Complementary and Alternative Medicine (CAM), Medical School Curriculum, medicine,allergy, immunology,asthma

Correlation Does Not Mean Causation


1. Shoe size is directly correlated with neat handwriting. Does this mean that there is something about increased shoe size that causes neater writing? Or is it because older children wear larger shoe sizes and by virtue of age, are more mature and write more neatly than toddlers? The correlation does not mean causation.

2. The number of drownings is highly correlated with the time of year, namely summertime. This does not mean that summertime causes drownings. There are more drownings because more people swim in the summer.

3. Myocardial infarctions are correlated with elevated troponin levels. This does not mean that troponin levels cause myocardial infarctions. It would be a mistake to try to treat heart attacks by lowering troponin levels, when in fact it is the MI that causes the elevated troponins, which leak out of damaged myocardial cells. Too obvious? How about the following:

4. Elevated blood homocysteine is correlated with increased risk for myocardial infarction. Does elevated homocysteine cause heart attacks? Studies designed to decrease homocysteine have not demonstrated any lessening of the risk for MIs. Perhaps a third factor causes a rise in homocysteine as well as a susceptibility to MIs.

5. Elevated LDL cholesterol is correlated with increased risk of cardiovascular disease. If a third factor (e.g. stress, heredity) is the cause of both cardiovascular disease and elevated LDL, it may not help to try to control arteriosclerosis by taking years of anticholesterol medication. Current medical opinion leans heavily toward LDL cholesterol as a causative act in cardiovascular disease, but there are those who disagree.

6.  Hypertension is believed to cause arteriosclerosis. But could a third factor (e.g. stress) be implicated as a cause of both?

6. According to a 2005 study in Finland, women who have abortions are more likely to commit suicide. Do abortions cause suicide, or are women who have abortions more likely to be in social situations that in themselves are more likely to promote suicide? Women who have abortions also are more likely to be murdered and die in accidents. If they are already high-risk for murder, suicide, and accidents, they may be more likely to be in situations where they choose an abortion.

7. People often are quick to judge patterns and often attribute causal importance to patterns that are only coincidental. I had an elderly patient who was sure he knew what caused Parkinson’s disease; he had purchased his home from someone who had Parkinson’s disease, and a year later he, too, was diagnosed with Parkinson’s disease. In his mind, it must have been communicable. However, about 1 million people in the USA have Parkinsonism, mostly people over 60. The chance that the person purchased the home from someone with Parkinson’s and also would acquire the disease is not so unreasonable, given the number of people who buy homes and the prevalence of Parkinson’s disease. In addition, there are thousands of other diseases that both buyer and seller might have had coincidentally. The chance that at least one of those diseases could have occurred in both buyer and seller is high. The clincher here was pointing out that the spouses of patients with Parkinson’s disease do not have a higher incidence of the disease than those not married to someone with Parkinson’s. One of the biggest mistakes in research is confusing correlation with causation.

8.  A study indicated that smiling a lot is correlated with a longer life. Should we then go around forcefully smiling at everyone like the Burger King king? Maybe good health induces people to smile more.

9. If people who take Dynamo MaxiForte vitamins have a lower risk of illness, is it because of the vitamins or because they take care of their health needs in other ways, too, such as exercise and a balanced diet?

10. Teenagers who spend a lot of time texting and on social network websites have a higher incidence of sex, stress, substance abuse, depression, and fighting. Should texting therefore be decreased? Which variable causes which?

The medical and popular literature is rife with examples of confusing correlation with causation. One must be on the alert not to confuse the two.

Allergy, asthma, Complementary and Alternative Medicine (CAM), Immunology

Two New Medmaster Books: 1. Alternative Medicine 2. Allergy/Asthma


Are You Afraid of Snakes? A Doctor’s Exploration of Alternative Medicine, by C. Scott Mahan

The many books comparing alternative medicine to Western medicine tend to be biased in one direction or the other. Are You Afraid of Snakes? A Doctor’s Exploration of Alternative Medicine offers a balanced view. C. Scott Mahan, M.D., an infectious disease specialist, is co-author of the best-selling “Clinical Microbiology Made Ridiculously Simple.” Are You Afraid of Snakes? describes his 5-year medical journey from Africa to Appalachia, as he encounters many alternative approaches to medicine (voodoo, naturopathy, homeopathy, chiropractic, acupuncture, hot yoga, barefoot running, performance enhancing drinks, titanium necklaces, magnets, hypnosis, detoxification diets, and ayurvedic medicine). Dr. Mahan relates his personal and often humorous experiences in the dual worlds of alternative and Western medicine. He offers an unbiased analysis and opinion of the differing approaches to medicine. 257 pgs; ebook $9.99; print book $16.95.


Allergy and Asthma Made Ridiculously Simple, by Massoud Mahmoudi


Allergy and Asthma Made Ridiculously Simple is a brief, clear, and practical guide to the diagnosis and treatment of allergies and asthma. Dr. Mahmoudi practices internal medicine, allergy, and immunology in California. He has published or edited numerous scientific papers and 9 books related to allergy and immunology, including the best-selling “Immunology Made Ridiculously Simple.” He was a medical columnist for local newpapers and the San Francisco Chronicle, has spoken locally and nationally on allergy and immunology, and appeared on local television and Fox News. Dr. Mahmoudi is currently president of the American Osteopathic College of Allergy and Immunology and on the faculties of the University of California San Francisco, Rowan University, and Touro University. 72 pgs; $22.95.

Complementary and Alternative Medicine (CAM)

What Constitutes Quackery?

Dr. Gilbert’s Five-Second Weight Loss Plan

While sometimes quackery is the product of deliberate deception on the part of the practitioner, at other times the practitioner is sincere but ignorant of the facts.

Robert Park described seven signs of quackery:

1.  The claim about effectiveness of the alternative treatment is proclaimed to the media [rather than published in a reputable peer-reviewed journal].
2.  The claim states that a powerful establishment [such as Big Pharma, or physicians who want patients to stay sick for monetary reasons] is trying to suppress the treatment.
3.  The therapeutic effect is barely detectable scientifically.
4.  Evidence for the effect is anecdotal, rather than based on properly designed experiments. [Improvement in one patient may not occur in another, or may be based on a spontaneous cure, the placebo effect, a mistaken diagnosis, or inaccurate reporting.]
5.  The practitioner points to the treatment having been in use for centuries [which does not constitute evidence; bloodletting was used for thousands of years and killed many people, including George Washington].
6.  The treatment was discovered in isolation by a lone genius who was laughed at by the establishment, as were so many great discoverers. [Science advocate Carl Sagan once commented, “They laughed at Columbus, they laughed at Fulton, they laughed at the Wright brothers.  But they also laughed at Bozo the Clown.”]
7.  The discoverer of the supposed treatment proposes new laws of nature to explain the claim.

I’d also add a few more:

8.  The claim is made that the alternative treatment is the cutting edge of medicine and has just not been taught in medical school [when the reason it has not been taught is that there is insufficient evidence to teach it.  I saw this personally when my grandson, who had a recurring inner ear infection, went with his mother to an alternative practitioner who spent a lot of time asking irrelevant questions and then, without examining him, prescribed an elixir of potassium, stating that conventional medicine had not caught up with this wonderful treatment.  Regarding potassium, I once had a patient with renal failure who insisted on treating himself with potassium [a no-no in renal failure], because, as he stated, “potassium is the great healer.”  He unfortunately died soon after].
9.  The practitioner points to the toxic effects of conventional medicine, whereas their own treatment incurs no side effects. [Treating with nothing incurs no side effects either; maybe, then, it would be safer to not treat at all!  Eating food can have side effects, too, but we don’t recommend not eating. Despite the potential side effects of many conventional medicines, you have to evaluate the risk of treating versus the risk of not treating.  Also, many nonconventional “natural” medicines can have toxic effects, and may interact unfavorably with conventional medicines.]
10.  The claim is made that the alternative treatment addresses the cause of the patient’s problem, whereas conventional medicine only treats symptoms.  [This claim is untrue, since conventional medicine always looks first for the cause, e.g. infection, allergy, heredity, diet, trauma, emotional, etc., and treats symptomatically only when the cause is not apparent.  Alternative practitioners, though, generally do not treat causes (unless you consider imbalances in a mystical vital energy life force as a cause) and frequently treat with only a placebo.]

A patient may say, “What difference does it make if it’s a placebo or not?  I feel better and that’s all the matters.”  It matters when reliance exclusively on placebo overlooks a more effective  treatment.  It also matters if the alternative  treatment carries its own set of toxicities or a significant and unnecessary expense to the patient.

Quackery can exist in both conventional and alternative medicine.   A previous blog post suggested reliable sources of information for evaluating alternative approaches to medicine.  Another source is the Medmaster Search Engine page and the (free) downloadable Medsearcher app.  It is very important for a practitioner to be able to evaluate the validity of  research reports.  It is for that reason that biostatistician Ann Weaver and  I wrote Clinical Biostatistics Made Ridiculously Simple.

Complementary and Alternative Medicine (CAM)

The Placebo Effect

“Take two aspirin and call me in the evening.”

Medical practitioners have been respected for thousands of years, even when their medicines have been toxic.  To a large degree (and this includes both conventional and non-conventional medicine), this success can be attributed to the spontaneous cure and the placebo effect.  Most medical conditions improve by themselves; and the placebo effect can be significant; thus, the patient attributes improvement to the practitioner.  Until the movement toward evidence-based medicine in the early to mid 20th century, there was great uncertainty as whether a claim for a treatment’s effectiveness was due to the intrinsic potency of the medicine or to the placebo effect and spontaneous cure. This uncertainty still exists, but to a lesser extent, due to the introduction of properly designed research.

The placebo effect, apart from the medication itself, also includes the bedside manner of the practitioner. The patient has confidence in the practitioner who spends time getting to know the patient, expresses concern about the patient, allays the patient’s fears, provides hope, and engages in laying on of the hands.  Such bedside manner, or “grooming,” is an important part of medical practice, regardless of whether treatment is conventional or not.  I learned this through 14 years of practicing Family Medicine with Lynn Carmichael, whom many consider to be the father of Family Medicine, having established the first Family Medicine residency in the U.S. and who was a strong advocate of grooming.  Patients often go to an alternative practitioner rather than the conventional practitioner when the conventional doctor does not have the time to spend with the patient, a problem becoming increasing more common with the need to see more patients in a day.  This problem will grow with future changes in the medical care system that may overwhelm doctors with more patients seeking care, with less time for grooming.  Alternative practitioners often develop great skill in grooming the patient.  It is important for conventional physicians to do the same.

Complementary and Alternative Medicine (CAM)

Complementary And Alternative Medicine (CAM)

The first Medicare bankruptcy

Alternative medicine refers to medical approaches to diagnosis and treatment that lie outside the province of conventional medicine and are practiced instead of, rather than alongside, conventional medicine.  Complementary medicine, which may consist of the same treatments as alternative medicine, is practiced in conjunction with conventional medicine, as a supplement.

CAM includes not only Acupuncture, Homeopathy, Chiropractic Therapy, and Herbal Medicine, but many other approaches to diagnosis and treatment, including (in alphabetical order) Alexander Technique, Alternative Diets, Alternative Exercise Therapies, Anthroposophic Medicine, Aromatherapy, Ayurvedic Medicine, Bach Flower Remedies, Cellular Therapy, Chelation Therapy, Colonic Irrigation, Craniosacral Therapy, Crystal Therapy, Cupping, Detoxification, Ear Candles, Feldenkrais Method, Feng Shui, Food Supplements, Hypnotherapy, Leech Therapy, Magnet Therapy, Massage Therapy, Meditation, Naturopathy, Neural Therapy, Orthomolecular Medicine, Oxygen Therapy, Reflexology, Reiki, Relaxation Therapies, Shiatsu, Spiritual Healing, and Traditional Chinese Medicine.

There is some difference in opinion as to what should or should be not classified as CAM. In a semantic sense, there really is no CAM that has been shown to work, since once a CAM treatment has been found effective it becomes adopted as a part of conventional medicine, so it is no longer “CAM.” Some CAM treatments have been shown to be ineffective, but for others there is insufficient evidence as yet to make the case one way or the other, and they might be useful.

While the same treatments can be used in alternative and complementary medicine, alternative medicine is more risky.  By dismissing conventional medicine (e.g. many alternative practitioners advise patients not to immunize their children or use antibiotics), alternative medicine runs the risk of neglecting treatment for conditions that are highly treatable by the conventional approach.  One plays Russian roulette with a child’s health by relying only on alternative medicine.  Administering an ineffective remedy for a high fever in a child will be successful when the treater is lucky and there is a spontaneous cure, which usually occurs.  But in the less common situation where there is a more serious illness, such as a meningitis or septicemia, the results may be disastrous.  Hence, the importance of working together with the conventional system if one wants to try an unconventional approach.

You are taught conventional medicine in medical school rather than CAM.  You will need to learn more about CAM on your own. You will be faced with patients who ask about or are using a variety of unconventional approaches. How do you sort through and evaluate all these options?  The Internet is full of misleading information, as are many TV and radio shows, and tabloids that patients rely on from supermarket check-out counters.  I suggest the following sites for trustworthy information:

Science-Based Medicine blog
Quackwatch, by Stephen Barrett
The SkepDoc by Harriet Hall, MD
New York’s Memorial Sloan Kettering Cancer Center’s herbal/botanical database
The Cochrane Summaries

There are also the following books:

Trick or Treatment: The Undeniable Facts about Alternative Medicine, by Edzard Ernst and Simon Singh
Snake Oil Science: The Truth about Complementary and Alternative Medicine, by R. Barker Bausell
Bad Science:  Quacks, Hacks, and Big Pharma Flack, by Ben Goldacre
Do You Believe in Magic?: Vitamins, Supplements, and All Things Natural: A Look Behind the Curtain, by Paul A. Offit