The American College of Preventive Medicine completed a project, with funding from the Health Resources and Services Administration, to advance the inclusion of so-called Integrative Medicine in Preventive Medicine residency programs. As a Preventive Medicine specialist, a former residency director, and both a practitioner of, and advocate for, responsibly plied Integrative Medicine, I was a logical choice for the leadership role ACPM proposed, and I accepted.
The culmination of the project, at least for the moment, is a special issue of the American Journal of Preventive Medicine, devoted entirely to the reasons, means, measures and tribulations involved in conjoining these two disciplines. Predictably, no sooner had the electrons announcing this settled into the Medline index, than the clique calling itself “Science-based Medicine” weighed in, with customary disparagements.
This group painted a bullseye on my torso (or head) years ago, and has had intermittent fun ever since alleging something close to quackery on my part. By and large, this all began following my participation in a Summit in Washington, D.C., convened by the (then) Institute of Medicine (now, the National Academy of Medicine) on Integrative Medicine and the Health of the Public. Having spent years deeply immersed in the teaching of evidence-based medicine at the Yale School of Medicine, where I directed courses in biostatistics, preventive medicine, public health, and epidemiology- I invoked the realities of patient care to argue for “a more fluid concept” of evidence than seemingly prevailed.
That this suggestion was parlayed into allegations of quackery, or flirtations with it, has always amused me when it hasn’t annoyed me, and struck me as absurd in every way. For one thing, I make for quite a bad quack. I have run a federally-funded clinical research labfor nearly two decades. My colleagues and I have contributed nearly 200 peer-reviewed papers to the literature, some few of which demonstrate the utility of certain “alternative” medicine modalities, some few of which suggest the futility of others. Along the way, our efforts spawned a novel technique, called evidence mapping, later adopted by the World Health Organization for other applications, which showed the variability of evidence underlying the domain of so-called “complementary and alternative” medicine.
My passion for science is rather an open book, as are my musings on what “holistic” medicine is, and should be. Speaking of books, I have authored one textbook exclusively about evidence-based medicine and its relationships with both research methods, and clinical decisions; and multiple editions, in the company of colleagues, of an epidemiology text much devoted to that same domain. I will protest no further in that regard.
Moving on to the “fluidity” that has proven such a diverting target for the slings and arrows of my science-based colleagues, what did I mean? Well, that, too, is a matter of the published record- previously, and again in the compilation in AJPM. Colleagues and I proposed, based on years of wrestling with complex patients, many of whom, urgent medical needs still insufficiently addressed, had tried and exhausted all of the well-supported, conventional treatments, that evidence traversed 5 key considerations. Those include: what is known about a treatment’s safety; what is known about a treatment’s efficacy; how well those first two are known (i.e., the clarity of evidence); the patient’s preferences; and, importantly, the availability of other, untried treatments for the condition in question.
One need not be a clinician, wrestling with especially challenging patients or otherwise, to see the relevant spectrum of decisions. Whenever a treatment option is unsafe, ineffective, unclearly supported by evidence, unpreferred by the patient, and/or surrounded by other, ostensibly better treatments for the same condition - it is time to move on, be that treatment a product of tree leaf, or test tube. Conversely, if ever a treatment is safe, effective, preferred, supported by clear evidence, and lacking in any competition - it is just as clearly the right choice, with similar disregard for its origins in a lab or a leaf.
However, what about when a treatment is almost certainly safe; might be effective; rests on evidence that is incomplete; but lacks any competing treatments that are more “science based,” because they don’t exist, or because they have been tried, and failed - for whatever reason? And what to do when that patient looks you in the eyes and says: “help me, doc - please; nobody else has”?
That is not an invitation for voodoo. But it is, in my view, an invitation to acknowledge that evidence is not dichotomous: present/absent, on/off. Evidence is not a light switch. Evidence, and its applications to patient care, are quite simply - more fluid than that.
That the proposition - the fluid nature of evidence, and more importantly science, should be respected- is contentious in the first place is, frankly, bizarre. I trust I am reliably conjoined to my science-based confrères (they are, in fact, male predominated so far as I know, and whatever that implies) in noting that the greatest of scientific minds- Einstein and Hawking and Newton; Darwin and Dawkins; Copernicus and Galileo and Herschel- were exceptionally devoted to the fluidity of science. They have, and in some cases still do, challenge the conventional understanding. They respect what we know, and how we know it, but humbly concede the potential for it to change as evidence accrues.
Brilliant as Dawkins is, for instance, and influential as The Selfish Gene remains, a fluid advance in that understanding first espoused in the 1970s is now suggested by E. O. Wilson in The Social Conquest of Earth. Famously brilliant, and humble, as Einstein was - he is now known to have been wrong as well about aspects of quantum physics, and in a timely bow to Halloween - spooky action.
Science is not either/or. It is never complete. Our understanding of it is never perfect. Science is, ineluctably, and as championed by the greatest of our peers and predecessors- fluid. If that is so, and irrefutably so, it becomes difficult to spot the controversy in the argument that science-based medicine must be likewise.
Of course, one could go too far, and fall into a vat of what the science-based detractors call “woo,” but that is hardly an epiphany. A willingness to put what is safe and makes sense in the service of patient care is not an invitation to disregard sense or safety and try anything. What those same detractors routinely, blithely, and perhaps even disingenuously dismiss is the proclivity for just such excesses in the service of conventionality. I doubt you, and wonder if they, are truly naïve enough to think that Big Pharma doesn’t care whether or not genuinely effective alternatives to patented pharmaceuticals are identified? That we have a system of profit-based medicine, as much or more than evidence-based medicine, is an argument I needn’t make, because others already have.
No one ever expects the Spanish Inquisition. Monty Python said it; it must be true.
And perhaps there is real wisdom in it. Perhaps the Spanish Inquisition is intrinsically shielded from all anticipation, because it is so improbable, even paradoxical. In this lamentable, historical episode, people were tortured and martyred for the heresy of their absolute faith in unknowable things, by people with absolute faith in unknowable things.
That’s why nobody expects the Spanish Inquisition. The martyrs and their murderers were too much alike, subject to differing versions of comparable hooey.
We have the inherent fluidity of scientific evidence to thank for every Nobel Prize in science. We have fluid thinking to thank for the innovations of Copernicus and Galileo; Darwin and Newton; Einstein, Edison, and Jobs. We have ideological rigidity to thank for the Crusades, the Salem Witch Hunts, 9/11, and the Spanish Inquisition. This is not a difficult comparison.
The use of poliovirus to treat cancer sounds a bit like homeopathy - using a toxin to treat a toxin- and a lot like woo. However, it happens to be a genuine and exciting advance solidly in the realm of science, and fodder for a future Nobel Prize in medicine.
There is nothing mystical about fluid; its physical properties are thoroughly elucidated. It moves through space and time. It is the opposite of rigid. It flows, in and out.
This is exactly how scientific evidence works. It flows in, as we learn what we didn’t know. It flows out, as we refute what we thought we knew. It accumulates over time, as the flow of rivers does in the sea. And it is unrigid, ever ready to shift again.
I have written about plausibility, and the presumption with which we generally approach it, ignoring over and again the follies of history along the way. But I happily defer here to an argument above my paygrade, made by E.O. Wilson, a preeminent Harvard biologist, and two-time Pulitzer Prize winner. In chapter 26 of the Social Conquest of Earth, Wilson opens with a stunningly vivid and succinct account of the almost laughably tiny aperture through which Homo sapien biology allows us to perceive “objective reality” at all.
What is most fascinating and relevant about Wilson’s account is not the technology that is now revealing to us realities to which we were insensate before: colors we could not see; sounds we could not hear; energy fields we could not feel. What is most compelling is that all of these ARE perceivable to biology, just not our biology. There are animals that see colors we can’t; animals that hear sounds we can’t; and animals that feel one another’s electromagnetic fields. This, of course, is not woo; it is established biological fact.
The sounds, the colors, and the fields exist; and biologies other than our own can access them. Given, then, the range of human aptitude- from Helen Keller to the Rain Man; Michelangelo to Mozart; Edison to Einstein- are we truly prepared to say that no human being could possibly perceive the energy field produced by our bodies? Are we prepared to know in the absence of evidence that no such person endowed with a heightened sensitivity blunted in the rest of us, could interact with the energy field produced by a body in close proximity?
My radical version of alleged woo is captured in my answer to these questions: no. I simply don’t know what we don’t know. No one else does, either. No one else, that is, save fools and fanatics.
We need no help from fanatics to know there is hucksterism in the world, or bathwater in the tub. A common dose of common sense will suffice. The same measure will serve to renounce the counsel of fools to overlook the baby in the tub, or the possibility of somewhat surprising truths in the fullness of time. We are most likely to find the advantages of wisdom in the realm of nuance and doubt; of open-minded skepticism; of caution, and hopeful curiosity.
The guardians will be there all along, telling us what is possible, and what isn’t - until it turns out it is. At which point, they will revise their fluid definition of woo, and pretend it never happened.
Bertrand Russell famously said: “The whole problem with the world is that fools and fanatics are always so certain of themselves, and wiser people so full of doubts.” How ironic that those ranks are now expanded by self-proclaimed sentinels of science, devoted instead to dogma, demagoguery, and the certainty that if it matters, they know it already.
Time, in its ineffable, relentless fluidity, will judge the judgments of us all.
David L. Katz, MD, MPH, FACPM, FACP, FACLM, is the Founding Director (1998) of Yale University’s Yale-Griffin Prevention Research Center, and current President of the American College of Lifestyle Medicine. He has published roughly 200 scientific articles and textbook chapters, and 15 books to date, including multiple editions of leading textbooks in both preventive medicine, and nutrition. He has made important contributions in the areas of lifestyle interventions for health promotion; nutrient profiling; behavior modification; holistic care; and evidence-based medicine. David earned his BA degree from Dartmouth College (1984); his MD from the Albert Einstein College of Medicine (1988); and his MPH from the Yale University School of Public Health (1993). He completed sequential residency training in Internal Medicine, and Preventive Medicine/Public Health. He is a two-time diplomate of the American Board of Internal Medicine, and a board-certified specialist in Preventive Medicine/Public Health. He has received two Honorary Doctorates.