“The trouble with the world is that the stupid are cocksure and the intelligent are full of doubt.”
Bertrand Russell

“Ignorance more frequently begets confidence than does knowledge.”
Charles Darwin

“It is one of the essential features of such incompetence that the person so afflicted is incapable of knowing that he is incompetent.”
William Ian Miller

I recently stumbled across an article on the Dunning-Kruger Effect, a theory of psychology that claims, “…the skills that engender competence in a particular domain are often the very same skills necessary to evaluate competence in that domain-one’s own or anyone else’s…” What this means in ordinary terms, is that while we all overestimate our own knowledge and skills, the less competent we are at something the more will will overestimate our abilities.

The original article is Unskilled and unaware of it: How difficulties in Recognizing one’s own incompetence lead to inflated self-assessment, and it is well worth a read. The authors conducted a number of experiments on that paradigm of Guinea pigs, the undergraduate psychology student. They gave them tests of social skills (recognizing how funny jokes were compared to a standard of professional comedians’ assessment) and cognitive skills (English grammar and logical reasoning), and they evaluated the accuracy of the subjects’ self-assessment compared with their actual performance. Those in the bottom quartile were most likely to overestimate their skills by the largest amount.

Subsequent tests and analyses indicated that this inaccurate self-assessment was tied to the lack of the same skills needed to perform well on the tests. Those subjects in the top quartile consistently underestimated their performance, but when exposed to representative samples of other subjects’ tests, these top performers were able to adjust their self-assessment appropriately, whereas the bottom quartile subjects did not correct their inaccurate self-assessment based on being able to see directly how their peers performed.

How is this relevant to medicine? Well, in the obvious way that the very people who most need to improve their knowledge and skills and those who are least likely to be able to see that they need this improvement. We all rationalize our failures under the pressure of cognitive dissonance, and we all assess ourselves more charitably than we assess others. But the Dunning-Kruger Effect suggests that those of us with the weakest skills, whether it be in medicine specifically or in the kinds of critical thinking necessary to separate truth from nonsense, we are also the least likely to be able to recognize our own deficiencies.

There is some good news, however. The study also looked at whether or not the least competent subjects could improve the accuracy of their self-assessment. As it turns out, if you make them more competent, by training them on the skills they are being tested on, they also become better able to accurately gauge their own performance. That’s a strong argument for widespread teaching of critical thinking skills and the skeptical outlook, since it suggests we can do better in both our assessments of the world around us and our judgments of our own capabilities.

A colleague recently received the following statement, as part of a follow-up report from a board-certified specialist to whom she had referred a case. The pet received a number of alternative medical therapies as well as conventional treatment for its condition.

“Integrative medicine can increase the variety of many different treatment plans and has the opportunity to reach a more successful health plateau for your patient. Invariably, integrative medicine acts as a adjunct protocol and offers more than a healthy body. Integrative medicine also provides a healthy sense of well being. As we progress towards newer and more extensive technology we lose the art of the basic touch and hands on treatment. In this day and age with our society relying heavily on technology and invasive sciences we must not look to holistic care as an alternative but as a way back to our soul.”

There are a number of elements to both the concepts and the logic of this statement which I find disturbing, especially coming from a specialty center to which I sometimes refer patients, and in which I must have confidence in order to keep doing so. It also illustrates one of the biggest problem in defending science-based medicine: overcoming the conflation of unproven or ineffective CAM treatments with a warm and caring therapeutic relationship.

1. “Integrative medicine can increase the variety of many different treatment plans”

This seems a variety of the bogus “health care choice” argument. Yes, adding unproven or implausible therapies to what we do gives us more things to do, but if these interventions aren’t shown to have a benefit, and might even be harmful, then so what? Variety is not itself a good thing, especially if it only serves our psychological need to do something without truly benefitting our patients.

2. “has the opportunity to reach a more successful health plateau for your patient”

This statement is meaningless without evidence to show it is true. CAM proponents freely claim better health through their methods, but shampoo makers freely claim their product is “New and Improved” every few months too. Should we believe it just because they say so?

3. “Invariably, integrative medicine acts as a adjunct protocol and offers more than a healthy body.”

Same problem. The assumption is made that adding this stuff helps, but I expect any doctor, especially a second-tier specialist, to have more than anecdote and faith to back up their claim that their treatments can help my patient. This statement suggests any and all CAM interventions added to conventional therapy will “invariably” bring benefit. No side effects? No interference with conventional therapies? No possibility of failure? If it sounds too good to be true that’s because it is.

4. “Integrative medicine also provides a healthy sense of well being”

Here we begin to get into the underlying philosophical position that will fully emerge later. These added interventions aren’t really about making the patient better in terms of their disease but about making them feel better. Of course, since we can’t access our pets inner feelings in any detail (well, except for pet psychics, of course), we have to decide if they get a sense of “well being” from CAM therapies. And given that both as doctors and owners we desperately want them to be and feel better, there is great risk of our projecting our needs and feelings onto them. CAM placebo effects certainly have an impact of people’s perceptions of their own disease, and they have an impact on their perceptions of how their animals feel (as the recent guest post illustrated), but I have yet to see anything more convincing than testimonial to show that they really affect our pets’ feelings as this statement presumes they do.

5. “As we progress towards newer and more extensive technology we lose the art of the basic touch and hands on treatment.”

Ah, we begin to see the cliché New Age notion that modern medicine is all about technology and that in the mythical Golden Age medicine was about caring and healing the whole person. There is no question the dramatic proliferation of knowledge and the subsequent necessary division of doctors into ever narrower specialties has affected the patient/client-doctor relationship, and this is part of why people are driven to the often warmer and more personal ethos of CAM. Scientific medicine must address this problem to protect our patients from turning to physically ineffective but more psychologically appealing methods.

However, the fact remains we live longer, suffer less, lose fewer of our children, and overall enjoy a far better quality of life and health than any humans who have ever lived, largely thanks to technology. We now have the luxury to indulge our search for meaning and fulfillment because most of us aren’t always battling to feed ourselves or struggling with an endless stream of physical ailments. I for one see no reason we can’t enjoy the opportunity for “self-actualization” technology has provided, and improve on the gains we’ve made, without jettisoning the very technology that has given us the opportunity to do so. I would love to have a close, supportive relationship with my health care provider. But I see no reason why that should require I also accept a host of implausible, vitalistic, and ultimately often ineffective therapeutic interventions too.

Finally, one must ask again if we are projecting our needs onto our pets. I believe I am as gentle, caring, and empathetic as any vet, and I generally have good success interacting with my patients. But frankly, many of my patients don’t appear to take comfort from being handled, however caringly, by strangers. The acupuncture and chiropractic sessions I’ve seen often involve a great deal of supportive, caring treatment of the client, who then feels their pet must enjoy the relationship as much as they do. However, judging from the behavior of the animals themselves, I remain unconvinced. They generally seem no more nor less distressed when receiving chiropractic or acupuncture than they do during my physical examination or vaccination procedures. Yet somehow, everyone involved believes the animals share their owners’ feelings the “spiritual” aspects of these encounters.

6. “In this day and age with our society relying heavily on technology and invasive sciences we must not look to holistic care as an alternative but as a way back to our soul.”

It isn’t entirely clear from the passage (especially given the awkwardness of some of the language which suggests to me it might have been written by someone not a native speaker of English) whether or not the use of “soul” here is intended literally or  is just a way of referring emphatically to feelings and emotions. It wouldn’t surprise me if it is meant literally since the notion that disease is fundamentally a spiritual rather than physical phenomenon is widespread in alternative medicine. Either way, however, the sentence echoes the theme of the statement as a whole, which seems to be that scientific medicine is cold and machinelike and that we need some “old-fashioned” psychological support from our doctors.

There is an element of truth to this, certainly for humans, though I think it is sometimes debatable whether what our pets need or desire in terms of a therapeutic relationship is the same as what we think they want. However, once again there is no reason this needs to be connected to alternative, unconventional medical treatments. The answer to a more supporting, warmer health care environment and better human relationships between health care providers and patients/clients isn’t to give up scientific medical therapies that work, or even to add unproven therapies to them. It is to change the economics and structure of the health care system to provide both the highest quality, most effective physical care and meet the emotional needs of patients/clients. This won’t be easy, and it will likely be more expensive, but turning to CAM isn’t the answer.

Linking CAM to the perception that modern medicine is cold and uncaring is a marketing triumph, but it doesn’t make the specific methods any more likely to be effective. This is why so much CAM is used by people with complex, chronic diseases, often for which scientific medicine has not yet found effective treatment. When choosing care for discrete, acute, critical illnesses few people choose CAM methods of questionable effectiveness. People want medicine that works, and though they want to feel cared for also, they shouldn’t have to accept bogus treatments along with emotional support.

One of the most common responses I get when I point out the lack of evidence for particular CAM therapies is, “So what? If it doesn’t do any harm and if people feel better, even just because of a placebo effect, then why do you want to convince them this stuff doesn’t work?”

Of course, the first answer to this has to be challenging the assumption of safety which seems to adhere to most CAM therapies, and I have done that at length. However, beyond that issue, it seems to me a fair question whether the truth matters when it takes away something benign that people want to believe and which might offer some relief from symptoms via a psychological mechanism, if not by way of actually changing the underlying disease process. I have several answers to this question, some personal and philosophical, others more pragmatic and directly relevant to medicine.

On a personal level, I share the sentiments of R. Barker Bausell, author of Snake Oil Science. He sees investigating the truth about the claims of alternative medicine as part of the larger project of science, and his research and writing are motivated at least “partly [by] a common professional objective for a scientist: to be able to claim a personal victory in one small skirmish in the perpetual struggle between knowledge and ignorance.” Though I understand that many, perhaps most, people don’t share the sentiment, a lot of us in science are driven by a visceral sense that truth matters, and that even unpleasant truths are to be embraced and comforting untruths disdained. I don’t see imparting this sense to others as a core goal, or justification, for challenging bogus medical claims, though I do hope my passion for what is true may resonate with some readers. But I must be honest and confess that this feeling is a large part of why I engage in my various projects promoting science-based medicine.

On a more practical level, there is clear evidence that the comfort taken from untrue beliefs in medicine does harm beyond the direct damage particular medical therapies may cause. While some turn to CAM only when they have exhausted the options provided by science-based medicine, CAM therapies are often promoted as an alternative to scientific medicine. However, when CAM is used in lieu of the more effective, better understood therapies of scientific medicine, people suffer and sometimes die unnecessarily. We see this happen in the asthma patients who have poorer compliance with drug therapy, and poorer quality of life scores, then they substitute herbs for medicine, and in the cancer patients who eschew effective mainstream treatment or palliation in favor of alternative therapies, leading to greater suffering and earlier death. What is more, because CAM therapies are so amenable to placebo effects and to false assessments of real efficacy, even casual experimental use in conjunction with conventional therapies can lead to a belief in not only the efficacy of the alternative interventions but create sympathy with the philosophical underpinnings of these interventions and skepticism of the underlying foundations of science.

CAM proponents frequently emphasizes supposed philosophical differences between alternative medicine and science. Some of these are marketing points rather than true differences, such as the nonsense about CAM treating the whole patient rather than just the disease, or scientific medicine treating only symptoms while CAM treats root causes of illness. However, there are some genuine philosophical differences between science as an epistemological approach and the world view of many CAM adherents. CAM often rests on a foundation of vitalism, the notion that invisible spiritual or “energy” forces are the true source of animation for living beings, and that disease is not a manifestation of disorders in the physical body but in these mystical forces. Vitalists claim to be able to sense and manipulate such forces, but these claims are never demonstrable by any objective means and must be accepted on the basis of faith alone.

This is in contrast to the position of methodological naturalism, in which scientists agree to put aside any personal intuition or revelation of a spiritual nature when investigating and treating the causes of disease, and focus solely on mechanisms and causes which can be objectively and repeatedly demonstrated to anyone. The claims of some CAM advocates that this approach is doomed to failure because it ignores the “real” nature of life and health are belied by the astounding success of the technology and medicine it has generated. Millennia of vitalist approaches to medicine failed to achieve the improvements in health and longevity a naturalistic approach has accomplished in only a couple of centuries. There’s a reason why mystical health care theories have had more success being adopted in the treatment of chronic diseases, particularly involving subjective symptoms like pain, and have failed to be widely accepted in acute, life-threatening situations. Homeopathic birth control hasn’t caught on too well either, so perhaps there is more to be said for “reductionism” than CAM proponents often credit.

Yet vitalist philosophies have an emotional and aesthetic appeal, and I understand the historical and psychological reasons they are so attractive and widespread. Nevertheless, I feel the evidence of history conclusively demonstrates naturalism to be a more accurate and successful model of reality, and there are real dangers in choosing to ignore this reality and adhere to comforting but unsuccessful paradigms when dealing with health and disease.

Similarly, many CAM advocates hold to an extreme relativism born of the post-modernist philosophical movement. This sees all models of reality as purely social constructs with no sound basis to give preference to one over another. Any attempt to assert one model is more faithful to an objective physical reality than another is dismissed as merely an attempt to justify a particular social and political power structure, to the advantage of one cultural group over others. Thus, even claiming objective reality exists and can be described is denounced as a form of political and cultural oppression. All points of view are held to be equally valid, and no truth claims are defensible.

This philosophy has had much success in the rarefied air of academe, though even there it is beginning to fray. It is buttressed by the reality that all of our models of reality are in fact  influenced by cultural factors, and that oppression is often justified by its intellectual apologists through the promulgation of scientific and pseudoscientific theories. However, postmodernism throws the baby out with the bathwater, and in an attempt to eliminate xenophobia and ethnocentrism it eliminates any hope of understanding the universe or improving our lives. Again, the history of science, technology, and medicine clearly and forcefully demolish the notion that there is no objective reality and that we can have no true knowledge of it. Such a perspective has no usefulness, and should have no place in medicine.

On a more practical level, one reason to care about the efficacy of CAM methods is simple economics. A 2009 study from the NCCAM found Americans spent $33.9 billion on “alternative” therapies (though the definition used in the study was quite loose). This is a lot of money to put into treatments of dubious effectiveness, and even if they have some positive effects in terms of subjective symptoms like pain or nausea, I think it is fair to wonder whether such resources could be better spent discovering more effective therapies or making health care more available to those who cannot afford even basic care.

Finally, Simon Singh and Edzard Ernst make the case in Trick or Treatment: The Truth about Alternative Medicine that it is nearly impossible to benefit from the placebo effect of a medical therapy without either lying to the patient or at a minimum deliberately ignoring the evidence against the placebo therapy. Most CAM practitioners obviously genuinely believe their methods work. However, maintaining this belief requires ignoring the principles and practice of science and evidence-based medicine. In today’s world, with the knowledge that scientific research has accumulated in the last few hundred years, sticking with such an attitude requires a kind of deliberate ignorance. CAM practitioners who utilize clearly disproven methods or concepts, such as homeopathy, the vertebral subluxation, and so on, must reject the very principles of science and the most basic, and well-established scientific understanding of the world. This is an act of faith that makes their approach more of a religion than a medical science.

There are those who honestly try to apply the principles of science and evidence to CAM. Unfortunately,  there are few CAM therapies that one can honestly justify in this way. Acupuncture for pain and nausea, chiropractic for idiopathic back pain, and a few well-studied herbal remedies and nutritional supplements are about all CAM can justly claim to be supportable by any sort of real research evidence, and even some of these claims amount to a primarily psychological, rather than disease-modifying, set of effects. There are important ethical questions associated with the use of placebo therapies, whether in mainstream medicine (where antibiotics and vitamins are often used to this end) or in CAM (where arguably the majority of the benefits seen are placebo-based). As I’ve argued before (here and here), the benefits may well be outweighed by the harm done to the caregiver/patient or client relationship by introducing deliberate deception, or even more the more subtly disingenuousness in sticking with what one’s experiences and intuition say and ignoring robust evidence against one’s approach, into this relationship. Though it is a philosophical point, and as such not provable in any objective way, I cannot help but feel that we are better served by honesty and a commitment to the truth than by accepting the short-term benefits associated with deceiving others or even ourselves.