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Uncertainty in Medicine

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One of the reasons I went into medicine was the naïve idea that doctors always know what to do. I was wrong. Marya Zilberberg got it right when she said, “The only certain thing about medicine is uncertainty.” Patient histories are uncertain, physical exams are uncertain, tests are uncertain, diagnoses are uncertain, treatments are uncertain, even human anatomy is uncertain. Doctors are not scientists; they are practical users of science who apply scientific evidence to patient care. Medicine deals in probabilities and informed guesses, not certainties. Symptoms can mean many things. They can be a sign of serious illness requiring treatment, an illness we don’t yet know how to identify and treat, a benign condition that will resolve without treatment, a hyper-awareness of normal bodily functions, depression, somatization disorder, malingering, or a cry for help.

The patient’s account of his symptoms and medical history is uncertain. Memory is unreliable. We forget, we distort, and we remember things that never happened. Patients want to present themselves in a good light; they tend to underestimate their alcohol and tobacco use and hesitate to mention sexual indiscretions and foolish use of nonsensical remedies. Their answers to “how much pain on a scale of 1 to 10” depend on variables such as their current mood and their degree of stoicism.

Doctors do a “review of systems” (often by a printed questionnaire) asking about symptoms in different body systems (respiratory, gastrointestinal, etc.). Answers will depend on how significant the patient thinks the symptoms are. One patient may answer “no” to heartburn because he thinks his heartburn is not worth mentioning; another may say “yes” because he remembers he had a mild burning sensation for about 2 minutes once last month.

Physical exams are uncertain. It’s easy to miss an abnormality like an enlarged spleen unless you suspect it and try hard to find it. Even anatomy is uncertain. Some people have reversed organs (situs inversus), where the heart is on the right and the appendix on the left. Some are missing a kidney. The location of blood vessels and nerves is variable. Look at the veins on the back of your hands; they’re not in exactly the same place on each hand.

Even something as apparently straightforward as the obstetrician’s announcement “It’s a boy!” can be wrong. In my recent article on gender differences (“Gender Differences: What Science Says and Why It’s Mostly Wrong” in Skeptic 18.2) I listed five determinants of biological sex in a newborn (sex chromosomes, gonads, hormones, internal genitalia, and external genitalia) and the many ways in which each of these can go wrong. Other factors later in life contribute to classification of sex and gender: development of secondary sexual characteristics at puberty, the sex the person was reared as, gender self-identification, object of desire, behavior, dress, role in society, and legal gender.

Laboratory tests are uncertain. Normal lab values are determined by testing lots of normal people, creating a bell curve, lopping off both extremes, and arbitrarily designating the central 95% as normal. Results outside the normal laboratory range aren’t necessarily abnormal, and results within the range aren’t necessarily normal. If a healthy person gets 20 tests, one is likely to be outside the “normal” range just by chance. Lab errors can occur from mislabeling, failure to calibrate instruments, procedural errors, and clerical errors. Diurnal variation, pregnancy, drugs, diet, exercise, and supplements may affect test results.

Imaging studies can be misleading or misinterpreted. A famous fMRI of a salmon appeared to show that it was thinking, but the salmon was dead. When the figure of a tiny gorilla was added to a chest CT scan, 83% of radiologists who read the x-rays looking for signs of lung cancer missed the gorilla: an example of inattentional blindness.

Screening tests involve a lot of uncertainty. False positive results can lead to unnecessary worry and further investigation including invasive tests that may result in harm or death. The United States Preventive Services Task Force (USPSTF) recommends the following tests not be used for routine screening because they are likely to do more harm than good: PSA tests, EKGs, TB tine tests, scoliosis checks, and chest x-rays.

Doctors are not scientists; they are practical users of science who apply scientific evidence to patient care. Medicine deals in probabilities and informed guesses, not certainties.

Direct-to-consumer genetic testing can be misleading. A blue-eyed man was told he had the genes for brown eyes. Testers only look for specific SNPs (single nucleotide polymorphisms) and report probabilities based on imperfect information. They may report that people with your SNP are 30% more likely to develop Parkinson’s disease than people with other SNPs. But disease is not destiny. Even if you have the gene for a disease, that gene may or may not be expressed. Gene expression depends on environmental and epigenetic factors and on interactions with other genes. Our access to genetic information currently exceeds our understanding of what that information actually means.

Diagnosis is uncertain. Some conditions, like Alzheimer’s disease, can’t be definitively diagnosed until autopsy. Tests don’t make a diagnosis; they only raise or lower the likelihood of the diagnosis compared to the pre-test likelihood. The Diagnostic and Statistical Manual of Mental Diseases (DSM) has been widely criticized: its reliability and validity have not been established, it categorizes by symptoms rather than causes, it is culturally biased, it tends to medicalize common life problems, and it labels and stigmatizes patients. Earlier editions of the DSM labeled homosexuality as a psychiatric disorder.

Doctors must constantly make decisions based on inadequate information. They can’t afford “analysis paralysis.” If they hesitate like Hamlet, their patients may die. They walk a fine line between indecisive humility and the reckless arrogance of overconfidence. Surgeons in particular must decide and act swiftly before the patient bleeds out.

Will Rogers said, “It isn’t what we don’t know that gives us trouble, it’s what we know that ain’t so.” For years we “knew” that routine episiotomies, radical mastectomies, and internal mammary artery ligations were benefitting our patients; but controlled studies showed they weren’t, so we stopped doing them. For centuries doctors were sure bloodletting worked, but it was actually killing patients.

Treatment involves a lot of uncertainty. Choosing the best drug for each patient is mostly a crapshoot. Genetic testing promises to eventually guide us in individualizing drug choices, but it isn’t of much practical use yet. Choosing an antibiotic for pneumonia or meningitis is a guessing game based on exposure, travel, immune status, allergies, the most common causes of those infections, and the prevalence of bacterial strains in the community. Waiting for culture and sensitivity testing is not an option, since the patient may die before the results are back.

There is uncertainty in communication. Patients don’t remember most of what a doctor tells them. In a recent study of patients on palliative chemotherapy for terminal cancer, many patients were under the false impression that it offered them a chance of cure or longer survival when its only purpose was to ease their dying.

When no diagnosis is found, doctors and patients must decide when to stop testing and accept uncertainty. Once serious diseases have been ruled out, the likelihood that further tests will identify something significant and treatable is diminishingly small. Too much testing can hurt the patient through false positives, unnecessary anxiety, false hope, wild goose chases, and invasive, dangerous, expensive diagnostic procedures. At some point we should stop asking “why” and focus on “how” to cope with symptoms and improve quality of life. Three things can happen. The symptoms may go away (in which case, who cares what caused them?). They may stay the same, in which case we can keep trying to find better ways of coping. Or they may get worse, in which case we can always reevaluate and reconsider the need for further tests.

We can learn to live with uncertainty, and surely it’s better to be uncertain than to be certain and wrong. Voltaire said, “Uncertainty is an uncomfortable position. But certainty is an absurd one.”

CAM (complementary and alternative medicine) deals in certainties. The chiropractor is certain your symptoms are caused by subluxations and treatable with manipulations. Naturopath Hulda Clark was certain all disease was due to parasites, and was certain she could cure everything with her zapper; but she failed to cure herself. Sherry Rogers, author of Detoxify or Die, is sure diseases are due to toxins. A business man named Robert Young is sure they are due to acidosis. Acupuncturists are sure disease is due to obstructions or imbalances in the flow of qi.

Skeptic magazine 18.4

This article appeared in Skeptic magazine 18.4 (2013)

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I once searched the web for “the one true cause of all disease” and found 67 of them! They included refined sugar, grains in the diet, stress, ama due to aggravated doshas, free radicals, sin, allergies, poisonous chemicals, a congested colon, witchcraft, overeating, food acidity, toxic metals, arrogance, impairment of movement of the bones of the skull, cold, and poverty. On one website I learned that “The United KKK States of America is the root cause of all disease.” I have no idea what that means, but I guess it’s convenient to have someone to blame.

Cranks and quacks lack humility in the face of disease; they demonstrate the arrogance of ignorance. They lure their victims with false promises of miracle cures for incurable diseases and less scary “natural” alternatives to surgery, chemotherapy, radiation, and drugs. They don’t know what they don’t know, and that makes them very dangerous.

Modern medicine is riddled with uncertainty, but it’s still far better than any other option. Doctors understand basic science, realistically judge probabilities, wrestle with the realities of uncertainty, and make informed guesses based on the best currently available evidence. CAM deals in certainties based on fantasy and intuition. Scientific medicine progresses over time and discards treatments that don’t work; CAM never admits errors and makes no progress.

Uncertainty can be a good thing. END

About the Author

Dr. Harriet Hall, MD, the SkepDoc, is a retired family physician and Air Force Colonel living in Puyallup, WA. She writes about alternative medicine, pseudoscience, quackery, and critical thinking. She is a contributing editor to both Skeptic and Skeptical Inquirer, an advisor to the Quackwatch website, and an editor of Sciencebasedmedicine.org, where she writes an article every Tuesday. She is author of Women Aren’t Supposed to Fly: The Memoirs of a Female Flight Surgeon. Her website is SkepDoc.info.

57 Comments

  1. Truthseeker says:

    Is Trump the symptom of disease in our body politic, a cause, or both?

    • geezer says:

      Trump is the CURE!!

      • J Dan Vignau says:

        Trump is only the cure to those unfortunate souls who believe in folksy, alternative medicine more than science.

        • Dennis says:

          Do you have some evidence supporting the existence of this ‘soul’ thing of which you speak?

    • Thomas says:

      To Truthseeker:

      It may be so. He is certainly a chance for change in an declining society and Government that is typified by Obama.
      The alternative is equally bad. The only redeeming point about Hillary Clinton is her being the first female Presidential Candidate.
      I am not certain which is worse for America, and the world.

      The article is superbly and wisely written. Kudos to the author!

      • alan neumann says:

        I’m just asking here, what is the decline in society and Government and how is it typified by Obama?

  2. Ronnie says:

    Or Trump is the unpalatable remedy for an ailing political system?

  3. grant says:

    piles can present in various ways!

  4. Beth Lawton says:

    I’m surprised that Dr. Hall lumps all complementary and alternative medicine (CAM) into one group and then disparages it. Although I mostly use allopathic medicine, my understanding is that many CAM options have demonstrated scientific benefit (such as acupuncture) and ought to be considered in the armamentarium, with the same caveat of uncertainty that is appropriate for allopathic medicine.

    Thanks for an interesting article – and a very nicely written explanation of why the uncertainty exists and some ideas for how to realistically conceptualize and use health care when appropriate.

    • Thomas says:

      To Beth Lawthon:

      Read about the debunking of Acupuncture in the last issue of Scientific American. It is the second article – the previous one was published in the August 2005 issue, entitled : “Full of Holes” Both are worth reading, unless you have your head firmly in the sand.
      Cheers!

    • J Dan Vignau says:

      Acupunctur3e and aspirin have been shown to have about the same percent of placebo effects on headaches as a sugar pill. Aspirin can alleviate some inflammation in the joints, apparently.
      new research on acupuncture is not promising for the discipline.

    • RussellWillmoth says:

      Your state that your “understanding is that many complimentary medicines have proven scientific benefit” – this understanding is wrong. If they did have proven scientific trials supporting them they wouldn’t be called “complimentary medicine” but simply “medicine.”

    • Dennis says:

      A demonstrated scientific benefit for acupuncture?? It has been pretty well established that acupuncture is nothing more than elaborate theatrical placebo. It makes no difference at all where the needles are placed. There is no credible evidence for any such thing as ‘Qi’. ‘Meridians’ appear to be entirely imaginary.

  5. Hypatia says:

    Print out a copy for your physician(s) and see how he/she/they react.

  6. Dr. Philip Puthumana says:

    excellent presentation.
    By the campaign by CAM practitioners, deadly diseases like diphtheria is making a comeback in Kerala, a state in india, which used to have health indices equal to the best of the west.
    would like to be allowed to translate it to my language( malayalam) so that people at large in kerala are made aware

  7. Dr. Philip Puthumana says:

    By the campaign by CAM practitioners, deadly diseases like diphtheria is making a comeback in Kerala, a state in india, which used to have health indices equal to the best of the west.
    would like to be allowed to translate it to my language( malayalam) so that people at large in kerala are made aware

    • Dr K S Parthasarathy says:

      Dear Dr Philip,

      It is ironic that Kerala which prides itself as the most literate in India has such an anti-vaccination attitude in parts of the State due to probably religious obscurantism. If you translate the present article, it will be widely appreciated by the discerning readership in Kerala.

      While on the anti-vaccination issue, let me give you a reference to a rapid response I published in the British Medical Journal a few years ago while an article discussed the issue in The BMJ.I believe it will be very useful to you. You may if you like it respond to me at my email ID ksparth@yahoo.co.uk which appears at the end of every article I write in The Hindu
      The link to my response:
      http://www.bmj.com/rapid-response/2011/10/29/history-vaccination-and-anti-vaccination-programmes-india

  8. Ira Goodman MD says:

    The categorization of CAM in this article is simplistic and clearly biased. Medicine, CAM or otherwise, is no more than the application of incomplete knowledge in order to better predict the future. In general the conventional therapies are more dangerous than CAM , however certain you may be in their rational or basis. That alone makes CAM safer if not more effective. Given the morbidity and mortality from conventional medical interventions , this should be of primary concern to a practitioner truly interested in ” doing no harm”. As far as efficacy goes, from what I see conventional medicine does have spectacular results in acute illness but in chronic disease ( 85% of patients) they mostly come up short compared to CAM.

    • Richard Scott,D.O. says:

      True many CAM are confidence men or quacks and tout a potion, method which will cure. These Hall mentions. Many use alternative medicine as adjunct. As a retired Osteopathic surgeon I found manipulation performed well and gently may help some, but never said it would cure or perfectly relieve back pain any more ths. A surgery would. There are those who tout a surgical procedure as near magic in their hands, without doubt and with questionable results.

    • Oldfart says:

      Ira Goodman. What is your degree in? It’s certainly not medicine. Where did you get your degree? I want to make sure none of my grandchildren go there. ” In general the conventional therapies are more dangerous than CAM , however certain you may be in their rational or basis. That alone makes CAM safer if not more effective.” And that statement alone marks you as an idiot.

      • DANIEL GAUTREAU says:

        I don’t know how an alleged treatment or method (homeopathy, acupuncture,reiki, …)that has been repeatedly shown to be useless can be called effective. The reason they are called alternative is that they are alternatives to that which has been shown to effective. Any “mainstream” medical treatment with the test records of CAM would get dropped at once.

        • Trish says:

          It was the practitioners who decided it was good PR to call their unproven remedies “alternative” and later “complementary” medicine.

      • RussellWillmoth says:

        I see where you are coming from but he may be right. Take the example of homeopathy – there is one thing that is sure – it has never killed anyone (assuming we exclude those killed by not taking a real medicine that may have saved them). On the other hand, real medicines have real physiological effects and do kill patients. Placebo is safe!

  9. Dr K S Parthasarathy says:

    Excellent article.Every stake holder including the arrogant specialist and the humble but ignorant practitioner of complimentary alternate medicine must read it. Most forms of treatments survive because most of the ‘diseases” cure by themselves with or without treatment.

    The success of a treatment often depends on the right inputs a patient provides to his physician who is willing to listen and willing to accept the patient as a partner.The right inputs emerge from those patients who have an awareness of their own body.They must be able to identify the subtle or the not so subtle changes in their body.Normally, a person who does not indulge in extreme habits will know what is “normal” and what is “abnormal” or “subnormal”.

    The present article cogently explains the uncertainties of medicine. It explains what a patient must legitimately expect.The criticism that the writer has some bias against complimentary medicine appears to be legitimate! though it does not diminish the value of the article.

  10. Robert Penczak, MD says:

    Wasn’t planning to read that article straight through this morning, but as I never hit a lull or patch of padding, and having reached the end, I have to say that was one of the most lucid and well thought out pieces describing the relationship between medicine and science that I’ve ever seen. Noted a couple of commentators who were disturbed by the brusque dismissal of ‘complementary and alternative medicine’ – would recommend taking a look at Steven Novella’s ScienceBasedMedicine site (which I’m in no way affiliated with) for those who are genuinely interested in understanding how acupuncture claims to work and the scant evidence used to justify any utility beyond placebo. Great article, Dr. Hall. Thank you for taking the time to pull all of that together.

  11. Paul Stolley, MD says:

    Excellent article by Dr. Hall. On 7/26/16 the NY Times ran an article about a surgical procedure of the knee to treat a ligament that may not even exist. No clinical trials and our regulation of surgical procedures permits such problematic behavior by surgeons.
    The attempted defense of CAM written above is anti-scientific and an example of several logical fallacies.

  12. Eric T says:

    I recall seeing my GP once after having an extensive set of medical examinations and being told that my results appeared abnormal.
    Worried, I asked just what was abnormal about them.
    My GP explained that every one of the individual results was within the ‘normal’ range — and that having a complete set of ‘normal’ results was, of itself, abnormal!

  13. Bonnie Topper says:

    As a hospice nurse I have seen patients and families pursue treatments that claim to extend their lives. A woman with lung cancer was given a coke bottle filled with herbs(?) and who knows what…she died. Another patient would lie under a box that supposedly realigned her energy fields. She did this religiously until she died. My college educated friends refuse vaccination based vague evidence that has been disproved by reliable science. I have used complementary techniques in my practice that is useful in palliation of symptoms: music therapy, massage, reiki therapy; but these techniques never claim to cure or provide total care. They are without side effects and can often calm. Good enough for me. For pain and other symptom management, medications are right and effective with proper understanding of their capabilities.

  14. ACW says:

    If patients do not accurately report their alcohol and/or tobacco consumption, food intake, and/or sexual practices, consider that it might be because they have been subjected to overly judgemental responses from doctors in the past. Don’t tell me you want to know honestly about my sexual history and then treat me like a slut. And if I say I do not drink or use recreational drugs (I don’t – don’t like either the taste or the sensation of being drunk or stoned) don’t assume I must be lying because ‘everyone does it’. It’s funny when Hugh Laurie does it on TV, but in the examining room, it’s a very good way to produce a self-fulfilling prophecy – that is, if the doctor is going not only to disbelieve me but to disrespect me, of course I will not respect him (or her, but usually this kind of M.Deity arrogance involves a ‘him’) and will withhold rather than subject myself to his scorn and scolding.
    I would add that with doctors you can’t win. If you come in unable to answer any of their questions beyond ‘ooh doc, it huuurts, please make it go away’, they treat you as an idiot. But if you try to give them what they want by taking careful note of what went wrong when and how, and possibly even have enough background to know the name of what is wrong (e.g., ‘abdominal distention’ or ‘amenorrhea’) they write you off as a hypochondriac and a crank.
    I subscribe to Skeptic and would love to see Dr Hall do a column from the other side of the examining table or desk.

    • Bad Boy Scientist says:

      Hear! Hear!

      I worked in medical research while in grad school and I have seen behind the curtain. Besides, the uncertainty of medicine, there is the issue of doctors neglecting things due to rushing, inattentiveness or just disliking the patient! Let’s not forget about MD’s “pranking” their patients! Then there are physicians notes in your file that can adversely affect your medical care down the road. If a patient is lucky, a new doctor will confirm some of the notes, but often something written in haste will follow a patient for their life and – like the TSA’s no fly list – the victim will never know about it. Some ‘legit’ Doctors are scarcely better than CAM scammers!

      I have personally had more than one experience of having to hunt down a doctor who is _willing and able_ to treat me. Most folks I know have also had experiences of having to go to multiple doctors before getting treatment. I realize that these experience are all anecdotes and are not reliable data – but then again, so is what happened to Steve Jobs as well as the other high profile stories we hear of people being harmed by CAM.

      I honestly believe that the rise in popularity in CAM is due to practitioners of medicine doing such poor jobs so often. If they are already dealing in uncertainty in situations of life and death there is no call for them being sloppy or unprofessional, too.

  15. Harriet Hall says:

    For those who think I was too harsh on CAM, I urge you to watch my free 10-part lecture series on YouTube about science-based medicine vs. CAM. https://www.youtube.com/playlist?list=PL8MfjLNsf_miVcNu6eJMNigAMNwQkk_B9

    • Jeff Kelley says:

      Science-based medical evidence….

      Published in May, 2016, a Johns Hopkins study suggests medical errors are the third-leading cause of death in the U.S.

      It is easy to find via GOOGLE.

      • Bad Boy Scientist says:

        Good point.

        Also deaths increase by a statistically significant amount at teaching hospitals for a couple of months after the new interns arrive.

      • DANIEL GAUTREAU says:

        It is also equally easy to find the refutation of it on ScienceBasedMedicine , and elsewhere.

      • Trish says:

        Modern medicine admits it makes errors. Alternative practitioners will just say their dead patients didn’t get on board with their “alternative ” treatment soon enough.

  16. Mike says:

    Excellent piece, as usual. I would also mention Dr. Hall’s video lecture series on Science Based Medicine at Randi.org (http://web.randi.org/educational-modules.html). Hall is a wonderful teacher.
    P.S. Oops, sorry. I just saw that the lecture series has been mentioned above. All the same, it’s well worth the time spent watching it.

  17. Marc Schneider says:

    This article was very helpful in a number of ways. I have had nebulous symptoms most of my life. In most cases, I can’t even describe exactly what I am feeling other than a vague discomfort or a variety of pains in different parts of my body that come and go. Yet, in terms of specific conditions, I have always been very healthy. In some cases, as the author mentioned, I may simply be noticing normal body processes, which I neurotically translate into problems. In other cases, I have symptoms without any kind of specific physical cause.

  18. Marvin Doolin, Jr. says:

    I usually read and enjoy Dr. Hall’s articles as soon as a magazine arrives. I don’t know how I missed this one. Thanks for repeating it.

  19. brad tittle says:

    Halleluja… Excellent piece Dr Hall. The challenge of uncertainty is never ending. Matt Briggs has just published a book “Uncertainty: The soul of modeling, probability and statistics”. It attempts to say the same thing but about all statistics, not just medicine.

    When my first son was born, there was a bump on his head that the doctors could not explain properly. Tests had to be done. In this case an MRI on a 3 week old baby. I let it happen. Hindsight has me approach it differently with different questions. After the fact I asked the following..

    Q: “What will you do if you find something in the MRI?”
    A: Nothing, we will wait six weeks and reassess.

    Q: “What wil you do if you don’t find something?”
    A: Nothing. We will wait six weeks and reassess.

    This happened again about a year and a half later. The doctor felt the spleen was a little big. He ordered an ultrasound. We had the ultrasound done.

    After the fact again I asked the same questions AND GOT THE SAME ANSWERS!

    My out of pocket costs on these tests was 0. Part of my brain was screaming at me though. This testing is why things are getting out of control in healthcare. If I were actively trying to help the healthcare system get better, I would have put a stop to those tests. I would have stood up and said “We will come back in six weeks and see if you still think it is necessary!” (The child at both time showed no other symptoms whatsoever. He was eating, drinking, peeing, pooping, sleeping with the normal range of infants/children at that age).

    Standing up and saying that isn’t that easy. I am not a doctor. I defer to the doctor ‘s expertise most of the time. I have to accept the expertise of the doctor. I also have to question it at all times. Add the time constraints that are being piled onto doctors, and we have a recipe for what we see in healthcare…

    As to alternative therapies, naturopathic in nature? I worry about folks who attempt to diagnose disease by looking at the iris of the eye. On the other hand, i do not fret too much about people who get relief from needles being tapped into their skin at different places. I do fret a little about doctors who completely ignore the fringe of allopathic medicine. I had a skin condition on my head. My parents had what seemed to be the same condition. The doctor was unable to help my parents. The drugs didn’t fix the problem. Baking soda and Apple Cider Vinegar DID fix the problem. Baking soda and Apple Cider vinegar are not alternative medicine. They are on the fringe of allopathic medicine though. They are definitely not as convenient as the center of of allopathy.

    Science is uncertain. Those who express certainty with scientific authority make me nervous. The data for most of science is not so certain.

  20. DMC says:

    I remember when my daughter was told by an obstetrician that she was harboring a daughter, and then, much later on, another one disputed this and, no, it was a boy… My oh my, she was really crestfallen, but things like that do happen, and she adapted (we too…). As you say, medicine is much more an art than a science, even though it is based on hard science (I was trained as a scientist).
    Good luck!

  21. Jeff Spencer says:

    While I found this article refreshing, I must say, Dr. Hall, that I wish you would focus some of your debunking and skepticism on what often appears to be collusion between big pharma, the insurance industry and the mainstream medical system. Many of your writings come across as breathless support for the present system, which many of us have found wanting, to say the least.

    Because new understanding often comes (and I would suggest, often MUST come) from outside the current system, it leaves many of us to our own devices—wandering from Naturopath to PubMed articles to scientists working around the fringes to find better answers. In my case, I would include in this category, alternative nutritional therapies and alternative approaches to endocrine system problems (particularly the thyroid).

    There is much emerging science about nutrition, for instance—the importance of balancing macronutrients, changing science of fat consumption, the devastating effects of refined carbs, premetabolic syndrome, the microbiome, etc.

    It appears to me that historically, mainstream medicine often waits for overwhelming evidence (that can no longer be denied by big pharma?), then reluctantly coopts while casting aspersions on those who have been slogging away without financial support. At the same time, the main-stream’s over-reliance on pharmaceuticals far too often results in a cascade of side effects and an escalating list of additional prescriptions to offset those side effects. Where is your skepticism for these orthodox-yet-destructive practices?

    Jeff Spencer

    • Trish says:

      If you understand the concepts that inform modern, science based medicine- one of the most important being willingness to reconsider and retire things once believed to work (admitting what appeared to work fails on further inspection) how can you champion “emerging” nutritional ideas? Those may turn out later to be valid – or useless – or harmful. In the late 20th C, emerging nutritional science said to replace fats with carbs, which hasn’t worked out so great.

      Looking into history, humans have always has firm opinions about nutrition, like the Tudor era aristocrats who believed their digestive systems were so delicate that they couldn’t digest veggies, but believed tons of meat and wine were healthy eating. The Supersizers was a great British show about nutritional ideas/practices in different eras.

  22. Bob Pease says:

    most replies here seem to say something like

    Since “Medicine ” is often crooked or ineffective, this means that
    MAGICK is OK to use,

    But somehow if Christian Prayer (magic too?? ) is suggested
    the Magick Newage holisters believers scoff or puke.

    ( or sometimes retort with Alexander VI vs nutso stuff )

    Dr Sidethink contends that although Magick may work at times it is dangerous to trusi except as a desparate last resort

  23. Billy J says:

    Dr. Hall,

    The article was excellent! Please keep up your wonderful work.

    I am a scientist by education and training, over 50 years in the field.
    The big problem with most people who have no formal science training is that they fall back on their religious or cultural conditioning when they cannot comprehend the words of the
    practitioners in the medical field and/or in other scientific fields.
    This problem is only going to get worse as the population of
    uneducated people increases every day. The human world is
    growing exponentially. When I was young, about 12 years or so,
    the world population was about half or possibly 40 per cent of
    todays number.

    My point is this: Seven billion brains have seven billion opinions.
    You know what the saying is: An opinion and about two bucks
    will get you a cup of coffee at Micky-D’s
    So, no matter what you do, there will always be many critics.

    Have a nice day Doctor, and best wishes for the future.

  24. factarcher says:

    Great Article. Applies to almost all fields.
    I am currently stalking mystery symptoms myself. Trying desperately to be honest… very difficult!
    Pain at 1 to 10? I have had 15 broken bones in my life, including a compound tib fib. How do I rate a chronic stomach ache?
    Really, thanks.
    R

  25. Neal Koss says:

    “Medicine is a science of uncertainty and an art of probability” as quoted from Sir William Osler

  26. Thangamani N says:

    In fact I read. I agree with the uncertainties mentioned but again she is certainly wrong when she thinks all or the mentioned alternative medicinal practices are very certain in dealing with symptoms or diseases. Here, she is unknowingly very certain like any other practitioner. :)

    • Trish says:

      Dr Hall has done far more research into alternative treatments than most physicians – examples can be seen on Science Based Medicine.

  27. Trish says:

    One sad thing is that a huge percent of Americans believe most diseases are caused by something the patient did, when that’s not true. Looking at a sick person’s life retrospectively to determine a cause is not possible.

    And even in the cases where something the person did may have – like a smoker who gets cancer, the person likely expected to be one of the smokers who don’t get cancer.

  28. Ron Woronov says:

    When I was twelve years old my father, a gifted surgeon, gave me a book entitled “The Century Of The Surgeon” by Jürgen Thorwald (Pantheon Books, 1956). What it taught me then and reminds now is that the story of medicine is that of a continuing search for knowledge and constant refinements in our understanding of what is at the core of the human condition, and our collective efforts to protect, sustain, and advance that condition … life itself. I was born with an intra-atrial septal defect, before open heart surgery was possible, and recall at a young age hearing the doctors at Johns Hopkins tell my mother I would likely not survive to twenty. At that same hospital by-pass was later perfected and at what was The Brooklyn Jewish Hospital I had life saving and altering surgery. Neal Koss (above, 7/27 comment) chose the right quote by Sir William Osler. I respectfully add that uncertainty will always define the outermost margins of medical advances, but eventually those margins will be redefined and yield new possibilities.

  29. Pete Molle says:

    As an anesthesiologist, I often wonder what preoperative informed consent is supposed to accomplish. There are certain risks, uncertain risks, remote risks or we may have an earthquake. Sure I know our sordid history of surgical procedures performed in witless patients in the days of yore. And I want to keep pesky lawyers away from my behind. Still. I do try to “scientifically” explain to my patients that they may die of anesthesia alone, or suffer brain damage or nerve damage or some other horrible damage. No one listens. Virtually no one. The common response is “but this will certainly not happen to me, right?” Everybody reverts to magical thinking, religious thinking, alternative (?) thinking. Under duress, we are all just one step out of the cave. One guy got his ASD fixed by a cardiac surgeon – good for you. Another one was drinking herbal tea for his liver cancer and is thoroughly dead. Just choices. As a pro I don’t judge, I don’t inquire why. You want me to do my thing for you? Fine. Still, we make slow but constant progress. I have not heard of alternative cures being offered for acute appendicitis. People know for sure that if appendix doesn’t come out, they may die a painful death. No room for herbal tea and acupuncture. Fibromyalgia? Different story. In the end, this is a free country and nothing is ever certain.

  30. Steve Funk says:

    Sexual identity is a hot topic, and it is very frustrating when you tease us with a link to an article that is behind a pay wall.

  31. awc says:

    Great article.

    Given the “alternative”, benign treatment I am a firm believer in the placebo. However, that is generally not how it works.

    I saw an interview the other day with a pharma guy. He said that currently the development cycle for new drugs is very costly because A) it takes a long time to find effective compounds and B) 95% of the compounds are not effective or have issues.

    I believe this as much speaks to the scientific process of discovery as it is representative of the expectations people have when it comes to finding cures or treatments.

    Good factual article restating the basic validation and discrediting of medicine vs cam respectively.

  32. awc says:

    Great article.

    Given the “alternative”, benign treatment I am a firm believer in the placebo. However, that is generally not how it works.

    I saw an interview the other day with a pharma guy. He said that currently the development cycle for new drugs is very costly because A) it takes a long time to find effective compounds and B) 95% of the compounds are not effective or have issues.

    I believe this as much speaks to the scientific process of discovery as it is representative of the expectations people have when it comes to finding cures or treatments.

    Good factual article restating the basic validation and discrediting of medicine vs cam respectively.

    The biggest challenge that healthy skepticism has, is when it is up against “lifestyle” marketing of psuedo-science or non-scientific approaches. It is scientifically proven that pleads to the emotional response is much more effective than logic, reason or for that matter good science. Now if science can present a lifestyle perspective on its positions then we will have something.

    It’s all explained in this 4 hour documentary… from the BBC http://topdocumentaryfilms.com/the-century-of-the-self/

  33. Wayne Yankoff says:

    In my current “State of Affairs” uncertainty rules. It starts out by a sole questioning of self. If, like, in the run of pique from Sargent Shultz, who repeated “I know nothing” to all the internists of prison fame in a TV show called Hogan’s Hero’s. Escape from the confines of a POW camp was an objective worth doing even if Shultz knew the “rumor” of how it was to be accomplished. One can be privy to a host of assented truths while being kept in the dark. Medical certainty is written on the “subway walls” (Paul Simon). Doctors lurk in offices absurdly treating the patient while finding suggestions, innuendo, and hesitation as traits of the reoccurring Force (angst of will).

  34. Nancy Stilwagen says:

    It is unfortunate you focus on only the few alternative medicine practitioners who make outrageous claims. Anyone who has studied alternative and complimentary medicine knows there are many causes of disease. Most conventional physicians don’t even seek the causes – they simply treat the symptoms. Make the patient feel better, keep them alive, and the money will keep coming in. Cure them, and you will not see them again. Our entire medical paradigm needs to change, and I think the alternative medicine world offers some very good ones.

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