Thunder god vine may not be a useful herbal medicine but the compounds isolated from it are fascinating – if not as medicines, then most certainly as laboratory tools. Nature Chemical Biology recently published an article where a research team from Johns Hopkins, the University of Colorado at Boulder, and Drew University in New Jersey, has determined the molecular mechanism of action of triptolide, an unusual triepoxide compound from the plant.

Tripterygium wilfordii Hook F, or thunder god vine, is known as lei gong teng in Chinese traditional medicine and has a history of use as an anti-inflammatory herb. As with many traditional medicines, usage patterns do not necessarily indicate scientific validity. In fact, a Cochrane review published just last month on herbal therapies for rheumatoid arthritis indicated that the efficacy of thunder god vine was mixed. More concerning is that the herb had significant adverse effects in some trials, from hair loss to one case of aplastic anemia.

Nevertheless, the herb’s components have been studied since the 1970s for since they also appears to kill tumor cells in culture with nanomolar potency and have immunosuppresant activity in animal models. The group of the late natural products chemist at the University of Virginia, S. Morris Kupchan, first identified the unusual structures of triptolide and tripdiolide from Tripterygium wilfordii as described in this 1972 paper from the Journal of the American Chemical Society. Cytotoxic activity toward tumor cells in culture was used to guide the chemical fractionation of extracts. The unusual presence of three consecutive epoxides in the structures of both compounds led Kupchan to hypothesize later in Science that they target leukemia cells by covalent binding to cellular targets involved in cellular growth.

As an aside: Epoxides are chemically reactive groups composed of an oxygen atom bonded to two carbons; the constraints of this triangular structure and the electrons on the oxygen favor the opening of this ring and attack of other atoms such as sulfur, often present in regulatory regions of enzymes. The Wikipedia entry gives a pretty nice primer. The reactivity of epoxides also makes these compounds highly useful intermediates in industry, particularly in the manufacture of ethylene glycol antifreeze and industrial paints and adhesives (e.g. epoxy resins).

Conventional wisdom would drive most scientists to take one look at triptolide and say that this stuff is a royal mess – so chemically reactive that it couldn’t possible have a specific cellular target. It’s probably too “dirty” – so promiscuous in its binding that it probably attacks all manner of sulfhydryl-containing enzymes and blows the cells to smithereens.

However, several groups have shown over the last 10 or 15 years that some epoxide-containing natural products have very specific cellular targets. Epoxides are not so wildly reactive that they bind everything in their midst. Instead, the environment in which the epoxide exists seems to provide some binding specificity. For example, the group of Jun O. Liu, then at MIT, showed in 1998 that another epoxide-containing natural product, fumagillin, exerted its antiangiogenic activity by binding to a protein called methionine aminopeptidase 2 (MetAP2). Similarly, Brent Stockwell at Columbia University and the Howard Hughes Medical Institute recently published a tour de force in another Nature Chemical Biology paper showing that a reactive 2-chloromethylketone compound specifically targets protein disulfide isomerase, preventing neuronal cell death from misfolded proteins with potential use in Alzheimer’s or Huntington’s diseases.

Jun Liu was again at the helm in the current thunder god vine study in Nature Chemical Biology. The group started with a simple approach to narrow down the target of triptolide from thunder god vine: they treated the venerable HeLa cervical carcinoma cell line with the drug and examined the incorporation of the building blocks of DNA, RNA, or protein. Triptolide was several orders of magnitude more potent in rapidly inhibiting RNA synthesis.

In an elegant series of experiments, the researchers progressively dissected the modulation of RNA synthesis – first identifying the multiprotein complex of RNA polymerase II (RNAPII) as the target but acting via a mechanism different from known RNAPII inhibitors such as the mushroom toxin, ?-amanitin.

Further experiments revealed that triptolide bound to a transcription factor component of the RNAPII complex called TFIIH. Then, finally, the investigators demonstrated that triptolide specifically attacked a component of TFIIH called XPB. XPB is a type of DNA unwinding enzyme called a helicase and is involved in DNA repair. The group then made semi-synthetic chemical analogs of triptolide to determine how inhibition of the ATP hydrolyzing activity of XPB correlated with potency in killing HeLa cells. While the rank order of potency of the compounds correlated, the drugs were less potent in attacking the enzyme activity of the XPB protein than in killing HeLa cells. So, it’s unclear as to exactly how binding to XPB is leading to cell killing. The investigators do note that triptolide may have other cellular targets that are less abundant than XPB that contribute to its activity.

Of course, we can’t tell right now if triptolide selectively kills tumor cells relative to normal cells. Again, conventional wisdom would argue that a drug that hits such a crucial target as a transcription factor is unlikely to have selective activity. After all, the classic RNAPII inhibitor ?-amanitin is well-known as a lethal toxin responsible for legendary poisonings by the death cap mushroom, Amanita phalloides. However, low concentrations of such a compound might indeed have some selectivity when given together with a DNA-damaging anticancer drug. But that’s a very fine tightrope to walk.

In the end, triptolide may end up “just” being a useful laboratory tool for understanding the basics of gene transcription and DNA repair. But if normally disregarded epoxides do indeed have some specificity in their action on cellular targets, perhaps analogs can be made with selective action against tumor cells. Many triptolide analogs have been synthesized over the years and should certainly be revisited in the context of cancer treatment. But this finding should also serve to warn us that the indiscriminate use of the herb as an anti-inflammatory should be revisited, particularly if the dose of the herb gives variable concentrations of compounds with a very low margin of safety.

Titov, D., Gilman, B., He, Q., Bhat, S., Low, W., Dang, Y., Smeaton, M., Demain, A., Miller, P., Kugel, J., Goodrich, J., & Liu, J. (2011). XPB, a subunit of TFIIH, is a target of the natural product triptolide Nature Chemical Biology, 7 (3), 182-188 DOI: 10.1038/nchembio.522

I’ve really come to detest Dr. Mehmet Oz.

You remember Dr. Mehmet Oz, don’t you? How can you escape him? He is, after all, Oprah Winfrey’s protege, and of late he’s really been living up (or down) to the example set by his television mentor, who of late apparently thinks nothing of promoting faith healing quack John of God on her show. Following in the footsteps of his much more famous and well-known mentor, this season on his television show, The Dr. Oz Show, Dr. Oz has in some ways imitated Oprah and in some ways gone her one better (one worse, really) in promoting the Oprah-fication of medicine. And this season has been a particularly bad one for science-based medicine on The Dr. Oz Show. Apparently Dr. Oz felt that he had to surpass what he did last season, which included inviting a man whom I consider to be one of the foremost sellers of quackery on the Internet, Dr. Joseph Mercola. Prior to that, Dr. Oz had done an episode touting the glories of that form of faith healing known as reiki. In between, he made appearances at various panels of woo-friendly physicians trying to coopt President Obama’s health insurance reform initiative to cover more “holistic” care (i.e., “integrative medicine”).

In the next season, in particular over the last couple of months, Dr. Oz showed me just how wrong I had been when I had previously been saying that Dr. Oz seemed to be mostly science-based but with a soft spot for certain kinds of pseudoscience. This season, Dr. Oz has thrown down the gauntlet to science-based medicine (SBM) and, as I like to put it, crossed the Woo-bicon. First, he not only invited Joe Mercola back on his show, but he did it defiantly, defending Mercola against what I consider to be much-deserved charges of being a seller of quackery and lauding him as a “pioneer of holistic treatments.” A couple of weeks later, Dr. Oz pulled the classic “bait and switch” of alternative medicine, featuring a yoga instructor on his show who also advocated all sorts of Ayruvedic quackery. Then, a mere few days later Dr. Oz, apparently not satisfied at his transformation from nominally science-based to being based solely on whatever would bring him higher ratings, completed his journey to the Dark Side of quackery by credulously featuring a faith healer on his show and hosting what has to be the lamest faith healing that I’ve ever seen in my entire life. After that, I didn’t think Dr. Oz could go much lower, although he tried, two examples of which were his anti-vaccine-sympathetic episode on autism in which he featured Dr. Robert Sears and his utterly reversing a previous scientifically correct stance of his and promoting a dubious and potentially dangerous diet.

So where could Dr. Oz go after these episodes? After his credulous featuring of a faith healer on his show, I didn’t think that even Dr. Oz could or would go any lower. Man, was I wrong. Wrong, wrong, wrong, wrong, wrong! I admit it freely and incredulously. As I found out from all of you, Dr. Oz’s guest on his show on Tuesday this week was psychic scammer John Edward, whose show Crossing Over with John Edward ghoulishly featured Edward convincing bereaved guests that he could speak with their departed loved ones. But it was even worse than it sounds just from my description thus far. How low can a physician go to feature someone like Edward, who claims to be able to talk to the dead but in reality is nothing more than a so-so cold reader? He can entitle his segment featuring Edward, Are Psychics the New Therapists (part 2 and part 3). Dr. Oz even helpfully features a segment in which Edward gives his audience advice on how to harness their psychic powers and a chapter from John Edward’s latest book. As I watched, I couldn’t believe my eyes. I guess that means I just haven’t become cynical enough yet, because Dr. Oz’s trajectory has been so obviously leading to something like this for several months now. After all, once you’ve had a faith healer on your show, there really aren’t any boundaries left with regards to your respect for science to justify barring someone like Edward from your show, are there? Certainly, I can’t think of any, but then I am not Dr. Oz. Come to think of it, Dr. Oz obviously couldn’t think of any, either, which is why John Edward was on his show.

Perhaps the most telling part of the episode came right at the beginning of the John Edward segment, telling about Dr. Oz’s audience, that is. Dr. Oz introduces the segment by saying:

We’ve had more requests to join this show than any other we’ve ever done before, more than weight loss, more than cancer, more than heart disease. The topic? Do you believe we can talk to the dead?

Yes, apparently Dr. Oz’s fans were clamoring to be in the audience for this episode above all others, and throughout the show the audience was completely enthusiastic and fawning, just like the show’s host, who asks the question: Is talking to the dead a new kind of therapy? I kid you not. I wish I were kidding. I really do. Then, Dr. Oz even goes one step beyond by answering his own question with a comment to the effect that “psychic medium John Edward believes it can be,” after which he asks another question: “Could it help you someday?” What follows is a taped segment about grief from “devastating loss” and how some people even resort to trying to talk to the dead, for which, we are told, they need a person like John Edward. Edward then describes grief as an “energetic form of cancer” that will, if not treated, “metastasize to other parts of your life.” This is actually not a bad analogy, but the devastating effect of grief doesn’t mean that one has to lie to the patient. Edward apparently disagrees, as he even assures us that speaking to a psychic medium can be very therapeutic if you’re suffering from grief due to the death of a loved one. Even if that were true, would it justify the lying and deceit inherent in claiming to “speak to the dead”?

After that, Dr. Oz comes back on and finishes the introduction by saying:

Now as a heart surgeon I have seen things about life and death that I just cannot explain and that science can’t study.

So, let’s see. Just because the great and powerful Dr. Oz can’t explain it, he assumes that talking to the dead must be real and that science can’t study it. It’s a massive argument from ignorance combined with special pleading, in which it is assumed that the methods of science are inadequate for studying the phenomenon of people like Edward who claim to be psychic mediums. Dr. Oz lives that attitude as well, as he shows not even the slightest whiff of skepticism, nor does he offer anything more than the most perfunctory of challenges to what Edward is doing. Actually, he doesn’t even do that. Other than a brief question near the beginning about whether people who have limited resources should spend money on a medium or use it to find a good counselor, there are no challenges. Throughout the entire segment, Dr. Oz’s tone is more than just respectful. It’s downright fawning and deferential.

Consistent with that, Oz doesn’t even include a “skeptic” in the audience as he has with previous woo-filled episodes. The closest he comes to it is having Katherine Nordal, PhD of the American Psychological Association, who not really introduced on the show but is described on the APA website as “the executive director for professional practice of the American Psychological Association.” Her job is described as overseeing “the promotion of the professional practice of psychology” and ensuring “psychological services’ accessibility and availability through legislative and judicial advocacy, public education and marketplace initiatives.” I’m not sure what purpose Nordal served because she didn’t really question whether Edward could speak to the dead, which makes her a pretty lousy candidate to play the role of token skeptic that is common on these shows. Then, when Dr. Oz asks her whether finding a medium might be a form of therapy, rather than stating unequivocally that it is not, or at least not a good form of therapy because it involves deceiving the patient in a major way and is thus unethical, she says that it can be a form of therapy, just answering the question in the title of the segment with in the affirmative and giving the imprimatur of the APA to psychic mediums. At the very best, Dr. Nordal was naive and credulous, which led her to be taken advantage of by the producers of the show; at the worst, her behavior was profoundly cynical. What she should have said is that, although some people might find imagining conversations with their deceased loved ones to be comforting, mediums are not professionals; most have no medical or psychological training; and there is no evidence that they can speak with the dead. Given these facts, it is far better to use the services of a qualified psychologist trained in grief counseling.

At this point, Edward goes into his routine. If you ever caught his television show back when it was still on the air, nothing Edward does in his segment on Dr. Oz will come as a surprise. It’s nothing more than the old psychic medium trick of cold reading. This time around, he was actually a lot better at it than I remember him. His “hits” were more common and his “misses” fewer than I remember from the handful of episodes of his old show. In fact, there was one part that turned out so conveniently that I have to wonder if Edward’s people had managed to stage it somehow. At one point, Edward insists that someone in the room has experienced the death of a loved one associated in some way with St. Patrick’s Day or occurring in March. Of course, in an group of people the size of Dr. Oz’s studio audience, the odds are quite high that at least one person there has a relative or friend who died in March within reasonable proximity to St. Patrick’s Day. After badgering the audience, finally a young woman says that a friend of a friend had died in a car crash on St. Patrick’s Day. Predictably, Dr. Oz was awestruck. In fact, if you want to know just how lacking in skepticism Dr. Oz is, just check out this TV Guide article released before the show in which Dr. Oz Says Psychic John Edward “Changed My Life”:

I walked out of that studio thinking, “There’s something here. It’s bizarre. I don’t know what exactly is happening. But it’s definitely something.” I’m a heart surgeon. I can explain a lot of weird things. I’ve seen people who should have died who didn’t. Over the years I’ve had some pretty deep conversations with people who died and say they saw “the light” and came back with stories. I’ve heard many things that are not easy to reconcile with the western scientific mind, so you try to think of a reason for what’s going on. Could it be synapses short-circuiting in the brain that make people think they’re having an out-of-body experience? That’s what a doctor does. He tries to find a rational explanation. But I can’t make up an explanation for what John Edward does. And, again, what was most eerie was his level of detail, the concreteness of it all.

Or, one could say that there are times when Dr. Oz’s knowledge isn’t equal with that of skeptics who actually pay attention to these things. Otherwise he wouldn’t be so amazed by Edward’s transparent schtick. But he is, and once again he uses the argument from incredulity. Worse, he uses his position as a physician to create a false argument from authority. Just because he can’t imagine a scientific explanation for what John Edward does, Oz assumes that there isn’t one, and most of his audience accepts his authority as a surgeon as being reason enough to accept his assertion that science can’t explain Edward:

But I can’t make up an explanation for what John Edward does. And, again, what was most eerie was his level of detail, the concreteness of it all.

Which is, of course, what psychic mediums do. It’s what they do and have done for hundreds of years, if not longer. It’s not for nothing that John Rennie characterized Oz as the “great and gullible.” Dr. Oz was gullible when it came to faith healing and quackery, and he surpasses himself in gullibility in his treatment of John Edward and psychic mediums. What they do and how they do it are not mysteries to, for example, James Randi or Joe Nickell, who quite properly described Edward as “hustling the bereaved.” Both describe how Edward uses the technique of cold reading, and Nickell even describes how Edward has been caught in the past using “hot reading,” or using information gleaned from his minions having chatted up the audience before the taping of his show and then presenting that information as having been received from the dead. When he can’t guess right, Edward’s technique is to do this:

What separates John from other cold readers, is that John works with a sizable audience (the Gallery) and when his readings go like the above, as happens far too often, he will just say that he’s picking up the “energies” of two different or distinct families which is suppose to explain away wrong guesses. Enough wrong guesses or if the guest isn’t cooperating, he will just claim the “energy” is pulling back and then move on to someone else he hopes this time will be more volunteering of information.

This is what Edward appeared ready to do with the “St. Patrick’s Day” connection; that is, until the young woman in the audience finally came forward. She later explained her delay in doing so to fear of standing up and being on the show, after which Edward praised her for being honest.

After watching a sad spectacle like this, that of a once respected surgeon debasing himself with faith healers and psychic mediums, I asked myself what could possibly be going on here. My first thought was that reiki must be a powerful gateway woo, leading to the really hard stuff, like faith healing and psychic mediums. After all, Dr. Oz’s wife is a reiki master, and he got his start in the CAM world by (in)famously allowing reiki masters into his operating room to work their magic (and I do mean the word “magic” literally) on his cardiac patients as he was operating. Ten or fifteen years on, that little incursion into woo seems very quaint.

In actuality, what’s going on here, I think, is more likely to be pure hubris. I submit to you that Dr. Oz has become so enamored with himself and his image as “America’s doctor” an the iconoclast who bucks the medical system, sees beyond “Western medicine,” and is just so much more damned smart than other doctors, that it likely never occurred to him that he could be fooled by a psychic scammer like John Edward just as easily as anyone else. Add to that his need to fill the insatiable maw of his daily TV show with new topics and new guests, coupled with the demands of his audience, who are clearly very much into this sort of thing, and it becomes easy for him to justify having a guest like John Edward as both evidence of his intelligence and open-mindedness and giving the people what they want.

Bread and circuses. That’s apparently what they want. I can only wonder what’s next for The Dr. Oz Show after this? I predict alien abductions. Or maybe the “conspiracy” to keep the One True Cure for Cancer from the people. One of those will be the next topic Dr. Oz tackles. Either that, or David Icke will be involved. It’s coming. I know it.

I often receive e-mail from SBM readers (or SGU listeners) who have had the experience of their doctor, nurse, dentist, physical therapist, or other health care provider recommending to them a treatment option that seems dubious, if not outright pseudoscientific. They want advice on what to do.  There are common themes to the e-mails – the writer often feels very uncomfortable in the situation. They do not feel comfortable confronting their provider directly, yet they do not want to acquiesce to the advice either. They are also often asking my opinion about the advice – is it really as wacky as it seems. This uncertainty saps them of their resolve, leaving them feeling a bit helpless.

Here is one such e-mail:

Ten days ago, my wife and I welcomed our first child into the world. She was born a couple weeks early, which left her mouth a bit too small and week to breastfeed effectively. To prevent her from losing too much weight, we were referred to a lactation consultant (who works out of the pediatrics department at the hospital where our daughter was born). This consultant (who is also an RN) suggested a regimen of supplementing nursing with pumped breast milk.

This was working great until my wife’s milk production dropped the day before our follow-up appointment. When we asked what to do about this, the nurse recommended that my wife take fenugreek, an herbal supplement. I was a bit skeptical of this advice, so I asked what it was about fenugreek that helped with milk production. The lactation nurse’s answer was vague — she said things like, Herbs can be helpful for lots of health issues, and, a lot of women I see seem to think it helps (oh, the logical fallacies). When we pushed her on this a little more, she handed us a flyer, printed by the hospital about fenugreek. The flyer seemed to support the use of the supplement, but mentioned that there was no scientific research demonstrating that fenugreek increases milk supply. When we asked why it hadn’t been researched, the nurse responded that there wasn’t a lot of money in lactation and that scientists generally aren’t interested in the kind of things she does (basically, that she was doing the good work that cold-hearted scientists refused to do).

She also mentioned that there was a prescription drug that boosts milk supply, but it carries with it the risk of a pretty serious side effect (depression), so she prefers her patients to try the supplement first. I asked how we could be sure the supplement didn’t also carry the risk of negative side effects if it hadn’t been studied, she simply said that it worked out fine for the patients she’s seen.

My wife and I decided to let it go for the time being and decide later whether or not to go the supplement route (it’s hard to argue with a nurse when you’re under-slept, one of you is topless, and the baby is screaming for food). Fortunately, her milk supply picked up a bit on its own, so we didn’t have to resort to using an untested therapy (yet).

First, let’s address the recommendation – fenugreek to increase breast milk production. Substances that increase milk production are called galactogogues. There are a number of drugs that have been shown to increase milk production, although the levels of evidence varies. For many there are only case series. Oxytocin is supported by double-blind placebo controlled trials, and is both safe and effective. Other commonly used drugs, like metoclopramide, are supported by unblinded case series only.

Fenugreek is a common spice and medicinal herb used in India. Among its putative effects is increased lactation, however, there are no clinical trials to support its use. Recommendations are based upon anecdotes only. This 2010 review article reports:

The side effects most commonly reported are a maple-like smell of the urine, breast milk, and perspiration, diarrhea, as well as the worsening of symptoms in individuals with asthma or hypoglycemia. The potential for transfer to milk or side effects in the infant are unknown. As is the case for most herbal products, the dose necessary to obtain a galactogogic effect has not been defined. Only one study on the effect of fenugreek on lactation has been reported. Swafford asked 10 mothers to maintain a diary of the quantity of milk produced with a pump for a period of two weeks. In the first week, baseline milk production was evaluated; in the second week, mothers took fenugreek, 3 cups, three times daily. In the first week average quantities were 207 ml/day, whereas, milk production in the second week averaged 464 ml/day (p = 0.004). Unfortunately, the report excluded any information regarding the characteristics of the mothers enrolled in the study or the postpartum period during which the study was done. Nevertheless, the daily milk quantities reported during treatment do not seem to be particularly high (reference: Swafford S, Berens P. Effect of fenugreek on breast milk production. Abstract 5th International Meeting of the Academy of Breastfeeding Medicine September 11-13, 2000, Tucson, Ariz Academy of Breastfeeding Medicine News and Views 2000;6(3).)

So – there are side effects, even potentially serious side effects like exacerbating asthma and hypoglycemia. The dosing is unknown, and the one small efficacy study that was done was unimpressive.

There is nothing implausible about the claim that an herb can be an effective galactogogue – herbs can be drugs with pharmacological activity. What is disturbing about the nurse’s recommendation is the double standard. She seems to believe that herbs are inherently safer than drugs, which is a false dichotomy based on the naturalistic fallacy, but not logic or evidence. She essentially recommended an untested drug with uncertain dosing, side effect, or efficacy over drugs with better evidence for both safety and efficacy.

It should also be noted that the e-mailer’s mild production spontaneously increased after the consultation. If she had taken fenugreek, that would have been one more anecdotal report apparently supporting its efficacy.

But onto the real question of the e-mail – how to respond in this situation. My advice is to first not be intimidated. Feel free to express your concerns or uncertainty about the recommendations being made. I commend this e-mailer for asking for published evidence, but don’t take an evasive answer as adequate. Ask for published evidence or authoritative reviews. If they do not have any handy, they can certainly prepare this material for the next visit or simply e-mail it to you.

If you feel up to the task, you can research the question yourself and then ask your health care provider to comment on the material you find (but don’t overwhelm them with mounds of material).

Depending on how egregious the pseudoscientific advice was, you should also consider simply leaving that provider for someone with whom you feel more comfortable and confident. I do recommend, whether or not you stay with the provider, to give them feedback. Express your exact concerns about their advice. How they respond will also tell you a great deal about their approach and dedication to evidence-based practice.

In short, I think patients should feel empowered to push back against practitioners who stray from science and reason as a basis for health care recommendations and practice. Those pushing for anti-science in medicine are certainly vocal, and their agenda will advance if others simply do nothing. In fact – if a practitioner recommended an outright anti-scientific treatment (like homeopathy, say) I would go beyond giving them individual feedback. I would write to the head of their clinic, hospital, or department and express your concerns. You are a consumer as well as a patient, and administrators listen to their consumers.

The above situation is becoming distressingly common, and it is not easy to deal with. It is one more type of harm that is caused by the infiltration of anti-science into medicine. I had a similar experience myself. My wife and I were referred to a practitioner to address a problem with one of our children (I am being deliberately vague on details). At the first visit the practitioner made a comment (as an aside, not directly related to the visit) about vaccines and autism. I, of course, politely challenged her on that statement, and she backpeddled – I think just to end the confrontation. My wife thought that I was inappropriate to challenge her – she was concerned about my accepting the role as patient rather than physician.

At the next visit, however – the visit when the practitioner was giving us her actual recommendations, my wife had a change of heart. The practitioner’s recommendations were entirely limited to “natural” interventions like diet and herbs, and she shied away from any medications. Her recommendations were ideology-based, not evidence-based, and in the end the consultation was entirely useless. My concerns at the first visit – that perhaps this practitioner does not have a firm grasp on the concepts of science-based medicine, were entirely vindicated.

This is an important point – if a practitioner recommends something that is blatantly against the science and evidence, how can you have confidence in any of their recommendations? I am not talking about not being up on one bit of latest evidence – no one can know everything. A serious lapse, however, can reveal a systematic bias in a practitioner’s approach to evidence and practice.

Unfortunately, patients cannot take for granted that a licensed professional is necessarily science-based.

Lest some of our readers imagine that the authors of this blog are mere armchair opinion-spouters and keyboard-tappers for one little blog, I’d like to point out some of the other things we do to spread the word about science and reason. Steven Novella’s new course about medical myths for “The Great Courses” of The Teaching Company is a prime example: more about that later.

First, some examples of the kinds of things we have been doing:

• Personal blogs.
• Podcasts, both as hosts and as interviewees.
• Magazine articles and columns.
• Teaching doctors and laymen in medical schools, hospitals, and workshops.
• Radio show interviews.
• Public speaking: informal talks to local groups and formal presentations at regional conferences, national conferences, even international conferences.
• Guest columns and letters to the editor in newspapers.
• Interviews by journalists who quote us in the media.
• Founding fellows and board members of the new Institute for Science in Medicine.
• Invited to write commentary to accompany published articles in major journals.
• Peer reviewing journal articles prior to acceptance for publication.
• Special Science-Based Medicine conference, workshops and panels at the annual Amaz!ng Meetings of the James Randi Educational Foundation (JREF) (more to come at TAM 9  July 14-17, 2011 in Las Vegas).
• Participation in online forums and discussion lists.
• Books: articles included in anthologies and even used as a chapter in a book.
• Links, reprints and translations of our articles have spread around the world (one of mine was even translated into Turkish!).
• Working with lawyers as medical experts on lawsuits about bogus health products and false claims.
• Co-authoring a new edition of a textbook.
• Advising organizations that deal with health information.
• Answering personal inquiries.
• Haranguing our friends and families.

I have done almost everything on this list myself (the only exceptions are that I don’t have a personal blog or host a podcast, although I have appeared on several). My colleagues have done a lot more that I haven’t heard about: if all their accomplishments were included, the list would undoubtedly be much longer. I am retired and at leisure; but my colleagues manage to practice medicine, do research, teach, constantly scour the Internet and the medical literature, raise young children, and still get so much else done that I find it hard to believe they ever sleep (particularly supermen Steven Novella and David Gorski). And contrary to the imaginative accusations of some of our detractors, none of us are in this for profit: most of our efforts to spread the word about science-based medicine are pro bono, without any pay. When we do get paid, it’s usually a pittance, often in the form of a small honorarium or reimbursement of travel expenses for a talk. If a Big Pharma teat exists, we certainly haven’t managed to latch onto it.

Steven Novella is our founding editor and has arguably done more to support science and reason than any of us. His latest triumph is one of the “Great Courses” for The Teaching Company entitled “Medical Myths, Lies, and Half-Truths: What We Think We Know May Be Hurting Us.” It consists of 24 half-hour lectures that cover:

1. Medical Knowledge versus Misinformation
2. Myths about Water and Hydration
3. Vitamin and Nutrition Myths
4. Dieting—Separating Myths from Facts
5. The  Fallacy That Natural Is Always Better
6. Probiotics and Our Bacterial Friends
7. Sugar and Hyperactivity
8. Antioxidants—Hype versus Reality
9. The Common Cold
10. Vaccination Benefits—How Well Vaccines Work
11. Vaccination Risks—Real and Imagined
12. Antibiotics, Germs, and Hygiene
13. Vague Symptoms and Fuzzy Diagnoses
14. Herbalism and Herbal Medicines
15. Homeopathy—One Giant Myth
16. Facts about Toxins and Myths about Detox
17. Myths about Acupuncture’s Past and Benefits
18. Myths about Magnets, Microwaves,  Cell Phones
19. All about Hypnosis
20. Myths about Coma and Consciousness
21. What Placebos Can and Cannot Do
22. Myths about Pregnancy
23. Medical Myths from around the World
24. Roundup—Decluttering Our Mental Closet.

The concept and presentation are pure genius. The “myth” format will attract people who might not want to listen to something labeled “Science-based Medicine” or “Alternative Medicine.” He manages to cover almost all the topics we discuss on this blog, and he does it in a way that is palatable, easy to understand, and non-offensive. He is not dogmatic about anything: he points out areas of uncertainty and even tells students not to treat him as a definitive authority, but to think for themselves. He comes across as serious, professorial, fair, balanced, calm, cool, collected, organized, thoughtful, and very credible.

The course is available at a sale price of $69.95 on DVD, $49.95 on audio CD, or $34.95 for audio download. It comes with a booklet that provides a 2 to 4 page summary of the information in each lecture, each with suggested reading and questions to consider; and a glossary and bibliography. The introduction includes a whole paragraph about the Science-Based Medicine blog, and he cites several SBM articles in the bibliography section.

Dr. Novella deserves a lot of credit for creating this course. It is a worthwhile source of medical information and teaches critical thinking about science. It will reach a lot of people that we wouldn’t be able to reach otherwise. Thank you, Steven!

We may not be as sexy or popular as the purveyors of medical misinformation, but I think we are making a dent. At least we are getting reliable information about SBM out there where people can find it.  And I know our readers and commenters have done a thing or two themselves to help spread the word. I’d like to hear more about their activities and their accomplishments.

Sometimes standing up for science-based medicine can feel like a losing battle. Achievements like Dr. Novella’s course make me pause from weeping about our bêtes noires and break out a smile. Quality efforts like his do much to spread the word. They encourage my optimism that science will prevail in the long run. We may have to keep running constantly just to stay in one place, but it’s well worth the effort. The consequences of letting pseudoscience and woo-woo overtake us are unthinkable.

I graduated from the University of Michigan Medical School in the late 1980s. If there’s one thing I remember about the four years I was there, it’s that U. of M. was really hardcore about science back then. In fact, one of the things I remember is that U. of M. was viewed as being rather old-fashioned. No new (at the time) organ system approach for us! Every four weeks, like clockwork, we’d have what was called a concurrent examination, which basically meant that we were tested (with multiple choice tests, of course) on every subject on the same morning. The medical curriculum for the first two years had been fairly constant for quite some time, with a heaping helpin’ of anatomy, histology, biochemistry, and physiology in the first year and the second year packed full of pharmacology, pathology, and neurosciences. Nowhere to be found was anything resembling “energy medicine” or anything that wasn’t science-based!

Of course, back in the 1980s, the infiltration of quackademic medicine into medical schools and academic medical centers hadn’t really begun in earnest yet, although the rumblings of what is now called “complementary and alternative medicine” (CAM) and, more frequently these days, “integrative medicine” (IM) were starting to be heard in East Coast and West Coast schools. Even there, though, the incipient CAM movement was viewed as fringe, not worthy of the attention of serious academic physicians. Indeed, in the late 1980s, even at what are now havens of quackademic medicine if someone had suggested that diluting substances until there is nothing left, as in homeopathy, or waving your hands over a patient in order to channel the “universal source” of energy into a patient in order to heal a patient, as in reiki, had any place in scientific medicine, he’d have been laughed out of medical school–and rightly so.

Not so today, unfortunately. Although the problem of infiltration of quackademic medicine into academic medical centers goes way beyond this example, I can point out that faith healing based on Eastern mystical beliefs instead of Christianity is alive and well and ensconced in academic medical centers such as the University of Maryland School of Medicine Center for Integrative Medicine, where reiki masters are roaming the halls of the University of Maryland R. Adam Cowley Shock Trauma Center and Bonnie Tarantino, a Melchizedek practitioner, holographic sound healer, and an Usui and Karuna Reiki Master holds sway. Meanwhile, all manner of woo, such as acupuncture, homeopathy, craniosacral therapy, reiki, and reflexology are offered. Truly, you know that when an academic medical center has gone so far as to offer homeopathy, reflexology, and reiki, it’s all over as far as academic credibility is concerned, and it has become a center of quackademic medicine. Sadly, even a hospital where I trained, MetroHealth Medical Center, has succumbed to the temptation to add the quackery that is reiki to its armamentarium. That aside, I had never expected that my old, hardcore University of Michigan would go woo in such a big way.

I was wrong.

Over the last decade, the University of Michigan Medical School has gotten into alternative medicine, adding IM to its curriculum and even having a fellowship in IM. At the time I first learned of this a few years ago, as disturbed as I was, I reassured myself that at least U. of M. seemed to be sticking to the milder woo, like acupuncture and massage. Then, while browsing the blogs last month, I came across reports by P.Z. Myers and Tufted Titmouse, both of which contained a link to the University of Michigan Integrative Medicine (UMIM) resource page. And what to my wondering eyes did appear? (Actually, I should rephrase that as, “What to my despairing eyes should appear?”) The answer: Anthroposophic Medicine. Yes, it’s anthroposophy, Rudolf Steiner’s mystical, magical system that is the bottom of a lot of quackery and anti-vaccine beliefs. Indeed, outbreaks of vaccine-preventable disease have been distressingly common at Waldorf schools, where the educational philosophy is based on the teachings of Rudolf Steiner, which is why they are sometimes called Steiner schools or Steiner-Waldorf schools. Although the European Council for Steiner-Waldorf Education, which represents approximately 700 of the 1000 Waldorf schools world wide, has stated unequivocally that opposition to immunization forms no part of the goals of Waldorf education, Waldorf schools are magnets for parents opposed to vaccination. One example occurred in California in 2008, when there was a measles outbreak at the East Bay Waldorf School in El Sobrante. Given that the UMIM program, although interdisciplinary, boasts heavy involvement of family medicine faculty, I can’t imagine the cognitive dissonance that must be going on. After all, many family medicine doctors also take care of children and are responsible for making sure they are properly immunized just as much as any pediatrician.

But let’s look at what UMIM’s webpage on anthroposophy says about it:

Anthroposophic medicine views health as a matter of mind-body-spirit balance. It is centered on the idea that humans are not independent organisms but, instead, beings composed of the interactions of physical body, inner life body, soul (mind and emotions), and spiritual ego (self-awareness). Whereas conventional medicine focuses on “fixing” the part of the physical body that is “broken,” anthroposophic medicine prescribes treatment for the whole being through conventional methods in combination with holistic methods. As such, anthroposophic medicine integrates theories and practices of modern medicine with alternative, nature-based treatments and a spiritual-scientific understanding of the human being. The practice is based on Austrian philosopher Rudolf Steiner’s concept of anthroposophy, a scientific and philosophical world view that connects the spiritual within the human being to the spiritual in nature, the world and the cosmos.

This is consistent with what the Holistic Health Internet Community says about anthroposophic medicine:

Austrian scientist and philosopher Rudolf Steiner (1861-1925) refused to accept the contemporary scientific view of the body as a purely physical entity. From that conviction was born the doctrine of anthroposophy, a word he coined from the Greek words for “man” and “divine wisdom.” Steiner believed in the uniqueness of each human being, and contended that health and well-being deteriorated without that belief. Trained as a scientist and a mathematician, he was influenced by Hindu and Buddhist beliefs and founded a school in which his theories became practice.

Anthroposophical medicine determines the nature of illness based on Steiner’s principal of polarity. His system attempts to link and harmonize both the upper and lower poles of the body. Good health then depends on a harmonious relationship between the physical, etheric and astral bodies, and the ego. Practitioners are trained as medical doctors and may treat childhood infections, hay fever and asthma, anxiety, depression, cancer, musculoskeletal problems and fatigue.

If twenty years ago someone had told me that one day that not only would my medical alma mater be publishing dreck like this, but that it would have formed an interdisciplinary program devoted to it, I would have told that person he was delusional. If you had told me that anthroposophy would be part of a larger program of woo run by a physician who is described as having “studied herbalism and spiritual healing for 14 years with a Native American Healer” and as having research interests that include the “use of herbs, energy healing, environmental healing, and the therapeutic relationship” or that a physician trained in “functional medicine” would be a big part of a program in anthroposophic medicine there, I wouldn’t have believed it. All I can wonder is what Bill Kelley, the infamously hardcore scientific chair of the Department of Internal Medicine while I was at Michigan, would think or say if he were still at U. of M. In fact, having read the section on anthroposophy on U. of M.’s website, I wish I were delusional. But I’m not. The section is real, and the medical school from which I graduated has not only started to tolerate such nonsense, but begun to embrace it.

Anthroposophical medicine, it turns out, is rooted in prescientific vitalism. Rudolf Steiner, before he came up with the idea of anthroposophy, had led the German section of Theosophy. When he became enamored of his spiritual concept of anthroposophy, Steiner in essence caused a schism. Anthroposophy, it further turns out, is far more a religious and spiritual philosophy than a scientific or medical one. Based on his philosophy, Steiner created Waldorf schools, anthroposophic medicine, and biodynamic farming, the last of which would be a suitable topic for an amusing post on a non-medical blog. Suffice to say that some of the practices of biodynamic farming involve stuffing Yarrow blossoms (Achillea millefolium) into urinary bladders from Cervus elaphus, Red Deers, placing them in the sun during summer, burying them in earth during winter and retrieving them in the spring, all to strengthen the “life force” of the farm. There’s also a lot of use of cow horns, based on Steiner’s rationale, “The cow has horns in order to reflect inwards the astral and etheric formative forces, which then penetrate right into the metabolic system so that increased activity in the digestive organism arises by reason of this radiation from horns and hoofs.” Moreover, many of the concepts of homeopathy are combined with Steiner’s woo, such that many of the concoctions of biodynamic farming, which consist of various bits of dead animals plus or minus ground quartz crystals, are diluted into many tons of compost, to be spread over acres of farmland.

But let’s get back to anthroposophic medicine, which is based on the same sort of mystical philosophy that biodynamic farming is. Simon Singh and Edzard Ernst characterize this form of medicine thusly in their book Trick or Treatment?:

Applying his philosophical concepts to health, he [Rudolf Steiner] founded, together with Dr. Ita Wegman, an entirely new school of medicine. It assumes metaphysical relations between planets, metals, and human organs, which provide the basis for therapeutic strategies. Diseases are believed to be related to actions in previous lives; in order to redeem oneself, it may be best to live through them without conventional therapy. Instead, a range of other therapeutic modalities is employed in anthroposophic medicine: herbal extracts, art therapy, massage, exercise therapy, and other unconventional approaches.

Perhaps the most common example of anthroposophic medicine is the use of mistletoe extracts for the treatment of cancer. Perhaps you’ve heard of Iscador? While Iscador might actually have some activity against, for example, breast cancer, it is not without toxicity, and the evidence for its efficacy in cancer is at best conflicting. Even if Iscador turned out to be an effective treatment for breast cancer, it would be an example of being right for a reason that is spectacularly wrong. That’s because Steiner argued that mistletoe is a parasitic plant that eventually kills its host. To him, this represented a striking parallel to malignant tumors, which, like mistletoe, are parasitic entities that eventually kill their hosts. Steiner’s conclusion? Because of this resemblance, mistletoe must be an effective treatment for cancer. Readers knowledgeable about homeopathy will immediately recognize that Steiner clearly must have believed in the homeopathic principle of “like cures like.” In fact, he even went beyond that to generalize that “a plant is a healing plant when it has a distortion or an abnormality in its physiology and morphology,” presumably related to human disease. Indeed, according to Dr. Peter Hindenberger this represents a “modern, scientific reformulation of what, in former times, existed in the ‘doctrine of signatures‘”; i.e., the belief that God has marked everything he created with a sign (signature) that is an indication of the purpose for which the item was created.

Although you can read more about anthroposophic medicine, either at a Steiner website or the Physician’s Association for Anthroposophic Medicine (to get it right from the horse’s mouth, so to speak) or over at The Skeptic’s Dictionary and Quackwatch, including a description of what being a student at a Waldorf school is like, because this is about UMIM’s apparent embrace of anthroposophical medicine, I think that I will close by discussing what UMIM says about it. But, before I do so, let me quote a passage from what PAAM says about it in a PDF booklet. After all, U. of M. includes a link to PAAM on its website, which leads me to assume that the UMIM program in anthroposophic medicine endorses PAAM. So does the fact that PAAM is based in Ann Arbor. But back to the PAAM pamphlet:

Medicine based purely on material science is limited to explaining an illness solely on the basis of the laws of physics and chemistry.

I’m sorry. I can’t help but interject here that PAAM says this as though it were a bad thing. Personally, though, I’m curious as to how we can explain illness not based on the laws of physics and chemistry. Unfortunately, PAAM is more than happy to tell us how anthroposophic medicine is “more ambitious” than us mere practitioners and proponents of science-based medicine. I suppose it is, casting off, as it does, all those inconvenient laws of physics and chemistry that took hundreds of years to discover and understand:

Anthroposophic medicine is more ambitious. It takes into account additional factors, both general and individual, that may affect the patient’s life, mind, and soul, and their physical manifestation: in growth, regeneration, microcirculation, fluid retention in the skin, muscle tone, biorhythms, head distribution, posture, uprightness, gait, mental focus, speech. When illness occurs, examination of the above may reveal deviations, imbalances, and extremes–additional diagnostic parameters that need to be considered when selecting a therapy. Anthroposophic medicine also has a different understanding of the role played by the patient in overcoming illness. The patient is not simply a passive recipient of medical skill, but an equal partner with the doctor. After all, nobody can know the patient better than the patient. During an illness, the patient has the opportunity to recognise the state of imbalance body and soul have reached, to understand this and rectify it. The illness can provide an opportunity to learn new modes of behaviour, to develop further insights, and acquire greater maturity.

And, yes, anthroposophic medicine embraces homeopathy:

In addition, other substances tailored to the patient’s unique characteristics are administered. These are frequently homeopathic substances designed to stimulate the organism and its powers of self-healing.

Science-based medicine, anthroposophy clearly is not. Of course, that’s quite obvious from what UMIM itself says about the anthroposophic view of health. According to UMIM, this consists of these tenets, with my comments in brackets after each item:

• Health involves a dynamic balance and high functioning of all aspects of a person’s life. [This is so vague as to be meaningless and all but impossible to argue with, but it's the sort of trope common in alt-med circles.]
• Illness is the result of disharmony and imbalance amongst the three systems of the body and their related forces and effects. [This sounds very much like attributing disease to imbalances in the four humors. Teach the controversy! about the Four-fold Man!]
• Illness is a tragedy, but also an opportunity for learning and transformation. [This sounds very much like the quackery that is the German New Medicine and Biologie Totale to me; that is, if you strip away Steiner's belief in reincarnation wherein illness isn't the working through of unrecognized emotional traumas in this life (as German New Medicine teaches) but is rather the working through of issues from previous lives.]
• The signs and symptoms of an illness are often the body’s attempts at healing and, in general, should not be suppressed, but rather, aided, observed and resolved. [More German New Medicine- and Biologie Totale-like gobbledygook. Again, odd how U. of M. leaves out Steiner's belief that these body's attempts at healing are related to past life experiences.]
• Many illnesses, especially benign ones, should not be artificially prevented, but should be allowed to occur and be treated and healed. The patient thereby gains strength and experience, both biologically and spiritually. [This would appear to be the basis for so many anti-vaccine beliefs that permeate every aspect of anthroposophic medicine and the education taught in Waldorf schools. After all, what is vaccination, but preventing illness? I guess your kids get so much stronger, spiritually and biologically, if you just let them, take their chances with measles, mumps, whooping cough, and Haemophilus influenzae type B. Because, you know, that worked out so well for children in terms of childhood mortality back in the days before vaccines could prevent these diseases. Oh, wait. No it didn't.]
• True prevention of illnesses involves a healthy lifestyle with positive habits, strengthening the biological, psychological and spiritual aspects of a person, and avoiding the detrimental and illness-producing effects of much of modern civilization. [Do I detect a reference to "toxins" here? I think I do.]

UMIM even goes on to link to a company that produces skin care products and medicines based on Steiner’s biodynamic farming (including Iscador and homeopathic remedies), as well as to point out that many anthroposophical remedies can only be administered as an inpatient at a facility like the Rudolf Steiner Health Center in Ann Arbor, Michigan. There, you can find a video about anthroposophic medicine:

Check out the part around 24:25, where a chemist describes how anthroposophic medicines are made, including the part about how he “potentizes” many of them in decimal fractions, just as homeopaths do with their remedies. His goal is, as he puts it, to “strengthen the vital forces within the living organism while at the same time respecting its natural rhythm.” He also heads out to the French border at 4 AM during the summer so that he can harvest Arnica plants at dawn, thus allowing the “morning strength” to be maintained in them. I kid you not. Then, get a load of this description of anthroposophic medicines, right off the U. of M. website:

Many anthroposophic remedies are specially prepared using homeopathic or modern alchemical pharmaceutical processes to naturally stimulate healing processes in the ill person.

Yes, it would appear that alchemy is alive and well at U. of M.!

Fortunately, the Rudolf Steiner Health Center does not appear to be affiliated with the University of Michigan, at least as far as I can tell. Unfortunately, it’s still very disturbing that UMIM would recommend such an institution and even more disturbing that “anthroposophic physicians at the University of Michigan” appear to be partnering with the Rudolf Steiner Health Center to research anthroposophic medicine as supportive care for cancer patients.

Personally, I think that Robert Carroll gets it exactly right when he characterizes anthroposophic medicine as being “even more out of touch with modern, science-based medicine than homeopathy.” Think about it. Homeopathy is based on just two magical ideas: The Law of Similars and the Law of Infinitesimals, which together can be viewed as an expression of the ancient principles of sympathetic magic. In marked contrast, anthroposophic medicine is based on many ideas with no basis in science that can best be described as pure magical thinking. Indeed, to me at least, anthroposophic medicine resembles more than anything else naturopathy in that there doesn’t appear to be a form of unscientific, prescientific, vitalism-based woo that it doesn’t embrace. In fact, anthroposophic medicine appears to go far beyond naturopathy in that respect. It also brings into play a veritable cornucopia of mystical concepts, including the etheric body, the astral body, and the ego. It postulates that the soul, the senses, and the consciousness are beings that have an independent existence outside of the body and further asserts that herbs, essential oils, and movement therapy known as eurythmy can bring these things into harmony and balance with each other and the physical body. Reading about anthroposophy and anthroposophic medicine, I had some serious acid flashbacks to my youth, when I used to be an avid Dungeons & Dragons player. My personal oddities during my high school and college years aside, anthroposophic medicine openly denigrates science-based medicine for only being able to diagnose and treat disease according to its understanding of the laws of physics and chemistry, to which I respond: Upon what else would a physician base his understanding of disease? As Carroll put it:

Steiner approached medicine the same way he approached everything else from astrology to Atlantis to education to farming to metaphysics: He dictated his visions. Why anyone considers him a scientist is a great mystery. His notion of science as involving the explanation of how immaterial entities affect material entities is the very opposite of science.

Indeed, and the medical school from which I graduated over 20 years ago now has a program dedicated to teaching physicians and medical students as fact the medical philosophy of this very man, whose philosophy is not only far more religion and mysticism than science but is indeed antiscience at its very core despite its superficial declaration of allegiance to science. Indeed anthroposophic medicine’s assertion of relationships between the various bodies (physical, etheric, etc.) and astronomical bodies is far more akin to astrology than science. Would that it were only homeopathy U. of M. were teaching and practicing!

I used to be very proud to have graduated from the University of Michigan Medical School. When I was there, it was one of the top public medical schools in the country and compared quite well with any private medical school in the U.S. you could name. In many ways, it still does. Unfortunately, like those other top medical schools, including Harvard, Yale, Stanford, and Columbia, U. of M. appears to have embraced quackademic medicine. I only wish it had, instead of imitating such schools, resisted the siren call of unscientific, prescientific, and pseudoscientific medicine. Unfortunately, as its embrace of anthroposophy demonstrates, it has not. As a result, the pride I have as a U. of M. alumnus is now tarnished with the knowledge that, even though the vast majority of what happens at the medical school and its affiliated hospitals is still solidly science-based and U. of M. boasts some of the best medical research programs anywhere, there now exists section within it that teaches pseudoscientific nonsense as if it were science. It makes me very sad and depressed to contemplate.

No doubt the U. of M. faculty and leadership responsible for this travesty will say that they pick and choose only the bits from anthroposophic medicine that are evidence-based and ignore all the woo. Quite frankly, to me anthroposophic medicine is pretty much all woo as far as I can tell. Or perhaps they would argue that the anthroposophic medicine program is a tiny part of a vast enterprise of science-based medicine. This is almost certainly true. It’s also probably true that relatively few U. of M. faculty even know about the existence of a Steiner-inspired program at their school. To me, however, there is zero place for such religious- and mysticism-inspired nonsense in any reputable medical school, other than as a footnote in courses in the history of medicine. Certainly there is no place for it being taught or practiced as though it had any validity whatsoever anywhere near medical students, residents, or fellows–and especially nowhere near patients.

Finally, knowing that U. of M. is teaching and practicing anthroposophic medicine makes me very irritated whenever I get mail soliciting donations for its medical school. From here on out, I think that, whenever a U. of M. Medical School solicitation arrives in the mail, I’ll send it back with a link to this post as the reason why I must decline.