Openmindedness vs Scepticism
With everyone in a panic as COVID-19 spreads across the planet and in Kerala, debate in social media today turned interestingly towards the ethics in suggesting homeopathy and other alternative medicines as a possible treatment. I feel this is a good time to talk about what evidence based medicine is and how even modern medicine works compared to alternative forms of medicine.
Evidence-based medicine means being totally open minded to new things while also being completely sceptical at the same time. Now this does not come naturally to anybody and it requires the right environment and guidance to develop these attitudes. And even then, biases can affect anybody, regardless of how respected they may be.
Just take a look at the recent study looking at the use of Vitamin C and Thiamine in Septic Shock. The idea was put forward by a very well respected critical care physician. When questioned by doubters, he'd say something along the lines of "You only doubt it because you haven't seen patients improve in front of your very eyes like I have" (Note - I'm paraphrasing). And then the study came out which showed that it did not do anything for survival or shorten length of stay.
https://jamanetwork.com/journals/jama/article-abstract/2759414
Now compare that to some of the comments by those practising alternative medicine defending themselves and you'll find things said along similar lines. "I treated my daughter with this and it works!" "Hey we treat colds and fevers all the times so..." It is very easy to get emotional defending your practice. We have spent many years learning this stuff and we have convinced ourselves that it is both pure and true. When someone tries to challenge that, the first instinct is to get defensive and emotional instead of relying on hard facts and stats. This behavior isn't unique to the alternative systems of medicine.
While I agree in principle with what many of my colleagues have been trying to say, I fear it gives a picture that they believe that everything in modern medicine is evidence based. Unfortunately, this is not quite true and this might come as a shock to some. One of my batchmates got disillusioned with medicine as a whole after he found out as his training progressed, that a lot of what we practice is not based on very good evidence. And sometimes, we have to unlearn things years after we learn it. Here is a great article on how difficult this process can be.
https://shortcoatsinem.blogspot.com/2014/02/the-unlearning-process.html
From the article - Harvard's medical school dean, Dr. Burwell, warns students, "Half of what we are going to teach you is wrong, and half of it is right. Our problem is that we don't know which half is which,"
Now the idea isn't that we should all just give up because medicine isn't perfect, it is that medical science is always improving and getting better and we should keep an open mind when new ideas arise or old ones get challenged.
When you look at levels of evidence, expert opinion (some of the I saw it with my own eyes evidence as we talked about earlier) is at the bottom. But this does not mean that it is the least important, far from it. It is not possible/feasible for all medical decisions to be decided on the basis of meta analyses or RCTs. While expert opinion can be misguided, as seen with the VITAMINS trial, it can also be the case that the expert is actually ahead of the evidence i.e the supported practice is based on sound judgement and is likely to be confirmed in future trials. The best clinicians out there are often the ones ahead of the curve and future recommendations by expert panels may eventually support what they have been preaching for many years. These are also the kind of people likely to be driven enough to do the research that will backup or refute their claims.
Coming back to COVID-19, this is a situation where everyone wants a good solution and that too quickly. So it is only natural that all sorts of ideas will arise and all of them need to be viewed with the utmost sceptism. Many a time in the past, a treatment that was promising in the early stages turned to be really not that helpful when more studies were done. Again we have a good example in septic shock, with the use of activated protein C which had a lot of hype before quickly disappearing.
https://www.cochrane.org/CD004388/EMERG_human-recombinant-activated-protein-c-severe-sepsis-and-septic-shock-adult-and-paediatric-patients
But here we need to make a distinction. When experts in the medical field say that drugs like remdesivir or chloroquine are "worth a try", it will be taken seriously and further studies will be done. When people with no medical background in any way or form start suggesting things like cow urine as a cure, they should not be taken seriously and no public money should be wasted in supporting these wild ideas.
Other alternative forms of medicine probably lie somewhere in between these 2 extremes. It would be obtuse to dismiss all traditional medicines because they don't have evidence behind them. Some of them may indeed have some benefit. I don't believe all those who practice alternative forms of medicine should be put in the same category as quacks, But blindly putting faith in them isn't a good longterm solution either. The question of who is going to study these medicines is unfortunately not going to be one that is answered soon.
The solution in the meantime would be to differentiate the quality of a recommendation, if at all the government is going to support alternative medicines. Or at least a disclaimer. Because people using these medicines may be trapped in a false sense of security and delays in approaching adequate medical care may result in further spread of the virus, something which could completely overwhelm our health system.
Unfortunately, during a crisis it is very easy to prey on people who are scared and confused.
https://policyoptions.irpp.org/magazines/march-2020/misinformation-alternative-medicine-and-the-coronavirus/
Remember, not everyone who sounds smart ("Boost your immunity!") actually is smart.
Evidence-based medicine means being totally open minded to new things while also being completely sceptical at the same time. Now this does not come naturally to anybody and it requires the right environment and guidance to develop these attitudes. And even then, biases can affect anybody, regardless of how respected they may be.
Just take a look at the recent study looking at the use of Vitamin C and Thiamine in Septic Shock. The idea was put forward by a very well respected critical care physician. When questioned by doubters, he'd say something along the lines of "You only doubt it because you haven't seen patients improve in front of your very eyes like I have" (Note - I'm paraphrasing). And then the study came out which showed that it did not do anything for survival or shorten length of stay.
https://jamanetwork.com/journals/jama/article-abstract/2759414
Now compare that to some of the comments by those practising alternative medicine defending themselves and you'll find things said along similar lines. "I treated my daughter with this and it works!" "Hey we treat colds and fevers all the times so..." It is very easy to get emotional defending your practice. We have spent many years learning this stuff and we have convinced ourselves that it is both pure and true. When someone tries to challenge that, the first instinct is to get defensive and emotional instead of relying on hard facts and stats. This behavior isn't unique to the alternative systems of medicine.
While I agree in principle with what many of my colleagues have been trying to say, I fear it gives a picture that they believe that everything in modern medicine is evidence based. Unfortunately, this is not quite true and this might come as a shock to some. One of my batchmates got disillusioned with medicine as a whole after he found out as his training progressed, that a lot of what we practice is not based on very good evidence. And sometimes, we have to unlearn things years after we learn it. Here is a great article on how difficult this process can be.
https://shortcoatsinem.blogspot.com/2014/02/the-unlearning-process.html
From the article - Harvard's medical school dean, Dr. Burwell, warns students, "Half of what we are going to teach you is wrong, and half of it is right. Our problem is that we don't know which half is which,"
Now the idea isn't that we should all just give up because medicine isn't perfect, it is that medical science is always improving and getting better and we should keep an open mind when new ideas arise or old ones get challenged.
Coming back to COVID-19, this is a situation where everyone wants a good solution and that too quickly. So it is only natural that all sorts of ideas will arise and all of them need to be viewed with the utmost sceptism. Many a time in the past, a treatment that was promising in the early stages turned to be really not that helpful when more studies were done. Again we have a good example in septic shock, with the use of activated protein C which had a lot of hype before quickly disappearing.
https://www.cochrane.org/CD004388/EMERG_human-recombinant-activated-protein-c-severe-sepsis-and-septic-shock-adult-and-paediatric-patients
But here we need to make a distinction. When experts in the medical field say that drugs like remdesivir or chloroquine are "worth a try", it will be taken seriously and further studies will be done. When people with no medical background in any way or form start suggesting things like cow urine as a cure, they should not be taken seriously and no public money should be wasted in supporting these wild ideas.
Other alternative forms of medicine probably lie somewhere in between these 2 extremes. It would be obtuse to dismiss all traditional medicines because they don't have evidence behind them. Some of them may indeed have some benefit. I don't believe all those who practice alternative forms of medicine should be put in the same category as quacks, But blindly putting faith in them isn't a good longterm solution either. The question of who is going to study these medicines is unfortunately not going to be one that is answered soon.
The solution in the meantime would be to differentiate the quality of a recommendation, if at all the government is going to support alternative medicines. Or at least a disclaimer. Because people using these medicines may be trapped in a false sense of security and delays in approaching adequate medical care may result in further spread of the virus, something which could completely overwhelm our health system.
Unfortunately, during a crisis it is very easy to prey on people who are scared and confused.
https://policyoptions.irpp.org/magazines/march-2020/misinformation-alternative-medicine-and-the-coronavirus/
Remember, not everyone who sounds smart ("Boost your immunity!") actually is smart.
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