Complementary and alternative medicine Medicine

On the “individualization” of treatments in alternative medicine

One of the claims most frequently made by “alternative medicine” advocates regarding why alt-med is supposedly superior (or at least equal) to “conventional” medicine and should not be dismissed, regardless of how scientifically improbably any individual alt-med modality may be, is that the treatments are highly “individualized.” In other words, the “entire patient” is taken into account with what is frequently referred to as a “holistic approach” that looks at “every aspect” of the patient, with the result that every patient requires a different treatment, sometimes even for the same disease. Indeed, as I have described before, a variant of this claim, often laden with meaningless pseudoscientific babble about “emergent systems,” is sometimes used to claim that the standard methods of science- and evidence-based medicine are not appropriate to studying the efficacy of alternative medicine. I’ve dealt with this latter argument before in considerably detail, but I want to revisit it in the context of looking at the “personalization” of treatments that alternative medicine practitioners tout as perhaps the greatest strength of their approach.

I was surprised to learn that even some advocates of alt-med have their doubts that it is such a great strength. Indeed, I never realized that this might have been the case until I came across a post by Travis Elliott, who runs a pro-alt-med blog, Dr. Travis Elliott and the Two-Sided Coin entitled The Single Most Frustrating Thing About (Most) Alternative Medicine. In this article, he referred to a case written up by a fellow naturopath, who used an anecdote the evaluation and treatment plan by a naturopath of a pregnant woman with nausea to show what is supposedly the “unique power of our medicine.” Oddly enough, Elliott did not quite see it that way:

The physician who wrote the article is a chiropractor and naturopath whose practice is nearly 100% musculoskeletal issues. He said that he nearly always refers patients out for other issues, but this case was a woman who requested that he treat her pregnancy-related nausea.

This physician tried, in a series of appointments: ginger root, rasberry tea, pre-natal vitamins, a blood-type diet, acupuncture, acupressure, and spinal manipulation. None of these treatments worked, but the patient persevered.

Finally, the physician reached further in to his toolbox and prescribed a homeopathic remedy that cured her on the spot. The physician noted, “we are so fortunate as naturopathic physicians to be trained in many modalities. … This case reminded me that [we can treat on a much more personalized level] when we are equipped with so many different tools.”

By coincidence, this very aspect of alternative medicine was brought up with not so glowing a description last week during my 2007 update of You Might Be an Altie If…, where item #80 states:

If you try bazillions of cures until symptoms go away, then declare the last one to be a cure, you might be an altie.

Which is most likely what happened in the case described, particularly since the last “remedy” tried was homeopathy, arguably the most utterly ridiculous and scientifically implausibly risible “treatment” ever conceived by a human mind. Most likely, what happened is that this patient’s symptoms regressed to the mean, and this regression to the mean happened to correspond with the trial of a homeopathic remedy. Be that as it may, however, Elliott brings up an interesting point, one that I’ve never heard an alt-med advocate bring up before:

This case can certainly be hailed as a success, since the patient was healed and no harm was done by the initial treatments that didn’t work. But I can’t help but feel badly for the woman for having to go through so much trial and error to get results. I mean, it probably cost a significant amount of money to keep returning to this physician for his next guess.

This is exactly the kind of situation that frustrated me when I practiced naturopathic medicine. How did I know what would work for a patient? (I didn’t.) And just like this physician, I didn’t think that there was any way to know, either. I could try and learn from each patient and apply that knowledge to the next one with similar symptoms, but each patient was so unique that what cured one person might have no effect on the next.

Meanwhile, patients are forced to try treatment after treatment, doctor after doctor in search of a solution that works.

Of course, I can’t help but marvel at the irony here. If such a patient went to a conventional doctor (or to multiple conventional doctors) with a complaint of nausea, and various remedies were tried and didn’t work, just imagine the reaction of alties to that. This same case, if it had been handled by “conventional medicine” would be cited by alternative medicine aficionados as “evidence” of how ineffective “conventional medicine” is! Indeed, how many times have you heard “testimonials” that begin with a patient describing a trek from doctor to doctor, all of whom were unable to diagnose the problem or find an adequate treatment? I can just hear it now: The sarcastic commentary about how poorly conventional medicine does with problems such as nausea in pregnancy and how superior “alternative medicine” is in dealing with such complaints. Yet, here we have a case being presented in which the patient was forced to try remedy after remedy, none of which worked until the end, where it is not clear whether the “homeopathic” remedy actually did anything (chances are that it did not) or the nausea simply regressed on its own thanks to the tincture of time. And this case is presented as a success! Now that I think about it, hanging around the alt-med Usenet newsgroups years ago, I heard similar stories time and time again. If you lurk on the CureZone message boards, you’ll find hardcore alties discussing trying various remedy after remedy, touting some and dissing others, all on the basis of little or no evidence.

After praising some sort of alternative medicine diagnostic modality called the BodyTalk system, which, supposedly greatly decreases this extensive “trial and error” approach, Elliott concludes:

Two years ago, I would have wholeheartedly agreed this case of nausea was a great success. But now that I know better, I see it as another sign of how far alternative medicine needs to go.

Yes, “individualization” of treatments is touted as the greatest strength of alternative medicine. Indeed, if you look at the UCSF alternative medicine manual that I blogged about previously, you will see in the descriptions of various modalities the emphasis on “individualization.” Who can argue that this is a wonderful thing?

I can, at least to a point.

Here’s the problem with “individualized” treatments. Taken to an extreme, as many alternative medicine practitioners do, it’s in essence an excuse not to have to list diagnostic criteria or show actual efficacy of their treatments in a way that others can replicate. Look at Dr. Elliott’s statement: “Each patient was so unique that what cured one person might have no effect on the next.” Certainly, biological organisms such as humans can and do show considerable variability in their biology and response to treatment, but not so much that what “cures” one person will have no effect on the next. Similarly, such extreme emphasis of “individualization” leads to exactly the sort of marathon trial-and-error treatment histories he described.

Let’s compare and contrast. In “alternative medicine,” it is very frequent that consultations by different practitioners for the same patient with the same symptoms will result in completely different diagnoses and courses of treatment. In contrast, although there can certainly be disagreement among conventional doctors about the diagnosis and/or treatment for an individual, such disagreements tend to occur within a much narrower range of possibilities. That is because they will have more standardized diagnostic criteria based on data, rather than the individual idiosyncrasies and beliefs of different practitioners. In essence, evidence-based medicine, through clinical trials and research, has done a lot of the trial-and-error work already, so that individual practitioners don’t have to, resulting in protocols that work for a majority of patients. When those protocols do not produce the desired results, then the choices for “individualization” of therapy are much narrower and based on science and evidence gleaned from clinical trials of large numbers of patients. (Yes, one danger is that this can devolve into “cookbook medicine,” but in reality, as long as the protocols are not too rigid, the good of such protocol-based medicine likely outweighs the bad.) In alt-med, however, what is tried first depends almost entirely on the individual practitioner, as does what is tried next–and next and next and next. There is no standardization and no scientific basis on which to choose treatments.

This emphasis on “individualization” in alternative medicine is particularly ironic when we consider certain specific alternative medicine practitioners, in whose practice disease causation all too often devolves into ludicrous commonalities in which there is claimed to be a single cause for many diseases. For example, Hulda Clark claims that “all cancer” is caused by intestinal flukes and that “the cure for all cancers” is in essence the same for everyone, a degree of standardization that even the most dogmatic practitioners of evidence-based medicine would find hard to swallow. After all, none of us would ever claim that “all cancer” has a single cause. Similarly, she claims to have the cure for AIDS based on similar principles, even though the causes of AIDS and various cancers are clearly different. Meanwhile Reiki therapy, acupuncture, and a wide variety of other alternative medicine modalities claim that all disease is due to an “imbalance” in your life energy (qi) or a blockage in the flow of qi that needs to be eliminated; the only way that the differ is in the methods that they use to alter the flow of qi in order to cure. Or consider the case of the frequent alt-med claim that some therapy or other “boosts the immune system,” as if that were always a good thing and there were no such things as autoimmune disorders due to the excessive or in appropriate activation of the immune system.

In the end, this fetish for “individualization” in alternative medicine is a sham. It’s invoked when it is convenient to do so, particularly in the cases of “treatments” like homeopathy, in which any therapeutic effect perceived is due to the placebo effect. However, if you think about it, many alternative medicine modalities are far more rigid than conventional medicine in ascribing a specific cause to disease. When you come right down to it, the emphasis of alt-med on “individualization” and “treating the whole person” consists of little more than marketing buzzwords. There’s no evidence that alt-med does any better at treating the “whole patient” than conventional medicine and considerable evidence that, by lumping many diseases of unrelated pathophysiology together and using the same treatments for them, alternative medicine’s claims of “individualization” means the freedom to keep trying stuff until the patient’s symptoms get better on their own.

By Orac

Orac is the nom de blog of a humble surgeon/scientist who has an ego just big enough to delude himself that someone, somewhere might actually give a rodent's posterior about his copious verbal meanderings, but just barely small enough to admit to himself that few probably will. That surgeon is otherwise known as David Gorski.

That this particular surgeon has chosen his nom de blog based on a rather cranky and arrogant computer shaped like a clear box of blinking lights that he originally encountered when he became a fan of a 35 year old British SF television show whose special effects were renowned for their BBC/Doctor Who-style low budget look, but whose stories nonetheless resulted in some of the best, most innovative science fiction ever televised, should tell you nearly all that you need to know about Orac. (That, and the length of the preceding sentence.)

DISCLAIMER:: The various written meanderings here are the opinions of Orac and Orac alone, written on his own time. They should never be construed as representing the opinions of any other person or entity, especially Orac's cancer center, department of surgery, medical school, or university. Also note that Orac is nonpartisan; he is more than willing to criticize the statements of anyone, regardless of of political leanings, if that anyone advocates pseudoscience or quackery. Finally, medical commentary is not to be construed in any way as medical advice.

To contact Orac: [email protected]

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