The dysfunctional relationship between skeptics and true believers

I question what I'm told, a great deal - so I could be called a skeptic.  I'm not a devotee of any pseudoscience and I agree with a great deal of what is said by skeptics. 

But the skeptical blogs and skeptical commentary online, and magazines like Skeptical Inquirer, are very far from the skeptical ideal of rational questioning.  There's a lot of ridicule.  For example, Orac on the Respectful Insolence blog likes to call the Huffington Post a "wretched hive of scum and quackery".  And what does it tell you when someone flaunts their insolence - when they say flat out that they are "presumptuous and insulting in manner or speech; arrogant; audaciously rude or disrespectful" (dictionary definition)?

Insults attract people who need a target, who want some Other to gang up on and put down.  If they are annoyed by their job, if they want to feel superior to someone, they can look up Respectful Insolence, and find an easy target, served up in a blog post.  The action is in the comments.  The commenters are generally in two sharply demarcated groups.  There are the people who post confirmation comments - anything agreeing with Orac, even if it's only an expression of prejudice, will be left unchallenged. 

Then, there are the the adherents of whatever alt-med protocol Orac is attacking, who comment to defend it.  Since Orac usually chooses easy targets to attack, the defenders are usually obviously deluded, and they don't make a rational defense.  They don't (because they can't) give solid references for their claims.  So, they are easy pickings for the confirmers of Orac, who - almost always in a kind of "gang", without disagreeing with each other - jump on the "altie" to tell them how wrong they are, by insult or in a judgemental way.  This is the pattern, post after post.  It's a Two-Minute Hate (a concept from Orwell's 1984). 

The "insolence" of the blog posts and the easy targets that Orac chooses, create this dynamic.

The Science-based Medicine blog has a similar dynamic.  If you take issue with things that are said there, you will very likely be "rebutted" with standard skeptical observations - even if what you say is not advocating alternative medicine.  It's quite insulting to be taken as expressing some simplistic prejudice that you don't believe in. For example, in answer to a comment I made, somebody posted rebutting the naturalistic fallacy - the idea that "natural is better".  My comment did not assume that natural is better. 

Orac's adherents are actually prejudiced themselves, in the opposite direction from the alt-med believers.  For example, Orac recently blogged about traditional Chinese medicine, and he started his blog with

Most, if not virtually all, of what is now referred to as “traditional Chinese medicine” is quackery.

I don't know how to evaluate "most" there, so I can't comment on his statement.  TCM is mostly herbal medicine and acupuncture, but I don't know what the most-used herbal remedies are, what acupuncture is most often used for, and how many of those uses have been shown to be ineffective. 

But Orac's adherents take that kind of statement and run with it, for example stating flatly that herbal remedies don't work. 

But an apparently even-handed evaluation of Chinese herbal medicine by NYU Langone Medical Center does give research evidence for some Chinese herbal remedies. 

Similarly with acupuncture:  the attitude on these skeptical blogs is that acupuncture doesn't work.  This particular post was by Steven Novella, but Orac says similar things. 

But the NIH Consensus Statement on acupuncture says

acupuncture may be a reasonable option for a number of clinical conditions. Examples are postoperative pain and myofascial and low back pain. Examples of disorders for which the research evidence is less convincing but for which there are some positive clinical trials include addiction, stroke rehabilitation, carpal tunnel syndrome, osteoarthritis, and headache.

The skeptical sites purport to be giving you the real scientific scoop, but it appears they actually take a hostile reactive position, biased against alt-med claims.  I say "appears" because it's possible the National Institute of Health and Langone Medical Center are being "inclusive" of alt-med rather than quite scientific.  The NIH consensus panel did include an acupuncturist, and that sounds like politically-motivated "inclusiveness".  And Langone does have an "integrative holistic urology" program - so perhaps they are motivated to make the research sound more positive than it actually is. 

But "Science-Based Medicine" did show a hostile reactive bias when they let a pharmacist blog about Food allergies - facts, myths and pseudoscience.  They allowed a pharmacist to present the purportedly "science-based" stance on food allergies.  Instead, they should have had a post by an immunologist familiar with the current research on non-IgE food allergies and non-celiac gluten sensitivity, which the pharmacist was ignorant of.

It's a common error of skeptics to assume that "not knowing" implies "knowing not". 

For example, Brian Dunning said in one of his InFact videos that people who don't have a wheat allergy or celiac disease, don't need to be on a gluten-free diet.

I informed him that research has shown that some people do better on a gluten-free diet even though they don't have celiac disease or a wheat allergy - with links to research papers.  It's called non-celiac gluten sensitivity (NCGS).  Brian Dunning did change his message. 

But, his original statement would have been wrong even if research hadn't shown the existence of NCGS - because science doesn't know everything!  If someone does better on a gluten-free diet, then they should be on a gluten-free diet, and a good doctor would tell them that. 

Brian Dunning assumed that science knows everything about the body's reaction to gluten, which is VERY far from the truth and caused him to give bad medical advice. 

A lot of skeptics probably think of skepticism as the noble goal of fighting delusions - bringing science to the ignorant.  But if they assume that "not knowing" equals "knowing not", they will only antagonize the people they are trying to reach. 

Many alternative-medicine protocols have SOME grain of truth in them.  It's easier to sell people on a protocol which does provide some actual benefit.  The protocol might also be exploitative and actually causing harm in other ways, as skeptics rightly point out.  But, if the skeptics' oppositional mentality prevents them from acknowledging why people might get some benefit from the protocol, it will discredit what they say about exploitation and harm. 

For example, there are a lot of special diets - "alternative" diets - that are gluten-free.  People who are gluten-sensitive might feel dramatically better on these diets.  That doesn't mean they need the entire special diet. 

Who are the skeptics - the people who take an interest in debunking popular credulities?  Many people disbelieve in alternative medicine etc. - but aren't interested in hearing about it.  It gets very boring to read over and over about the irrational things that some people believe.  The active skeptics are not the same as the disbelievers - why do active skeptics take such an interest in irrational beliefs? 

David Leiter, who was once a member of a skeptical group, claimed that many of its members had an "unfortunate experience with a faith-based philosophy" at an earlier period in their lives, and that they had sought an organized skeptical group as a reaction to this.  Probably many of them were wounded by religion as children - a religious upbringing has profound psychological effects in a way that having a parent who believes in homeopathy, for example, is unlikely to. 

The skeptical doctor-bloggers are motivated partly by professional defensiveness.  They wish to fend off "creeping woo" in medical practice.  Many mainstream MD's do enthuse about alternative medicine and dish out useless advice about "natural" remedies.  And perhaps it aggravates doctors to hear, over and over again, the same irrational claims from their patients. And some of the skeptic-doctors, just like their adherents, have a (perhaps unconscious) need to heap contempt on something.  Orac seems emotionally messed up. 

And why would I read these skeptical blogs, you might ask? 

It's certainly not to find out "what science says".  The skeptics are not reliable sources of information about science.  Actual medical researchers are much more informative and less likely to make unfounded assumptions.  If I want to find out about the current state of medical research, I go on Medline and read research papers and review articles.  If I want to find out about the current state of scientific knowledge, I look at science journals. 

No, my motivation is much more personal.  I go to those blogs because I came from an abusive family where people constantly denigrated each other.  My father showed "impenetrable condescension" - a brother's description - and when I was a child he dominated me into a kind of profound silence (abetted by my mother's violence).  If any of us children resisted or talked back he would erupt into terrifying rages, screaming insults and sometimes hitting us. So now, going to those sites is my way of doing the talking back, challenging and "speaking truth to power" that I didn't get to do as a child.  When I comment on those blogs, it is usually to correct some exaggeration, error or bias that I see. 

Perhaps as a safe way of resistance, I committed long ago to not being myself insulting and denigrating.  Dostoevsky in The Brothers Karamazov shows a lot of psychological insight, and one thing his Abbott Zosima say is "Avoid contempt, both of others and of yourself".  I agree with that - contempt is a kind of emotional toxin. 

I'm often not aware of my motivation when I go to skeptical sites.  I'm coping with physical illness, debilitated by illness and I'm not much in touch with my feelings as a result.  Sickness becomes my "personal story" when I'm sick, rather than my personal development or exploring the wounds from my past. 

Spending time and energy on responding to other people's toxic emotional stuff, does waste a lot of time, and perhaps as I get over my sickness - I am slowly getting better - I will be more centered. 

Comments are moderated for thoughtfulness (including thoughtful disagreement).  I do not want to host comments that are empty or jeering on my blog.

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Comment by Luara on November 11, 2013 at 10:33am

The skeptical doctor Ben Goldacre wrote a couple of books Bad Science and Bad Pharma, which seem likely to have good criticism of both alternative medicine and the pharmaceutical industry.  So he seems to have avoided that pseudo-skeptical credulity about mainstream medicine that I'm criticizing in this post.

I haven't read these books, but they seem worth checking out, to me. 

Comment by Luara on November 11, 2013 at 4:39am

I tend to be wary too of integrating alternative medicine like acupuncture into mainstream medical centers like Langone. 

It seems like mainstream medicine could take some clues from the ability of alternative medicine to sell itself.  Alt-med people have to be good salespeople to survive. 

But I'm not so sure about selling mainstream medicine by adopting unproven alt-med techniques wholesale.  Some of them can be risky, and the idea of using a placebo that might actually harm someone grates on my ethical sensibilities.  Acupuncture needles can cause infection or even puncture a lung. 

And, using alternative medicine in mainstream medical centers, does tend to confer an unearned air of legitimacy to it. 

I've been helped by "integrative" MD's, because they did take time to discuss lifestyle factors that mainstream doctors didn't. There's some justice in the criticisms that are made of mainstream MD's. 

And I wish that in the gray areas where science doesn't know much, mainstream doctors would realize that not much is known and the patient could well be right about subjective symptoms, and adopt the best empirical approach they can. 

They are better qualified than alternative providers and lifestyle counseling and empirical methods shouldn't be left to the alternative providers, whose perspective is distorted by their need to sell their methods in competition with lots of other alternative providers. 

For example, I've been investigating the research on non-celiac gluten sensitivity (NCGS), which has been confirmed by double-blind food challenges.  About 30% of people with irritable bowel syndrome (IBS) have NCGS, and I've read that for many years, patients with IBS have been telling their doctors that specific foods cause their symptoms.  And doctors have often told them that IBS doesn't involve food allergy - driving patients into relatively disorganized self-help methods, and perhaps driving them to alternative providers. 

This is bad medical practice.  It's that error of substituting "know not" for "don't know".  The doctors should actually have told their patients "Maybe you actually are affected by wheat" and suggested a reasonable way to experiment and find out what foods actually bother them.  Maybe they could even do single-blind food challenges with patients (where the patient doesn't know what they're eating but the doctor does).  Single-blind food challenges are much less cumbersome than double-blind challenges. 

Nobody knows how common non-celiac gluten sensitivity actually is.  But a rate of 6% is estimated, if 30% of people with IBS have NCGS, and 20% of people have IBS. 

And this 6% doesn't include people who may have NCGS without having IBS. 

So more like 10% of people might actually have immune reactions to specific foods - food allergies of some sort - when you include NCGS, classical food allergies, celiac disease, atopic dermatitis, etc. etc. 

For ages, I've heard skeptics repeat over and over like a mantra, "30% of people think they have food allergies, and only 5% actually do".  This really grates on me because it's so arrogant.  Again, it assumes that food reactions that haven't been nailed down by science, don't actually exist. 

There is a huge discrepancy between perceived food hypersensitivity and medically verified hypersensitivity.  But the actual cause of that discrepancy, how much of it depends people knowing what they're eating and how much it is independent of their knowledge, isn't known.  It IS known that food reactions of unknown cause that are confirmed by double-blind food challenges, exist. 

Sometimes one can know pretty well that claimed reactions are caused by people's knowledge of what they were exposed to.  I'm pretty skeptical of claims of multiple chemical sensitivity (MCS) because double-blind experiments have been done on people with claimed MCS, and they did not confirm MCS. 

When skeptics substitute "know not" for "don't know", they fall into a caricature of skepticism.  This will alienate people who know this caricature isn't an honest picture of reality.  If skeptics want to reach out to believers in alternative medicine, they have to be willing to acknowledge what justice there may be in the believers' claims - both the claims about faults of mainstream medicine, and the claims of benefits from alternative medicine. 

Comment by Luara on November 11, 2013 at 3:32am

Well my late sister was diagnosed as being celiac several years before she became ill with pancreatic cancer. It was not even known then as a real health hazard, but she had a very forward thinking doctor who told her that if she kept on with her high gluten (she loved fresh bread rolls from the bakery) diet, she could be prone to developing serious conditions like stomach, intestinal and/or bowel cancer.

She ignored his advice and some think that this ignorance may have been her downfall

Celiac disease raises the risk of pancreatitis and pancreatic insufficiency, and chronic pancreatitis does raise the risk for pancreatic cancer, but I don't know that celiac disease and pancreatic cancer have been directly linked.

Sometimes people with celiac disease seem to be actually addicted to gluten.  It can be gut-wrenching when someone has been told by a doctor to go gluten-free and they don't.  I went through this, with someone who seemed likely severely affected by gluten, both emotionally and in other ways.  It's like watching an alcoholic destroy themselves. 

Comment by Dyslexic's DOG on November 10, 2013 at 2:47am

Well my late sister was diagnosed as being celiac several years before she became ill with pancreatic cancer. It was not even known then as a real health hazard, but she had a very forward thinking doctor who told her that if she kept on with her high gluten (she loved fresh bread rolls from the bakery) diet, she could be prone to developing serious conditions like stomach, intestinal and/or bowel cancer.

She ignored his advice and some think that this ignorance may have been her downfall, though I also believe that the cancer may have been triggered by many other issues such as severe stress, toxins or asbestos, which we she was exposed to.

Though I tend to look at it from a rational perspective.

Sure alternative treatments may even work for some patients.

Yet, it is highly risky for any GP to prescribe alternative treatments, so they will always prescribe treatments that have been tested and proven to have objective value.

Holistic medicine is fine, though in the medical profession, this means simply looking after the sensibilities of the patient and playing closer attention to their pain, feelings and concerns.

Very few GPs will risk lawsuits and possible loss of registration through prescribing alternative treatments that have not been proven to work.

I also agree with the tribunal in that any such GP willing to risk patients health by prescribing such treatments, should be deregistered.

Same as any GP who starts practicing unsubstantiated alternative treatments.

If a GP starts a program to test such treatments for value, with the approval of the tribunal and Medical bodies like the AMA, I consider that okay, because any advancement in treatments is most surely welcome.

Comment by Luara on November 9, 2013 at 9:50am

I was not writing about subjective Symptoms, many symptoms are subjective, deferred pain, phantom limbs, etc...

No, it's purely subjective treatments, or subjective cures, in other treatments that are considered as godsent by one sufferer and thus they promote it as such, only to find that is really never works the same for anybody else.

There's often an element of truth in alternative methods that become popular. They will be more popular if they are actually doing something for people.
For example, the Specific Carbohydrates Diet, which was relentlessly pushed on a celiac mailing list I was on, involves eliminating a lot of difficult to digest foods and foods high in fructose.  And a lot of bullshit.  I was very annoyed by the persistence of the people pushing the SCD.  They were like the Hare Krishna of diets, chanting the same things over and over. 

But recently, researchers have discovered that a low-FODMAPS diet helps many people with irritable bowel syndrome.  The SCD eliminates a lot of similar things to the low-FODMAPS diet. 

So I can see how the SCD might be helpful for people with IBS.  Also the SCD is gluten-free and that would help people who are gluten-sensitive. 

I was annoyed by the pushiness about the SCD because I'd already figured out my food sensitivities.  I'm not particularly bothered by FODMAPS. 

But some people would be helped dramatically by the SCD.  They become the annoying pushers. 

Comment by Luara on November 9, 2013 at 9:26am

Here's an example of doctors dealing relatively well with subjective symptoms.

In the late 90's I got allergy skin tests.  I had 3 allergies including Candida (which is a standard part of allergy testing panels). 

The allergist told me that Candida allergy suggests that one might have food problems.  He suggested I do an elimination diet followed by food challenges, to check it out.  (allergy testing is not very good for food allergies).  He said I could get an elimination diet from a library book. So I did.

Unfortunately, the elimination diet I got wasn't gluten-free (!)  Back then, celiac disease was the only known immune reaction to gluten, and it was only being diagnosed at 1/5000 or so - the actual frequency is about 1%. 

I had no reactions to food challenges, probably because I was still eating gluten on the elimination diet.

Then in 2003, I came down pretty sick in various ways.  I was feeling vaguely worse after meals, so I thought it might be food-related.  An an allergist had given me another elimination diet and food challenges protocol.  That was gluten-free, and I did have reactions from food challenges - bad reactions where I got quite sick. 

I felt much better after I stopped eating the foods that had made me sick after the elimination diet.  A lot of symptoms went away. 

So that started me off.  Over the next few years I figured out my delayed food allergies, and that improved my health greatly.  Both my physical and psychological health - these allergies had huge emotional consequences. 

There aren't yet good lab tests for delayed food allergies.  There aren't even good lab tests for immediate IgE-mediated food allergies, the kind that can cause anaphylaxis.  The gold standard for diagnosis of food allergies of any kind, is an elimination diet followed by double-blind placebo-controlled food challenges - with emergency assistance available, because food challenges can be dangerous. 

Double-blind placebo-controlled food challenges are rarely done outside a research setting, because they are very time-consuming and laborious, and they would involve a lot of extra sickness for the patient, if they are positive. 

Open (un-blinded) food challenges are the best reasonably accurate way of testing for food allergies, without causing too much sickness and waste of time for patient and doctor. 

Many people are diagnosed with food allergies by alternative medicine providers.  But these tests are mostly bogus. 

I was chatting once with a guy who came to work on my house.  I told him I'd figured out my food allergies with elimination diet and food challenges.  He said he didn't have to do all that - his naturopath diagnosed his food allergies for him - and he was told to avoid combinations of foods, not single foods! 

This is almost certainly a completely bogus diagnosis.  Sometimes, allergies can have synergistic effects - but much more often, it's individual foods. 

Most likely the naturopath told him to avoid combinations of foods because this sells better!  It gave the guy a ritual to do with his meals - sort of like magic rituals - and avoided telling him to actually stop eating any particular food - which is often hard for people.  The naturopath had to sell his remedies and his methods, so he didn't want to displease his customers by telling them to stop eating a food.

This is an example of MD's doing relatively well, in an area where not much is known.  Without good lab tests, they did the best they could, using the symptoms when a person eats a food after having avoided it for awhile.  It was a possibly dangerous suggestion for me to do food challenges on my own, and if they had known back then that celiac disease wasn't rare, they would have suggested I get tested for it before doing the elimination diet. 

But otherwise, they did reasonably well.

And doing reasonably well, avoids driving people to alternative practitioners who might do some  hocus-pocus bullshit like the naturopath did. 

Comment by Dyslexic's DOG on November 4, 2013 at 10:48pm

I was not writing about subjective Symptoms, many symptoms are subjective, deferred pain, phantom limbs, etc...

No, it's purely subjective treatments, or subjective cures, in other treatments that are considered as godsent by one sufferer and thus they promote it as such, only to find that is really never works the same for anybody else.

If the pain or symptoms are subjective, it usually means the brain is the culprit and it may actually be a condition where the brain is not accepting or is ignoring reality, such as in phantom pain.

It is no longer getting feedback from the limb, but it considers the limb or body part is still there, regardless of there being no feedback, or it is mistaking feedback from another part of the body as feedback from the missing limb, such as feedback from the face keeping a missing hand in the brain's body map. Which is common.

The pain is not objective, it is subjective.

Yet the treatment for this can be completely objective, in deliberately fooling the brain to accept that the limb is moving, and eventually no longer there, such as Ramachandran's mirror box.

You may consider such treatments as subjective, because they are mind based, though they are objective in that the mechanisms by which they work are now very well known and the objective is deliberate deception of the brain, which has been clinically verified by experiment.

Though it is extremely hard to accurately replicate such treatments, so the replication rate is very low.

So you can consider it a subjective treatment that works.

Though such treatments are extremely rare.

Neurology may discover more.

Comment by Luara on November 4, 2013 at 5:20pm

If scientists don't listen enough to people's subjective symptoms to investigate them, then whatever disease they are suffering from, will tend to be the province of alternative medicine, and "disreputable", the subject of scoffing skeptical blog posts, and scoffed at by some doctors. 

Subjective symptoms have to be taken seriously by researchers so that people who suffer from these hard-to-diagnose diseases, can escape from that twilight country of magic and delusion where many doctors place them.  And taking them seriously means not having an oppositional "skeptic" mentality. 

Comment by Luara on November 4, 2013 at 4:17pm

Also, it's not true that subjective symptoms have no place in medical practice. 

Doctors do ask about subjective symptoms.  Sometimes that's what doctors have to go on, and very often subjective symptoms (fatigue, pain, etc.) are part of the clinical picture. 

It's certainly better to have objective medical tests available, but in the real world, doctors may not have definitive information. 

It's part of being a good doctor, to still be able to help even when there isn't enough information.  Medicine is an art as well as a science. 

Comment by Luara on November 4, 2013 at 1:45pm

Subjective evidence needs to be tested for its objectivity.

Because subjective experiences may be simply a placebo effect and not a realistic treatment for the condition.

Unless it becomes objective evidence, it really has no place in any medical practice, mainstream nor natural.

The problem is that when people's subjective experiences are discounted, it feels bad to them. One thing people like about alternative medicine providers is that they respect subjective experiences.
Mainstream doctors do not have a reason to tell people that subjective experiences are "all in their head" when in actuality, they do not know.  They do often give such messages to people when the only justified message is "I don't know what the reason for your symptoms is". 

Doctors do this partly because they would rather tell the patient they're making something up, rather than admit to simply not knowing. 

But in reality, a great deal is not known about the causes for subjective symptoms.  For example, cognitive impairment from allergic rhinitis has been objectively documented - but last I checked, nobody knows why it would cause a "fuzzy-headed feeling" or make it hard to think. 

It's a kind of prejudice that is common in mainstream medicine, and it's very alienating to people. 

Fatigue for example is a very common complaint.  Especially in women.  Yet women who have problems like chronic fatigue syndrome often tell stories about the dismissive comments they've gotten from doctors, the messages about how they should "just drink some coffee", etc.  When they're so wiped out they can hardly sit up in a chair. 

It is possible to research subjective symptoms, for example with double-blind challenges with allergens. 

If the people who allocate money for research care about not alienating people from mainstream medicine, it is very important to research subjective symptoms.   

But in fact, researchers are often more comfortable with objective symptoms.  For example, I've been looking into the research on non-classical food allergies, and the research I've seen so far, is on allergies with objective symptoms like diarrhea. 

Symptoms can be very real, and yet subjective, and treating people as if subjective symptoms are "all in their head" is a great injustice. 

Alternative medicine providers are often very nice people.  That's how they get customers - people who've been treated unfairly by MD's, feel better around the alternative provider. 

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