Naturopathic Medicine, EBM and the Skeptic

Image source: pakmed.net

It seems that, for every person who embraces the idea of holistic medicine with open arms and an open mind, there is at least one skeptic who refuses to acknowledge that alternative medical practices not only exist, but  are growing in popularity, helping thousands of people and, most likely, are here to stay.

A friend recently shared a Globe and Mail article about naturopathic doctors gaining regulation in the province of Alberta.  This means that naturopaths must attend a 4-year college (such as CCNM) and pass the required licencing examinations in order to practice in Alberta.  This is great news for the profession because it honours our expertise and builds respect for the work that we do among the public and the medical community.

The article, for my colleagues and I, represents good news.  However, every time the words “naturopath”, “alternative/holistic medicine” and “homeopathy” are uttered, it triggers an inevitable slew of negative comments.  I don’t usually have respect for most internet commentators, but some of the comments that were made represent common arguments against our profession.  You can make note of the logical fallacies present within these attacks, which I find ironic considering the fact that many of these “skeptics” consider themselves to be quite logical and rational in their viewpoints.

Here are some of my favourites:

1) Homeopathy killed Steve Jobs.  Steve Jobs had end-stage pancreatic cancer, which, unfortunately, is what killed him.

2) If alternative medicine were proven it would simply be called “medicine”. This argument is based on the false assumption that all “medical” treatments are proven and allopathic medicine contains absolutely every treatment that has evidence supporting it. It also fails to acknowledge the lag time between widely accepting a form of treatment and incorporating it into current medical practice.

And finally, the most popular argument against naturopathic medicine, and one of my favourites:

3) Naturopathic medical therapies (of which there are thousands) have not been shown to work in Randomized Placebo-controlled Trials.  If they have been shown to work outside of Evidence Based Medical studies, then the results can only be attributed to the “placebo effect.”

This third argument, of course, is plainly false.  A simple Pubmed search for any widely used naturopathic therapy will show that holistic treatments are constantly placed under scientific scrutiny, and are frequently subjected to Double-blind Randomized Placebo-controlled Trials (a trial in which the patients are randomly assigned to one of two groups – one group receiving treatment and the other group receiving a “placebo” or sugar pill). CCNM itself, is one of the significant research houses for medical science in Canada. However, these studies are expensive to conduct and the wealth of the naturopathic neutraceutical industry pales in comparison to the financial capabilities of the pharmaceutical industry, which has a large amount of funds available for “proving” their methods, which explains the discrepancy between the number of pharmaceutical RCTs and the number of RCTs testing alternative treatments.

Then there is the false assumption that Randomized Control Trials (or RCTs), are the sole source of scientific medical information.  RCTs are useful because they attempt to eliminate the many variables that could contribute to clinical results.  However, they are not the only form of information a clinician uses when evaluating treatment options for best patient care.  Even the father of Evidence Based Medicine, Dr. Dave Sackett wrote,

“Good doctors use both individual clinical expertise and the best available external evidence, and neither alone is enough.Without clinical expertise, practice risks becoming tyrannized by evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient.” (Sackett, 1996)

Evidence Based Medicine has proven to be a useful tool in figuring out best practice but it’s not the only tool.  Using only EBM when making clinical decisions can be harmful to the patient because it fails to acknowledge the patient’s uniqueness.  In fact, many essential medical practices have never been proven by EBM.  Think of applying a tourniquet to stop the bleeding of a gushing wound.  The practice seems to be common sense and we can all infer what would happen if we failed to attempt to stop blood loss in a patient who is bleeding profusely but yet, this practice has never been subjected to an RCT.  The reason? Putting patients into a “placebo group” would be both impossible and unethical.

Our 3rd year nutrition professor, Dr. J. Prousky showed us this insightful (and entertaining) video in a case against, as Sackett calls it, “the tyranny of evidence”.

This video makes several points against the EBM “religion”.

– It talks about the Ecological Fallacy: it is not rational to apply group statistics to individuals.  Naturopathic medicine is individualized medicine.  We concentrate on the individual, and, while it is important to use information garnered from group studies when deciding on a treatment, it is even more important to consider the person before you.  Many practicing naturopaths have attested to the fact that no two conditions are the same; even if the symptoms are identical, the reason behind those symptoms and the treatment for the condition are almost always distinct.

Scientific proof does not exist.  In elementary school we all learned how science works: scientists formulate a hypothesis and then test it.  If the hypothesis does not pass the test it becomes suspect.  Scientific theories are never proven, they are only ever disproven.  Therefore claiming that naturopathic treatments should be proven to work is not only impossible, it is non-scientific nonsense.

Evidence based medicine is not as unbiased as it claims to be.  The “Gold Standard” of EBM is the meta-analysis, which is a statistical analysis of several RCTs.  The “best” RCTs are selected and their results are subjected to analysis.  However, as the rainbow bear in the video points out: how do you know what the “best” evidence is? We do not know the answer that the meta-analysis is trying to provide, therefore how is it possible to select the “best” evidence that will give us that answer?  This means that whoever selects the data to be used in the RCT already “knows” the answer that they want.  This selection process, must then reflect the bias and prejudice of the researchers who are selecting data.  Selecting data is unscientific.  In science, all available evidence must be used or the fraction of evidence used must be randomly selected.  There is no such thing as “best” evidence.

The conclusion is, don’t believe the slander.  Naturopathic medicine is gaining more recognition for a simple reason – it helps people.  It is highly individualized medicine and, while it takes into account the results of Randomized Control Trials and meta-analyses for information about risk factors and treatment effectiveness it places more importance on the individual uniqueness of each patient and the condition that that patient presents with. Treatments are evaluated for suitability to the patient and to address the specific combination of symptoms that the patient may have.  And, as many patients of naturopathic doctors will tell you, they work.

Just please don’t ask us to “prove” it.

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5 thoughts on “Naturopathic Medicine, EBM and the Skeptic

  1. I do wish the obsession with categorising branches of medicine would end. We’re all in it to help the patient.

    There is a lot of quackery out there. Not mentioning any names. With the amounts of money that desperate patients are willing to spend, it is no surprise.

    I profess no expertise in the field and have done little research but I imagine that naturopathy is quite a ‘niche’ area still, compared to traditional medicine. They are however, both are industries with billion$ at stake, so no wonder they fight for reputation.

    It’s ultimately up to individual physicians and patients to decide on their treatment – but don’t shoot the EBM, shoot the scientists! Remember that our careers are built on the shoulders of scientists who applied scientific method. And got lucky, Can we tell Watson & Crick that evidence base didn’t matter? Clinicial EBM & RCTs, which you mention, are rigorous scientific methods. Whether they are applied *well* is another question.

    We can only hope that the best treatments, be they herbal, pharmaceutical, surgical or otherwise will prevail.

    1. I agree with you that shoddy research methods can be to blame for certain studies. However, EBM is not a religion it is a specific kind of research and should not be confused with the “scientific method” as such. It does a good job of testing 2 variables against each other and trying to control for other variables that could affect the study outcomes. However, real medicine is not like that. In real medicine variables do matter and matter significantly. They contribute to patient outcomes and success of the treatment. EBM is an extremely useful tool and can be credited for the advances in medicine over the past decades. However, it is not the ONLY tool, and is not free from faults or inherent biases. And that is the point. As Sackett said, neither EBM nor clinical expertise in and of themselves is sufficient. Everything must be put into context.
      Thanks for the comment.

      1. I am not involved in research so I’m just regurgitating what I am taught and extrapolating my limited knowledge.

        No doubt in time, medicine will evolve to select the treatments that work and ignore those that don’t. The same goes for methodology: if EBM doesn’t work then it’ll be either stand the test of time or be replaced.

  2. You are my hero for writing this! Having just spent too long feeding the trolls (one of which claimed he was a surgeon ha!) this is good medicine 🙂

    It’s frustrating arguing with people that may be afraid of the unknown (if they can’t understand it, it’s dangerous and should be banned!) or hold this single-minded arrogance for the Modern Western Way. I just think of planting seeds when I post well-formed and fact-based replies in those comment boxes, keeping it positive so that the nay-sayers may one day consider benefiting from Naturopathic medicine too!

    1. I find that people who regularly work with patients, so family doctors especially, are very open to the idea that it’s not just drug=cure and that there are so many other factors when it comes to health and healing. Most of the skeptics out there are people who have never had to seek help for a chronic illness or people who have never had to help someone with a chronic illness. I think having those experiences makes it become clear – the conventional medical model simply does not serve those patients. Luckily, there’s a naturopath for that!

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