It’s a part of my paleo fantasy, it’s a part of my paleo dream

I'm not an American and I won't practice there. I'm Australian and we score an improved 19th on that league table. However I recently had the opportunity to study/work in a hospital in the states and these are some of my observations.

- The US healthcare system is fucked.

- there is a major disparity of care by region and neighbourhood (from my experience)

- poor people are discriminated against by the healthcare system

- these inequalities of care and resources are perpetuated down the line by a social system which doesn't support the most needy n society

In comparison, Cuba has one of the highest rates of doctors per capita and a healthcare system that performs astoundingly well, especially when compared on a dollar basis. You don't need high tech to perform life saving basic medical treatment, such as that which infant mortality measures.

I feel that the US healthcare system over-emphasises technology to deliver solutions, when what is actually needed are people on the ground in places where they are needed. Unfortunately for those people, they are unable to pay so no-one is going to go to them.

Now to the meat and potatoes of your claim. Firstly let me say that it strikes me as a bit aggressive. I said * in the same way as taking a drug that has been through a RCT does.*

If I am to respond to your whole query, then really I am throwing open the whole of medicine. And it's a big area. Everything from the correct techniques for birthing to height projection charts for children, through immunisations and treatment for common illnesses, to whole specialties of cardiology, renal medicine, .... Many many more.

But let me give you some anecdotes to show you how much of medicine HAS been studied. Maybe You will cry 'liar, deceiver!'. Or maybe I will be able to convey to you a bit of the never-ending torrent of information every doctor is swimming in (and I will admit, there are some that simply stop looking at it all).

Firstly. We have to do assignments called PEARLS. basically, w come across a clinical question and go and try and find evidence for it. As (at the time) a 3rd year med student, I still didn't really have much idea what was going on in the hospital, let alone how to formulate a clinical question and find an answer.

My question involved an elderly patient who had been transferred to the service I was on. He was on an ace inhibitor and an Angiotensin-receptor blocker. That is, 2 types of drugs which supposedly do the same thing.

This was a bit weird to me but it turned out there is some plausible science behind it - combination treatment might lead to being able to use lower doses, which can mean less side effects, as well as more effective RAAS blockade which might lead to better control of blood pressure.

Well it turned out that for this question I thought was stupid and pointless there had been a recently completed RCT, The ONTARGET Study, which proved that dual blockade is worse than single drug use.

My housemate is currently doing his, and his clinical question is whether an infected abdominal surgical wound should be closed or left open. Also seems like a Bizzare question but turns out there are several papers on this, and they say that the wound must be left open.

No RCT this time, but it is notoriously hard to do RCTs in surgical patients for reasons I'm sure you can understand.

A thir anecdote: when we start med, they tell us that 50% of what we learn will be obsolete at the end of 4 years of study, the problem is we don't know which 50%. Such is the rate of scientific advancement.

When I first heard this I just thought it was an embellishment, a story designed to boast of the speed of discovery. Turns out its true. Some significant changes have occurred since I've started studying that have overturned long-held practices.

An example would be the use of lidocaine and adrenaline/epinephrine in local anaesthetic for closing a wound in the extremity.

It was thought that the adrenaline would cause vasoconstriction which would lead to infarction and possible loss of a finger or toe if used. Recently a RCT was performed which showed it to be totally safe. That Overturned a practice that had been going for many many years.

The truth is, I can't give you a figure for the amount of evidence that has an RCT done for it. This is not shirking from the responsibility, but it is simply admitting that the scope of the practice of medicine is so unimaginably vast that even after spending 4 years deep in the thick of it, I know I will only ever be able to be proficient in a tiny area of the whole.

I can assure you, however, that people are working hard to ensure that everything will be studied. I would estimate that 99%+ of our practice has been published in some form, ranging from the worst - simple case reports, through to the most expensive and rarest- RCTs. We even study how reliable the examination signs are - by this I mean the percussion of fingers on your chest to detect various conditions (dullness indicating pneumonia has a likelihood ratio of 3, hyper resonance indicating COPD has a positive LR of 5.1) and every other thing that we do.

Some of these studies are bad; some are outdated; and sometimes we do things for years because they became habitual and weren't re-examined for a long time. And sometimes these things cause harm to patients.

But you can bet that it is the aim of medicine, and of science, to test and re-test all of the things we do, continually, with the aim of improving our practice and providing better and safer care.

The same can't be said of alternative medicine

With that said, you still, to me, seem to be saying that women are currently employing less rationality than men, due to failure in education, culture, or something else. This is what I want to dispute. I disagree that alternative medicine being more popular with women means that women as a whole have been given less critical thinking skills. I think it's just because some things are more popular with women, and some with men. Alternative medicine appears to me to be something that is more popular with women, and it also happens to be irrational.

Even if there are millions of distinct plant chemistries out there, a small number (say, 100) will account for 90% of the herbal remedies prescribed and taken. These will have been studied by scientific methods exhaustively. The next most common chunk will have received some cursory attention, and then you enter into the vast fields of the unknown.

But the fields aren't unknown to just science: they're unknown to cultural practitioners as well. I'm willing to believe that, even without double-blind clinical trials, people were able to find effective treatments with enough trial and error. But "enough trial and error" means "not the long tail". So once you start talking the 1000th most common plant used for medicinal properties, the amount of experience pre-scientific practitioners have accumulated is negligible, and handful of anecdotes at best. Not even enough to ascribe correlation, let alone causation.

So on the head of plants of potential value, I'm betting that they've all been studied exhaustively. On the tail, there are countless plants which could have countless benefits, but essentially no evidence to do anything but pick one at random and hope it cures what ails you. The middle, of enough evidence to suspect or know a plant does something, but not how, is going to be fairly small.

Do you mean it has been tested and found to work, even if it has nothing to do with medicine (some herbal supplement or meditation) or just medical approved/ordered?

I don't buy into much of the alt-med areas (homeopathy, acunpunture, etc, just not my cup of tea) but I do research a lot about natural 'supplements' and many have been proven quite useful for human health. In what category would you put this?

The other part of the problem is the influence medical staff have. One example is the food advice we have been getting the last couple decades.

'No fats, a lot of cereal. That's the way to live.' which still today doctors here advise (my dad is pre-diabetic, his doctor recommended to change to wholegrain bread and stop eating animal fat, and take his medicine, can't forget that along with his statins for the cholesterol!) which we all know now that isn't the way to go, but many doctors are still making their informed decisions by things they learned 40 years ago in medical school.

I'm also pretty sure you're right that it puts a lot of people off, and I'm not the right person to talk to them :)

Oh and I absolutely agree that the days of listening to experts and authority figures are over. I'm not one. You'll find me the last person to say that the medical establishment has everything right, or that we should always listen to doctors because they're just so clever. I just think that most of the thought behind alt-med in its various forms is nonsense too.