COMMENTARY

Should Doctors Embrace or Reject Alternative Treatments?

Arthur L. Caplan, PhD; Ronald Hoffman, MD; Steven Novella, MD

Disclosures

October 18, 2017

Hi. I'm Art Caplan and I am the head of medical ethics at New York University School of Medicine. I want to welcome you to Both Sides Now. We are going to look at a controversial issue that will really merit your attention. It's the topic of alternative and complementary medicine, and by that I am referring to treatments that are untested and unregulated. While there may not be hard data about them, there are often stories and testimonials that people have that say things work.

It is said, for example, that Steve Jobs regretted trying to cure himself through some alternative forms of healing—acupuncture, fruit juices, and visiting spiritualists—while he delayed having an operation and chemotherapy for his pancreatic cancer, which ultimately killed him. There is a downside that many are well aware of and invoke about alternative and complementary medicine.

On the other hand, more and more consumers say that they find relief, and benefit from alternative and complementary medicine. More medical centers are adding nontraditional therapy options for patients in their cancer centers. What are we actually talking about in this topic area?

Alternative medicine is used instead of traditional therapy. We see alternative as an "instead of," such as using acupuncture instead of chemotherapy or radiation. Complementary is used together with conventional medicine; it might be to supplement something. You might use massage therapy or yoga or tai chi, or supplements and herbs.

Integrative medicine is a holistic approach that uses conventional and alternative medicine together; it might say, "Take your medicine, but here is your acupuncture."

There are different definitions for "complementary," "alternative," "integrative," and "holistic." Some of the things we are talking about in terms of the alternative or the complementary are acupuncture, biofeedback, chelation therapy (which claims to remove toxic substances and heavy metals from an individual's bloodstream), chiropractic, osteopathy, homeopathy, massage, meditation, special diets, and supplements.

Americans are becoming increasingly involved in their own health. Many of them put a lot of credence in alternative and complementary treatments. They say that traditional medicines do not work for their problem—"Why should I use it?" You see that all over the Internet.

The danger is, though, that a patient could go on a special diet that claims to cure cancer instead of taking known effective, evidence-based drugs that their oncologist might prescribe to them.

Well, plenty to talk about here, and we have two guests who will shed a lot of light on the pros and cons of complementary and alternative medicine. Dr Steven Novella is at the Yale School of Medicine. He believes that complementary and alternative medicine is more a scam than it is something that we ought to be pursuing and that it can be counterproductive.

Dr Ronald Hoffman, who I have had the chance to talk with in the past, is the founder and medical director of an independent clinic, The Hoffman Center, in New York City. He is a complementary medicine practitioner, a certified physician, and believes that a natural or nontraditional medical approach can be the key to wellness, a way to optimize or make someone healthier than they might otherwise have been.

It is a real pleasure to have both of you here to talk about this thorny area. I will ask you first, Ron. I gave a couple of quick definitions for alternative, complementary, integrative, and holistic. Was I in the ballpark? Are we accurate with those definitions?

Ronald Hoffman, MD: I appreciate the clarification because when we talk about alternative medicine, it is sort of an all-or-nothing proposition. If you have cancer, are you going to eschew conventional therapies, and are you going to adopt taking herbs or using special diets to cure your cancer? What I am personally interested in is integrating traditional conventional medical therapies with natural approaches. I think that is where it works best.

Dr Caplan: That supplement or complement that.

Dr Hoffman: I call this intelligent medicine—using the best resources from both sides, because there clearly are benefits and drawbacks to both approaches and often you can integrate them. The task is to properly mix them so that one doesn't interfere with the other.

Dr Caplan: Steve, how do you see the geography here?

Steven Novella, MD: I think you have to ask me, what are you integrating? We start from a point of view that we need to have one rational science-based standard, basically the best methods possible to decide what works and what does not work, what is safe, to establish risk versus benefit. If you agree that there should be one fair science-based standard, then either you pass that standard or you don't.

If you are carving out a double standard for things that don't meet this sort of reasonable standard for risk versus benefit for using treatments that work, I do not think that is in anyone's best interest, unless you are making money from it. The patients are certainly not benefiting from lowering the standard and using treatments which probably do not work because they are either implausible, they have already failed clinical trials, or they are untested.

Most ideas in medicine turn out to fail; only a very, very tiny percentage actually are of net benefit to a patient. If we are shooting in the dark, if we are going back to the pre-scientific Wild West of medicine, that was not a good day for patients.

Dr Caplan: Back to leeching and purging.

Dr Novella: This is not in the interest of patients at all.

Dr Caplan: We did a poll. We found out that of 800 survey respondents—it is not a structured sample, but a large number of folks responded to the poll from Medscape—about 80% of them (physicians and other practitioners) said they will not work with patients around alternative and complementary medicine. About 20% in this poll said they would. I do not know what the overall picture is.

I do know, however, that there are a lot of medical schools that are teaching alternative, complementary, and integrative medicine. Mine happens to be one that has at least a course. There are plenty of places. I think the Yale Cancer Center does, and I know that Penn's Cancer Center has options of alternative and complementary opportunities for patients.

How would you respond if somebody said, "Wait a minute—aren't you guys offering some of these things within your own domains?"

Dr Novella: Well, yes, that really blurs the lines, and I think the whole category of "alternative," or however you want to rebrand it, is about blurring those lines, so they do a number of things. I can give you a lot of personal experience. At Yale, for example, they said that the medical student association says you have to teach students about alternative medicine. They do not tell you how you have to teach them, but old-school physicians do not really know a lot about it. They say, "Okay, we will let the people who are prescribing it teach the classes." Then all I really had to do was show them what they were proposing to teach, for them to be utterly scandalized about the horrible pseudoscience that they were about to teach their own medical students.

A lot of academics are just seriously not paying attention. Hospitals can offer new treatments [and get] incremental income for things they use that are often low-tech and do not really have a lot of infrastructure costs. That is just a win-win for them.

A lot of centers, like Yale's Cancer Center, for example, offer things they have always offered and just rebranded it as alternative and complementary: quality-of-life type of stuff, like massage or whatever, which are fine as long as you are not making claims that go beyond the evidence. They just sort of rebranded lifestyle and quality-of-life interventions as alternative, but it really is not. That is just marketing.

Dr Caplan: It is sometimes pointed out that a lot of what medicine does is not evidence-based because it is either grandfathered in or no one got around to a clinical trial or the trials are weak. Other people might say, "For certain things, if I feel better, I am okay with a testimonial. I had my massage, I felt good." What is your position or stance when somebody says, "Where are the data?"

Dr Hoffman: I am on the same page as Dr Novella. I really do believe in evidence-based therapies. Some therapies, which have been branded quackery or implausible, have been put to the test, an example of which is chelation therapy.

Dr Caplan: By the way, let me just point out that this would be the kind of therapy you might see somebody use to get toxins out of the body.

Dr Hoffman: It's to remove lead or heavy metals.

Dr Caplan: Some vaccine victims sometimes say that we can chelate away the mercury.

Dr Novella: It does do that, just to clarify. It does remove heavy metals. The controversy is, does it take plaque out of your arteries or prevent your heart attack?

Dr Caplan: The mercury that comes out may not be in the greatest amount.

Dr Hoffman: It was put to the test, and actually it was part of the study design. I was apprehensive because I said, "You know, perhaps the study will not come out positive for us and it will negate something that is really a mainstay of many practitioners' therapies," and it did turn out positive, to the amazement of some of the editors of the journal in which it was published.[1]

Now the question is whether it should be used as a mainstream therapy. But it is an example of something that was once considered the height of irresponsible quackery, a dangerous, unproven therapy that actually did have merit.

Dr Novella: If I might, though, it is an excellent example because that study that you are referring to, which my colleagues and I have thoroughly reviewed, is actually a terrible study. It did not show what they claimed that it showed. It actually does not show that chelation therapy prevents heart disease or prevents heart attacks. They did some squirrely things and massaged the data, and the methods were very questionable. That one study is certainly not definitive. It is, at best, controversial. In my opinion, it simply does not establish chelation therapy as effective for that reason.

Dr Caplan: It is important, I think, as we get into the debates about evidence, that we all recognize that a single study probably doesn't ever prove anything about anything. It is suggestive.

Dr Hoffman: That is the nature of scientific advancement in general.

Dr Caplan: I like to remind my students that we do not have breakthroughs; we have confirmed breakthroughs.

Dr Hoffman: There is no such thing as settled science.

Dr Caplan: We just started to get into the discussion of evidence-based. Do you think, in the alternative and complementary world, that your view is more, "I do want to go with what perhaps might have some supplementary power. I am not trying to replace known effective remedies for MS or cancer or parkinsonism or whatever"? There are plenty of practitioners out there who do not take that stance. They say, "I am going to cure this in an alternative way." What do you say to them? Should they be condemned?

The vast majority of doctors-to-be, medical students, will not practice alternative medicine, but they will encounter patients who, for one reason or another, are very committed to this.

Dr Hoffman: I am not with them, but, for example, the study of this in medical school is essential because the vast majority of doctors-to-be, medical students, will not practice alternative medicine, but they will encounter patients who, for one reason or another, are very committed to this. This is a real phenomenon. We cannot eradicate it, and like it or not, these doctors in training need to understand where these patients are coming from.

The worst possible thing to do is encounter a patient who is explaining something to you, just for you to say, "Well, that is just utter bunk; it is ridiculous, there is no scientific basis for that." The net result of that is the patients will leave, or they may continue as your patient but they will not communicate what they are doing. That is the worst possible outcome.

Dr Caplan: A lot of people believe that what is natural is what is good. I do not happen to be in this camp because I have met mosquitoes—not my best friend.

Dr Hoffman: They are just trying to kill us.

Dr Caplan: Right. I think it was Charles Darwin who got off the HMS Beagle and said, "You know, I have been out there in nature and I am not going back. It is too dangerous." There are problems with what is natural. A lot of people, nonetheless, believe that natural is good, and we certainly have plenty of advertising and marketing. How do you [dissuade a patient from using a natural treatment] and at the same time not turn them off and sort of lose them as a patient?

Dr Novella: I have no problem being frank with my patients. Of course, you never ridicule a patient or make it personal, but if they are asking me, "Should I get acupuncture for my migraines?" you don't be dismissive. I agree that we should teach and understand. As physicians, we need to understand this phenomenon from a scientific point of view. I will say, "I have reviewed the evidence about that treatment very thoroughly and this is my opinion. I think the published scientific evidence does not support its effectiveness." My patients really appreciate the fact that I took the time to talk to them about it, I looked at the literature, and I have an opinion about it.

Dr Caplan: If somebody said that they are still going to do the acupuncture, would you tell them that they cannot be your patient?

Dr Novella: No. I never turn patients away. I always work with my patients, even if they do not follow my advice. They still need a physician. I am there to guide them, not to control them. That is fine. I will give my unvarnished professional advice; that is my job. That is what I am there to do.

Dr Hoffman: I agree with that. However, I take the position that I am kind of an air-traffic controller; a lot of my constituency are patients who believe in natural medicine, and I have to sometimes debunk their beliefs and say, "I'm sorry, but that is a little too way out and there is no scientific evidence that this works." On the other hand, I may tell them, "You know, you really need surgery, or you need to take the medication." I think there is a role for physicians as arbiters of the information that is out there.

But as you know, there are many studies about natural substances, things like curcumin and sulforaphane.

Dr Novella: You mentioned curcumin, which just happens to be one I reviewed recently. Curcumin is a classic example of taking the research you are talking about, and it is all preclinical. Curcumin seems to work for everything, but it is one of those hyperreactive substances that chronically tests positive in pretty much every assay but has almost no bioavailability. It is a perfect example of something that will give you false positives on preclinical studies but has absolutely no established value.

Dr Hoffman: But there are clinical studies that show efficacy in inflammatory conditions, depression, and rheumatoid arthritis.

Dr Novella: They show an anti-inflammatory effect in preclinical studies. There is always potential harm if you are using something that is ineffective. If you are doing something that is real, that is actually having a physiologic effect, there could be direct harm, and it can distract patients away from more effective therapies and cost them resources, time, money. Even if it is worthless, even if it is benign.

There was a very recent review of patients of cancer therapy and those who used alternative medicine. Even if they were using it in a complementary way, and if they were using it at all, whether or not they were using their conventional therapy they had a higher mortality rate because they were delaying their conventional therapy.

Dr Hoffman: It really spoke to the issue of alternatives—people who eschewed conventional therapy, and I am not for that. Perhaps 50 years ago, when they had less-refined methods of treating cancer. But now with advances in cancer treatment, it makes sense for most cancers to undergo some element of conventional therapy.

Dr Caplan: Let me ask you this, Ron. I happened to be surfing around on the Internet, where I get all of my valuable medical information, and someone had put up a Facebook posting about soups that detoxify. They were touting these soups. Now, I grew up in a culture that had chicken soup, and it was supposed to be pretty medicinal. How do you, as a person who has some sympathy—at least on the wellness end and maybe to work with established conventional medicine—how do you help a patient sort through the endless amount of information, a snowstorm of "this works and that works" on the Internet?

Dr Hoffman: It is a continuous task for me, but I approach this with an open mind. I do not come from what seems to be a preconceived bias against these therapies, and if they are poor studies, I say, well, this just does not meet the threshold of substantiation. There are some things that just don't. I agree with you.

It is not a bias against any particular modality; it is just a standard of science.

Dr Novella: But it is not a bias against any particular modality; it is just a standard of science—that's it. If it turns out that chelation therapy works for heart disease, I will prescribe it. If it is curcumin and it cures cancer, great. That is wonderful. I have no bias against any individual treatment. Just don't water down the standard of science because you are selling it as natural.

Dr Caplan: What do you say to those who say that it's a conspiracy? "They have these natural and simpler cures; they just don't want to give them to us because they would rather sell us $145,000 precision medicine."

Dr Novella: You can always wipe away all evidence and all inconvenient scientific facts by just saying that it's a conspiracy. That's what people say when they do not have the facts on their side, right? I say, well, show me the evidence that there is actually a conspiracy. They can't. They say, well, of course not because it is a conspiracy. But again, it a self-contained belief system. It is an article of faith. The scientist decides. Science is not perfect. What we do in science-based medicine is criticize how mainstream science is doing it. Obviously, there is a lot of room for improvement. We want to raise the standard. Meanwhile, the alternative medicine side, to use the generic term, is trying to lower the standard or create a double standard, and that is what we object to. It's not any particular treatment, not anything specific. Just don't create a double standard.

Dr Caplan: Should the FDA have more authority on the alternative-complementary side?

Dr Hoffman: That is precisely it. I think you have to acknowledge that it is difficult to test the efficacy of a multifaceted lifestyle intervention. For example, Dean Ornish did a study.[2] He may not be your favorite scientist, but he did a study with a small cohort of people looking at a variety of interventions to prevent cardiovascular disease. It wasn't a clean study. It wasn't a double-blind, placebo-controlled study, because there may have been a big placebo effect when a bunch of people meditated, followed a perfect lifestyle, met together, had companionship, took a couple of vitamins, and later their coronary arteries were clearer. That may be an imprecise description of that. It is hard sometimes to test the efficacy of these therapies that actually do work. It is not an attempt to dilute the scientific standard.

Dr Novella: I disagree.

Dr Hoffman: I think consumers are results-oriented and people are looking for answers that are not completely addressed by conventional medicine.

Dr Caplan: I heard you say that you disagree.

Dr Novella: I completely disagree with that. That is one of the standard replies: "Well, you cannot test these things in a rigorous way." And I just disagree with that. You can study them. Studying them in a rigorous way just means doing good science, good methodology. You do have to try to control for variables and isolate variables as best as you can.

From my point of view, I want to know what actually works and not deceive myself.

Dr Hoffman: I was not able to answer your FDA question.

Dr Caplan: I am going to go right back there, so fire away.

Dr Hoffman: Here is the problem. If the FDA were to subject supplements to the same rigorous standards that they subject drugs to, you probably would see about 95% of the market disappear. That may be a result that you might cheer.

Dr Novella: That would probably be a good thing for the health of the average American.

Dr Hoffman: I respectfully disagree with that. The point being, I think that a lot of good is done, by and large, by the supplement industry. I think there are problems in the supplement industry, but I think that the FDA is not the place to do that regulation because you would have to have a vast, vast bureaucracy, and you would have to have years of studies and tens of millions, hundreds of millions of dollars on each individual ingredient to prove safety and efficacy. We would have a total destruction of our supplement industry.

Dr Caplan: I have heard, and I may have the number wrong—either of you can correct me—but I believe that we are way past the $10 billion level on supplements. We spend a lot of money on this.

Dr Hoffman: It could be as much as $30 billion.

Dr Caplan: Isn't that worth— give me the animal trials, and let's do phase 4 monitoring out in the real world. Couldn't we do more? I mean, a little bit?

Dr Hoffman: We can and should do more, but part of the problem, too, is that they are products of nature, they are generic. Let's use the example of curcumin, which is something that you are not that fond of, but—Say that a company sponsors its own $5 million study on curcumin. It's not proprietary any longer. It's like everybody can draft off the success of that study and sell their version of curcumin for whatever indication the study suggested. There are some perverse economic incentives when it comes to drugs versus supplements that make it a little more challenging to do this research.

Dr Novella: You hit upon it. There is a lot of real estate between what we have now, which is really the Wild West, and regulating supplements as if they are new drugs. I don't think anyone is arguing for that. Herbs, maybe. Herbs—here is a shock for you: Herbs are drugs. They are drugs. They are used for pharmacologic drugs so I think they should be treated like drugs. But for things like vitamin B12, I'm not saying that you have to do a $100 million study to say that this is good for some specific indication. We definitely need some standards for making health claims. We are not the only country in the world. There are other countries that get this a lot better than we do. Australia has much better balance here than we do, and we can follow what they do.

Dr Caplan: Homeopathy?

Dr Novella: Canada, you know, has its strengths and weaknesses, but we need to have a thoughtful conversation about where the sweet spot is, where we need to have some kind of reasonable standard, where you cannot just make claims willy-nilly without making it impossible to get something to market that might actually be helpful. I mean, if something is helpful, I want people to have access to it. What we have now is an industry that is really effectively unregulated, and we know from studies that most of the products out there are adulterated; they're substituted, they're contaminated.

Are you even getting what is on the label? The dosing is all over the place, the purity is all over the place. With a very tiny percentage of supplement products, are you actually getting what is on the bottle? We have not even gotten the basics of regulating it to that extent. I think we need some level of regulation of what kind of claims you could make beyond what we have now, which is effectively nothing.

Dr. Caplan: I have to say, with the world of direct-to-consumer advertising of drugs, we certainly see a lot of Wild West information.

Dr Hoffman: In terms of regulation, what is actually happening, I do not believe that the supplement industry is completely unregulated. The FDA is empowered to get in there.

In terms of preapproval, yes, there is an open door. But in terms of whether there is a dangerous supplement, it can be seized and banned by the FDA. The FDA is empowered to do that. They have done that with a few ingredients, but maybe not enough ingredients.

There are a lot of bad players in this industry, and then there are very responsible players. I have visited many of the places where they make vitamins, and they very carefully assay the materials before, during, and after production. They standardize, they publish on the label. Industry organizations are trying to rein in the industry because they realize that it is bad PR, that there are these renegade players in the industry. It's in the interest of the supplement industry to try to clean up its act, and it's in the process of doing it.

Dr Novella: They are regulating themselves. I mean, this is a separate debate beyond just medicine. It has not worked that well, in my opinion, and I think we need to have tighter regulation of supplements. I have nothing against vitamins. I prescribe them every day. But I prescribe them in an evidence-based way, individualized to patients' needs—not with claims that are not supported.

Dr Caplan: I do see a lot of vitamin D moving out there.

Dr Novella: We have been really focusing the conversation on the more plausible end of the spectrum, but my big beef is having an umbrella term like "complementary and alternative medicine" or "integrative medicine" because then you say, well chelation therapy turned out to work. I don't think it did, but let's say that it does work. That doesn't tell us anything, however, about homeopathy. You are using the things on the plausible end of the spectrum that may turn out to work and then get incorporated into science-based medicine as if it justifies the really implausible stuff.

Dr Caplan: Some of the most miserable ethics problems I get are cases involving young kids whose parents do not want to use chemotherapy for various leukemias or other types of cancer. They see on the Internet that they can use the Hoxsey treatment or find some herb to do something. I am trying to go to court to force standard proven treatments that will work, and at the same time, as Steve says, they are waiting, they are delaying. Should we not be more vocal in speaking up about that end of the spectrum?

Dr Novella: There is a replicability problem in medicine. We are doing too many small studies and not enough larger, definitive studies. There is too much pressure to publish interesting studies rather than replications, which is really the bread and butter of science. How do we know if something really works if someone does a boring replication? Nobody wants to publish it.

Dr Caplan: Nobody ever got tenured by doing boring replications.

Dr Novella: We should get tenured for boring replications. That is what we absolutely need. There are a lot of systemic problems that we need to improve, but as we are trying to improve the standard of science and medicine, the alternative medicine movement is trying to degrade it or, again, create a double standard or flip it on its head and say, well, we cannot really control for variables or we need looser definitions of evidence. No, we don't. Looser definitions of evidence are going to get us into trouble. We actually know what that is like. We had that.

There is a fuzzy ground of compassionate use. If you have a disease that is terminal or progressive, and we do not really have an effective treatment for it, the threshold of where the evidence is going to be different from that of just another diabetes drug or whatever other established therapy. You need to at least get to the established therapies. If there is no established therapy, we will take something rather than nothing. There is a range of where we set the threshold. It should be ethics-based, thoughtful, science-based. But that does not mean we go to witchcraft.

Dr Caplan: I want to take us to a different context, which is end of life. This is a place where you start to see alternative and complementary things sometimes appear too. People will say, "We have run out of what traditional medicine can do," and yet in hospice or other types of palliation, maybe there is a bigger role here. What about palliative care and complementary medicine? Should we close the cancer center because it is touting things that are not evidence-based, or should we say, "Whatever [makes you] feel good? I don't know if we ever got the evidence in on marijuana smoking for whatever, but it seems like people find that supportive under some circumstances. How tough do you want to be?

Dr Novella: I don't mind interventions that are designed to make people feel better, to help them get through chemotherapy, get through palliative care. That is fine; again, it is not alternative. Where I have a problem is when you make magical claims that are going to confuse patients, when you deceive them about the efficacy of something.

Dr Caplan: When you hang out the stem cells?

Dr Novella: Yes. You hold out false hope, because I see the really dark side of that and you cannot separate these. Once you say that pseudoscience is okay, as long as you mean well, then it is springtime for charlatans, basically. I have seen patients mortgage their house, $100,000, raise money from everybody because they are going to Mexico to get stem cells injected somewhere, or whatever based upon false hope. Once you give up the science-based standard, you really have no way of protecting patients from this false hope from the sharks in the water.

Dr Caplan: What about the sharks?

Dr Hoffman: That is an aspect of alternative medicine that I am really not proud of and invade against it from my podium, radio programs, and podcasts. I am an air-traffic controller for some of these therapies, which I think are really spurious. You're right—there is this magical aura, and science and critical thinking are suspended in regard to them. The stem cell thing has a great aura because it has tremendous potential, but it is not ready for prime time, for the most part.

Dr Novella: Exactly.

Dr Caplan: If you could, would you encourage more teaching about alternative and complementary medicine, pro and con, in our medical schools for the next generation? Would you say, let's be really negative about it or let's be really positive about it?

Dr Hoffman: I think it's important, and even if physicians are not going to espouse it, the goal is not to get doctors to train in it so that they can administer it. They can easily go to specialized programs to learn about that, should that be their interest. But I think doctors should have a basic orientation to what is out there. You are right—there could be a critical orientation to it, like, here are some of the potential drug-herb interactions that we have to watch out for. Here is where we might abrogate the effectiveness of a therapy with a vitamin. This is what doctors in the future are going to be encountering. It's not going away and they need to learn about it. In that spirit, we should have more of it and more nutrition study. Keep in mind that curriculums are so jammed in medical schools that you get only 1 hour or 2 hours of learning about nutrition. Whether we claim it as alternative or whether it is part of the conventional armamentarium, we need more of it.

Dr Caplan: Let me add: hardly enough bioethics.

Dr Novella: I agree that we need to teach about alternative medicine. I teach about it all the time. My approach is, we should teach students how to evaluate evidence and how to practice science-based medicine—how to know what works, what doesn't work, how to do good clinical decision-making and apply that uniformly to everything, whether it's called alternative, natural, or mainstream. It is one scientific, rational approach that is in the patient's best interest. Forget all of these false categories and just use what works. At the end of the day, that is what matters.

Dr Caplan: I want to thank both of my guests for a spirited and civil discussion of a very interesting, and obviously major, issue in healthcare. I come away thinking that alternative and complementary medicine is not going away, so in that sense, we have to learn how to manage it within healthcare, within medicine.

It is certainly the case that many aspects of alternative medicine are dangerous for patients. We have to recognize that and steer people away and say, "Look, I know you don't like chemotherapy. I know that you are not thrilled about undergoing a vigorous and tough intervention to go after disease, but it does not make what is natural or what is allegedly claimed on the Internet valid."

On the other hand, there are times when people can make changes in their behavior, or they can be led down the complementary path, and these things may make them respond well and be healthier. It is also the case that we have seen, in some aspects of palliation, that sometimes people are going to pick things that just make them feel well, and that's a part of healthcare too.

It's a complicated message. I hope you came away with some ways to think about this area. I suspect that it will not be the last time we will talk about this topic. I suspect that it will not be the last time both of our guests talk about this topic. Again, thank you for coming to Both Sides Now.

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