After the success of the first AHSNZ conference in Christchurch we had many people who were unable to make it contact us hungry for more information. In response we have requested that our speakers write a post on their presentation. Reading it on your computer screen pales in comparison to hearing it in person, in a room full of like-minded passionate people, but we felt that these talks were too important. So, without further ado, allow us to present the AHSNZ Conference series of posts. Let us know what you think, which presentations sparked your interest, and what topics you would like to see addressed at our next conference in Wanaka on October 25.
Ancestral Health in General Practice: Art, Science, or Quackery?
In the second part of “Ancestral Health in General Practice: Art, Science, or Quackery?” the task fell to me to examine the scientific basis of General Practice, looking at a few fundamental questions:
- What principles underpin it?
- Does it work, and if so in whose interest?
- Where does Ancestral Health fit in?
The “science” of general practice has become virtually synonymous with evidence-based medicine and clinical guidelines. These, in my view, have become increasingly autocratic as simultaneously the weakness of much of the underpinning evidence has been exposed.
The food pyramid is unfortunately not the only questionable three dimensional triangular structure in medicine. I refer to the pyramid of “evidence-based medicine” (or EBM). When I was at medical school, EBM was the Brave New World of medicine. The culture of medicine, in caricature, was shifting from “what does the Professor say we should do” to “what does the evidence say we should do”. The pyramid was meant to convey a hierarchy of evidence, from “weak”, “anecdotal” evidence at the bottom, like clinical experience and case reports, to systematic reviews of meta-analyses of double-blind randomised controlled trials at the top. Such a review becomes the final arbiter of “truth”. That age-old philosophical question, “what is truth?”, so memorably articulated by Pontius Pilate around two thousand years ago, is actually rather difficult to answer, even in the scientific arena. As laudable as the hierarchy of evidence is in theory, the practice turned out to be very different.
Much of what should have been “gold standard” evidence, turned out to be cheap tin. Conclusive findings were often claimed on the basis of a single study, however repeating studies to check the findings has tended to yield a high rate of non-replication of results. Various ways to influence the outcome of a study exist, including the following:
- Publication bias – where studies which do not report positive findings quietly disappear;
- Misuse of statistical measures to show a difference where none exists;
- Use of composite endpoints or subgroup analysis;
- Run-in periods before a trial officially starts, to exclude those who have side-effects to a drug;
- Finishing a trial early.
All of these biases can be inadvertent or deliberate, and conflict of interest is rife.
A perfect storm has been cooked up by elevating large multi-centre randomised controlled trials to the unique status of “gold standard” evidence, while governmental funding of research has all but vanished. This leaves the pharmaceutical companies as pretty much the only entities with the money to fund the trials. I’m not here to knock the pharmaceutical companies per se, as we absolutely need high quality drugs, but these companies naturally have commercial imperatives which may not necessarily align with a clinician’s priorities. In summary, we have a very serious problem knowing what is really true.
Even with the best trial data in the world, however, there is a more fundamental problem – statistical significance does not necessarily imply clinical significance, and what works across a population may not necessarily apply to an individual. Margaret Thatcher, somewhat of a polarising figure in my native United Kingdom, once said, “There is no such thing as society”. She took quite a bit of flak for this, but she did have a valid point. Is there any such thing as a forest? Or is a forest merely a philosophical construct, a collective noun for a whole bunch of trees which happen to be planted close together? In the same way, is there validity in using population-based evidence as a guide to individual patient management?
I am a GP, not a public health physician. I am not interested in relative risk reductions which vastly overstate benefits. I have a real problem with the concept of risking harm to many people in order to convey tiny potential benefits to a minority. Evidence-based, population medicine principally functions at this abstract, theoretical level but it has been used to bludgeon GPs into over-prescribing multiple pharmaceutical agents for each disease at the individual patient level. These are medications that patients may not need, that doctors may not really believe in, which may interact with each other, and which may fundamentally compromise the doctor’s primary purpose by causing harm.
The very process which was supposed to improve the practice of healthcare, by moving us from a culture of eminence to that of supposedly objective evidence, has ended up full circle. The old eminence-based paradigm had its issues, and I’m not saying research is irrelevant, far from it. We absolutely need good quality research, more tools in our toolbox, genuine advances to be embraced. However, under the old paradigm the best doctors amassed a body of knowledge and over many years filtered, refined and developed their approach, using common sense, reasoning from first principles, and learning from clinical experience. The new paradigm rests on the authority, the new eminence, of experts on their committees producing guidelines. Humble GPs are expected to just fall in line, even though the bases for a lot of these guidelines are potentially less valid than the reasoning of a thinking, experienced clinician. Check your brains out at the consulting room door, doc.
This is where that pyramid, that hierarchy of evidence, falls down. We are back to eminence but without nuance, without discretion, without humility.
If it is indeed very hard to know what is really true, we need to be wary of being definitive or categorical. Everything we “know” is coloured by nuance of interpretation, and as that wise anonymous fellow once said, “scientists should always state the opinions upon which their facts are based”. Like it or not, we all have a belief-system which affects how we interpret the world around us, and evidence-based medicine is merely another belief system, just another form of dogma. It was interesting to see a major editorial in the BMJ recently from some much bigger hitters than me questioning what EBM has become, and suggesting means of possible reform, so potentially I have something of the zeitgeist here.
So what of Ancestral Heath – is this merely another dogma, another competitor in the marketplace of ideas? I don’t think so, because it is a broad framework which is not prescriptive. Its timeless principles, based on natural law, do not contend in the same ideological space. And when you ask the most important question, cui bono, the answer isn’t drug companies, doctors, or food conglomerates, it’s the patient.
As an ancestrally-minded GP, the way I practice is actually quite simple: I treat the patient, the n=1. The art and the science of General Practice meld together in serial n=1 experiments. It’s not about rejecting all research, guidelines, or evidence. It’s not about being anti-drug or “alternative”, or uncritically embracing any theory irrespective of plausibility (sorry, there is no homeopathy in my practice). I work with the patient in deciding which bits to apply, or not, to their health objectives. Nutrition, exercise, sleep and lifestyle factors are considered first, before reaching for the prescription pad.
In my interactions with colleagues, I frequently witness the phenomenon that a doctor will criticise a patient in front of them who has benefited from an approach which doesn’t match the doctor’s own belief system. Instead of being pleased that an improvement has been experienced, they are dismissive. There is “no evidence” that what the patient is doing works, even though the patient is telling them that it does work, because it has.
It’s not about being clever, or right, or squeezing the world into your own frame of reference. The bottom line is that there are two sorts of medicine – medicine which works and medicine which doesn’t – and the only thing which really matter is the outcome.
Carl Sagan said that “Science is a way of thinking more than it is a body of knowledge”. I believe this very nicely encapsulates the practice of Ancestral Health within mainstream General Practice.
Which brings us to quackery. One definition is “the promotion of unproven or fraudulent medical practices”. If it’s fraudulent to listen to my patients, help them find the tools they need to improve their health, reduce their dependency on medical care, and then leave them alone, then I am guilty as charged. I would argue, however, that this is what health care, as opposed to disease mitigation, is all about. As for “unproven”, the research evidence is certainly out there, hiding in plain sight, and growing in quality and momentum. However, as a front-line clinician, my contention is that the n=1 is proof, particularly when it is repeated time after time, and in many ways is better evidence than a poorly-constructed or biased randomised controlled trial. When I see type two diabetes mellitus reversed, the symptoms of ulcerative colitis or rheumatoid arthritis completely ameliorated, or scores of people losing excess body fat and changing their lives for the better, I can’t help but think this is damned effective “quackery”.
My ongoing experience is that incorporating Ancestral Health principles into general medical practice is the most thrilling, compelling, and fulfilling way to practise the art and science of medicine. The charge of quackery is most definitely a dead duck.