You know me to be a very smart man. Don’t you think that if I were wrong, I’d know it?
Sheldon Cooper, theoretical physicist, in “The Jiminy Conjecture” (an episode of The Big Bang Theory)
When confronted with two things said to be true, one actually true and the other false, each of them said by someone who seems to have authority, how can anyone tell the difference? The naked claims have equal weight … unless you know how each of them came to be! If one was generated by careful experiment and logic, and the other by wishful thinking and pride, then we can judge them.
If we teach only the findings and products of science — no matter how useful and even inspiring they may be — without communicating its critical method, how can the average person possibly distinguish science from pseudoscience?
The Demon-Haunted World, by Carl Sagan and Ann Druyan
Ultimately, only actual training in logic and science — only some concept of how real knowledge works, the kind of knowledge that can build bridges and cure polio, the kind of knowledge that makes lasers and moon-landers possible — can somewhat reliably distinguish between truth and fiction. Even then, it’s usually necessary to think in terms of degrees of confidence rather than “true” and “false.” Certainly common sense is not up to the job — as we all know, because we have all seen people be wrong when they think that they are right.
Health care consumers are frequent witnesses to a “battle of the experts.” Often we have no personal stake in it: it is just an irritating feature of modern living that there is an almost daily barrage of “new studies” that challenge our beliefs … and usually challenge last week’s new study as well (or seem to). Unless you live in a cave, you’ve probably had the experience of hearing about a new study, rolling your eyes, and thinking, “To hell with the experts! I’m going to eat whatever I want!” Or perhaps this is why you live in a cave.
Of course, there is a perfectly good explanation for the battle of the experts: medical science is half-baked. Experts can’t agree because they don’t know. New research constantly invalidates old research because we’re still learning. The latest evidence should never be presented or interpreted as a fact, but simply as another piece — or a replacement piece — in a gigantic scientific jigsaw puzzle.Experts can’t agree because they are still learning.
It’s frustrating, but it’s actually unreasonable to expect medical science to be “done” or even mostly done at this point in history. It hasn’t even been a hundred years since penicillin. Homosexuality was still considered a pathology in the 1950s. The human genome has only just been sequenced. We still don’t know why aspirin works, why knuckles crack, or what the biological function of sleep is.1
But what if the experts disagree about you?
What if you have a problem — a painful problem — and doctors or therapists can’t agree what’s wrong with you, or how to treat it? What if the science about your problem is half-baked?
We all understand, of course, that many diseases are still a mystery. Celebrity victims throw their weight behind public awareness campaigns and fund-raising for research. Marathons with more participants than the town I grew up in are run to raise money to find the answers. In spite of this, it’s interesting how often we are surprised to discover that our problem turns out to be poorly understood. We act like it’s some kind of shock that our doctors often seem to be kind of clueless.2
This indignation that we feel when we encounter medical ignorance is particularly strong when we are struggling with (relatively) minor problems. What if the science about your problem is half-baked? We understand that cancer is mysterious. But back pain? Knee pain? How complicated can a knee be, compared to cancer? Shouldn’t the pros pretty much have a lock on this kind of thing by now?
Don’t bet on it!
We know even less about many minor health issues than we do about the brand-name pathologies. And the explanation is simple: there’s no money in it. There are no celebrity advocates for low back pain sufferers. There is no fund-raising marathon for scoliosis. No pharmaceutical company can cash-in on a drug for runner’s knee. And where there’s no money, there’s not much research and plenty of questions that still need answering.
Has nobody noticed the embarrassing fact that science is about to clone a human being, but it still can’t cure the pain of a bad back?
Pain, by Marni Jackson, p5
I have seen patients who have been assessed and diagnosed by as many as a dozen different doctors and therapists, and it’s routine to meet people who have received several conflicting expert opinions.
Most places, training to be a massage therapist is a night school kind of thing. You put in a few hundred hours, maybe a thousand in some provinces and states, you learn a little muscle anatomy, and then you get down to work. Not around here. Where I come from, training for massage therapy is a big deal: three years, 3000 classroom hours, countless more with my nose in a textbook, scary government certification exams, continuing education requirements …
You’d think it would be enough, wouldn’t you?
It isn’t. There is no such thing as “enough” medical training. It’s a bottomless pit, there is always more to learn, and in a perfect world every single health care professional would consider him or herself to be a “beginner” … permanently. But that’s not what happens.
The overconfidence probably sets in early, starting with textbooks. Medical texts seem to be written by people who think that medical science is complete and all they have to do is report the results. You would be hard-pressed to find a single example of acknowledged ignorance in any medical textbook. An honest medical textbook would be like a medieval map, with large blank chapters saying only, “Here be monsters.” But what we get is textbooks that take us right up to the edge of that intellectual wilderness and then just … change the subject. If you’re not looking hard for this little sleight-of-hand, it’s easy to miss it entirely.An honest medical textbook would have large blank chapters saying only, “Here be monsters.”
I can only speak with confidence of massage therapy, but I’m sure the same thing is true of all the health care professions: we graduate with an alarmingly deluded notion that we basically understand our craft. In reality, we graduate with only a primitive notion of how bodies work, and — much more dangerously — we graduate thinking there can’t possibly be that much more to learn. Speaking from my own experience, this is true even when we think we know better.
No matter how humble we are, we can never be humble enough.
This story is one of my favourite examples of how medical science is a work in progress …
A few months ago I did some research for a client. Her physician had prescribed a drug called “amitriptyline,” an old-school tricyclic antidepressant, from the days before Prozac. For many years, amitriptyline has been prescribed in low doses for severe insomniacs and fibromyalgia patients (who may have chronic pain due to sleep disturbance). If you Google it, you can easily find literally thousands of repetitions of this conventional wisdom. Yet most of those assertions are simple statements, unsupported by any reference to research. Doctors writing about it obviously feel that there is no need to back it up. That always makes me suspicious, so I decided to dig a little deeper.
Searching the medical research database PubMed, I quickly found several peer-reviewed scientific papers from the eighties and nineties that backed up the conventional wisdom. Several times, researchers had tested the drug and found positive results. But you’ve got to get up pretty early in the morning to fool me. I noticed that none of those studies were “controlled” — which means that nobody had bothered to compare the drug to a sugar pill. Had anyone done that recently? Was there a newer study with a better design?
Well, golly, there sure was. Starting with a study in 2001, someone finally got around to testing it properly, and two more have been done since then. And guess what? According to those studies, amitriptyline is no more effective than a placebo.34 The conventional wisdom is probably dead wrong, (or at least controversial now). Low doses of amitriptyline may well be useless for sleep problems.
This kind of thing is alarmingly common, business as usual for an imperfect science. But it interested me that it took until 2001 for researchers to get around to asking the right question.This kind of thing is alarmingly common, business as usual for an imperfect science.
I have a client who is a pharmacologist. She has a doctorate in drugs, and she’s about as mainstream, credible and credentialed as they come. I asked her, “Does it seem strange to you that this claim wasn’t studied properly until just recently?” Her answer amazed me.
“Actually, no,” she said. “It’s a bit embarrassing. Believe it or not, proper control of drug trials has really only started to become routine in the last decade. There are many examples of drugs that have only recently been studied properly … and even more that still haven’t been.”
Wow. That’s heavy.
But this story isn’t done. Almost a year later, after telling many people about these insights, including clients and my own doctor, I stumbled upon another properly controlled study of amitriptyline from 1986. And guess what it said?
“Amitriptyline was associated with significant improvement in all outcome parameters …”5
Hoo boy. This weakens my story quite a bit. Even in the process of trying to be humble about science, I walked right into my own trap: I thought I was so clever, just because I found a couple recent studies that seemed to demonstrate that conventional wisdom is wrong, and I love to do that.
But it is just never, ever that simple. Sigh. And I guess that’s as good a lesson about science and expertise as any.
(So … does amitriptyline help people with sleep problems and fibromyalgia or not? Obviously, the only honest answer is: I don’t know! Some recent evidence suggests it may not. Some older evidence suggests that it does. Battle of the experts!)
Many health care professionals are joining what is called the “evidence-based medicine movement,”6 including yours truly. Evidence-based medicine is the practice of choosing therapies and making recommendations to patients that are — this is pretty crazy, I know — based on scientific evidence whenever possible. Or, if the evidence is sketchy or contradictory, we like to — even crazier! — discuss it with our patients.
If it seems strange to you that there would need to be a “movement” for this, you are not alone. It may seem strangest of all to those of us who have joined it. It really seems like it shouldn’t be necessary. It’s like having a “profit-based business movement” or a “plant-based gardening movement.”Having an evidence-based medicine movement seems like having a “profit-based business movement.”
Perhaps evidence-based medicine became a “movement” because of opposition and complicated philosophical debate. Critics rightly point out that if medical and therapeutic practices were limited only to what can be proven (i.e. known with nearly perfect confidence), the entire health care system would grind to a halt. Fortunately, we evidence-based types are not soft in the head: the point is to make the fullest and best possible use of available evidence, not to be hamstrung by its limitations.7 There is still art in health care, of course.
Unfortunately, for many alternative therapists, “art” is almost all there is. Alternative medicine is under siege by intelligent critics for being scientifically bankrupt.8 I’m not talking about a knee-jerk rejection of anything new and different: I’m talking about serious, credible criticism from smart, respectable professionals like Dr. Edzard Ernst, Simon Singh, Dr. Steven Novella and many more.9 They all allege that “alternative” medicine is just hanging on to tired (but profitable) old ideas that have failed one scientific test after another for several decades. The great majority of defenders of alternative health care never studied science,10 and yet they present their ideas to patients as if they were proven, and are generally intolerant of criticism. The “experts” arguing in favour of most of alternative medicine are not really expert. They are running on automatic.11
So what is a patient to do?For many alternative therapists, “art” is almost all there is.
As a patient, your best general defense against the “battle of the experts” is to eliminate some of the so-called experts, because they are not all as expert as they’d like you to think.
Go into the offices of health care professionals with your eyes wide open, knowing that even the best of them are imperfect ambassadors for an incomplete science. They are only human. They put their pants on one leg at a time. Not all of them graduated at the top of their class — and maybe that’s a bad thing, or maybe it’s a good thing, because test scores don’t mean much in the real world.
Choose the therapist, not the therapy (see Choose the Therapist, Not the Therapy). Look for signs of professionalism and of humility. Real experts rarely act like experts. Give your confidence to therapists and doctors who can say “I don’t know” or “I’m not sure” — no issue should ever be “cut and dried” or “textbook.” Give priority to the professionals who explain their thinking, who present specific evidence for key choices, who seek your input and consent for treatment plans.
There are warning signs, too: give less weight to the opinions of those who rush through appointments, who don’t know you or your story well and don’t try to get to know you, who don’t take time to do a thorough assessment. Watch out for over-prescriber: excessive prescriptions are likely to be better for the prescriber than they are for you.
Above all, beware of extraordinary claims, of flaky nonsense. Beware of professionals who are gung-ho evangelists for a particular way of doing things, who make big promises, who have an answer for everything. Lord knows, science is imperfect and incomplete, and not everything worthwhile is yet supported by the evidence — but science is also the only serious game in town, the only real hope of ever being close to sure of anything. So do not accept strange ideas easily. Don’t be gullible! Don’t be a sucker! Remember that everyone “just knew” that heavy objects fell faster than lighter objects … until Galileo tested it at the Leaning Tower of Pisa in the 16th century. See Extraordinary Claims: A guide to critical thinking, skepticism and smart reading about health care on the web.Science is also the only serious game in town, the only real hope of ever being sure of anything.
Also be alert for overly complex, “dot-connecting” diagnoses that make the therapist sound terribly clever to have worked out a complex chain of causes: the trouble with these is that, the more impressive the dot-connecting, the less likely it is to be right. See The Humble Therapist: Why you need to be skeptical when your massage therapist, physiotherapist or chiropractor tells you where the pain is really coming from.
From the abstract: “All three groups improved after treatment ... in fibromyalgia, placebo groups are important in drug trials.” No kidding!BACK TO TEXT
From the abstract: “Amitriptyline had no significant advantage over placebo during the study period.”BACK TO TEXT
The earliest controlled study of amitriptyline for fibromyalgia I’ve found so far, and contradicting two more recent ones. From the abstract: “Amitriptyline was associated with significant improvement in all outcome parameters, including patient and physician global assessments, patient pain, sleep difficulties, fatigue on awakening, and tender point score.”BACK TO TEXT
Complex but interesting philosophical analysis of narrative- and evidence-based medical practice, concluding that “appreciating the narrative nature of illness experience and the intuitive and subjective aspects of clinical method does not require us to reject the principles of evidence based medicine.”BACK TO TEXT