Gillian McKeith and Ian Marber) in the long tradition of American snake oil salesmen and mountebanks.  His programme discusses the history of these travelling showmen and also of food faddists turned businessmen such as Kellogg, Graham and the seller of Hadacol.  It’s a good programme, and I recommend  it.

However, it’s disingenuous of him to let his listeners infer that there are only two kinds of people providing health services – scientists and quacks.  He’s not alone: most of the sceptical commentators out there make a clear distinction between the good and the bad, the sheep and the goats, the disinterested practitioners of empirical science and the cynical and opportunistic pedlars of sugar-pills.  In fairness to Ben Goldacre, he’s more a much more subtle thinker than that, but even he tends to simplify the message to make it easy to convey.

It seems to me that there is no neat correlation between sincerity and science, and that it’s more useful if we consider that there might be four categories of people offering to help us with our health.

To make things snappy, I’m calling them the Good Doctors, the Celebrity Surgeons, the Profiteering Quacks and the Sincere WooWoos.

1. The Good Doctors are scientifically-minded as well as scientifically-trained, they are men and women of integrity who frequently work in shitty areas and research shitty diseases
2. The Celebrity Surgeons specialise in “diseases of the rich”, as Tom Lehrer put it and can be found practising perfectly good plastic surgery in Florida and dentistry in Harley Street.  Big Pharma can come into this category of profit-motivated scientists.
3. The Profiteering Quacks are the ones Goldacre really dislikes – they don’t let truth, logic or inadequate training stand in the way of getting tv deals and book deals and products on shelves – they know it makes cents.
   And finally:
4. The Sincere WooWoos are good people let down by a lack of critical thinking. They are troubled by modern medicine, particularly the cynical and profitable kind, so they they train as homoeopaths or acupuncturists or naturopaths, and then the Hawthorne effect and the Placebo effect builds them an anecdotal evidence base which reinforces their sincere belief in their success

The problem is that the debate ends up at cross purposes.  Too many sceptics restrict their criticism to the profiteering quacks without addressing the question of what is troubling about modern medical and surgical practice.  And likewise, far too many alternative practitioners throw out the baby of medical science with the bathwater of the profit-motive.

People like Ben Goldacre and John Diamond rightly argue that Profiteering Quacks are dangerous and leech on the vulnerable and insecure simply to make money out of them.  But those of us who defend science and evidence-based medicine need to accept that the group that I have flippantly categorised as “Celebrity Surgeons” do exactly the same thing, the only difference being that their interventions which are frequently unnecessary do in fact work – think of Jordan’s boobs and Michael Jackson’s nose if you doubt what I’m saying.

It isn’t enough to attack the woolly-thinking which leads trusting people to accept alternative practices like acupuncture and homoeopathy, we must also understand what it is about these practices which attract patients and practitioners, and what it is about “scientific” or “western” practices” which repel them.

Good Reading:

Bad Science – Ben Goldacre’s blog in the Guardian – eg his column about Gillian McKeith
Snake Oil – John Diamond’s searing criticism of alternative practitioners

Good Listening:

Skeptoid – a weekly 10 minute dose of evidence-based good sence
Bad Science – Ben Goldacre’s infrequent podcasts