"A Randomized, Double-Blind Trial of Nystatin Therapy for the Candidiasis Hypersensitivity Syndrome," was published 12-20-90 (NEJM 1990; 323:1717-23). The first sentence of the editorial comment (NEJM 1990; 323:1766-1767) is as follows, "Few illnesses have sparked as much hostility between the medical community and a segment of the lay public as the chronic candidiasis syndrome." The last sentence of the same editorial is, "Additional scientifically sound studies will be needed to determine whether this syndrome does or does not exist, and if it does, what the optimal treatment is for patients." 

A vigorous rebuttal to my article on "Candida Overgrowth Syndrome" (COS) was anticipated. You can't expect to broach this, or other, controversial subjects without drawing a strong response. It was no random act of foolhardiness or masochism that prompted me to take on this subject. That some physicians would disagree with me is less important than how they disagree. Questioning my logic and my evidence is entirely appropriate. Constructive debate is healthy -we can all learn from it. Questioning my intelligence, motivation and ethics and that of the administration that hired me is inappropriate. Hostile disagreements rarely change anyone's mind - we are all demeaned by them. This is in fact what many patients face when they try to talk to their physicians about CAM. Patients' beliefs in CAM are often belittled by physicians who convey the following message, "It's bogus because I say it's bogus. After all I am a scientist and you are not. What medical school did you go to?" Guess what? Those patients will either not talk to their physician again about CAM or they will find another physician! In either case the patient suffers because they lose the benefit of potentially useful medical guidance and oversight and the patient-physician relationship is compromised. As a profession we are guilty of being unprofessional in how we disagree with each other and with our patients. Is it any wonder that the studies consistently show that patients don't tell their physicians about their use of CAM? 

Set aside the issue of COS, for the moment, and let us imagine a patient who comes in with a bunch of subjective symptoms and suspects they have "bogusemia" which can only be treated by "quackicillin." The easiest and most natural response in this situation is to categorically discredit the patient's beliefs based on the fact that bogusemia and quackicillin are not taught in medical school nor approved by the FDA. Unfortunately there is no good research on bogusemia or quackicillin that you can quote that disproves them so the patient has to take your not so humble word for it. The next easiest, and somewhat unnatural, response is to patronize the patient and give them a placebo, perhaps even quackicillin if it's harmless. The most difficult response is to disagree without belittling or patronizing. Explaining to the patient that other treatable conditions might cause the same symptoms as bogusemia and you are not comfortable with this diagnosis unless you have ruled out other possible causes and there is some objective evidence for bogusemia allows both you and the patient to respectfully disagree. The patient-physician relationship is strengthened and the appropriate evaluation and treatment are facilitated. If by chance you stumble on a patient that does appear to have objective evidence of bogusemia and who in turn has a favorable response to quackicillin then you can risk your reputation and share this experience with your professional peers. Those who agree with you will call this a case report. Those who disagree with you will call it an anecdote. Those who are intellectually curious don't care what it's called, they simply want to do a study to see if there's anything to this. Those who are infuriated by your suggestion that in some cases treatment of bogusemia with quackicillin may be appropriate, but who lack objective evidence to refute your position will resort to personal attacks to discredit you and if possible see to it that you are ostracized, fired or burned at the stake for voicing such blasphemous heresy against the precepts of flat earth medicine. Eventually the appropriate scientific research is done and the truth is known. In some cases bogusemia and quackicillin are discredited and become forgotten in the ash heap of medical history. In some cases bogusemia gains respectability and becomes "newdxemia" and quackicillin becomes magically transformed into "eurekacillin."

Many CAM diagnoses and treatments, including COS, are described by the above illustration. With respect to COS it is usually diagnosed without a shred of objective evidence and treated with a variety of untested interventions, some benign, some potentially dangerous and none verified by research. The 1990 NEJM study did no objective testing. The inclusion criteria were entirely subjective. What were they treating? Your guess is as good as mine. I agree with the observation that total serum immunoglobulins are meaningless from a diagnostic point of view, have never stated or implied otherwise and don't use these in my clinical practice. The assertion that candida antibodies are totally worthless is an opinion that is not supported by research. The patient I described had "off the scale" candida IgA antibodies >400. The laboratory reports that 60 % of patients have readings less than 25, 32% have readings between 25 and 100, 8 % have readings >100 and less than 1% have readings >400. To say that this laboratory result is meaningless when it is greater than 20 standard deviations above the mean is statistically ludicrous and clinically irrational when the patient had a dramatic response to antifungal therapy after years of not responding to other interventions. The patient had every appropriate conventional medical test in her work up and none of the medical interventions tried had any significant effect on her symptoms. The tests were either negative or inconclusive. At no point have I ever or will I ever suggest or imply that a diagnosis of COS somehow nullifies any other conventional testing, diagnosis or treatment. While there is much interesting research on how to diagnose and treat fungal infections no good research has been published regarding COS. This is precisely why I submitted a research proposal to Pfizer Pharmaceuticals last August to study this question in detail. Several physicians have expressed an interest in participating in this research. I welcome the input and participation of any physician, especially skeptics, in this and other projects to research CAM controversies. 

Until we have definitive answers we are dealing in the realm of opinion. It seems fewer facts promote stronger opinions. Until we have answers we should learn to disagree with more gentility and less hostility. Learning how to disagree with patients and with each other will benefit everyone. The rapid growth in the use of CAM therapies means that we will have and more and more opportunities to disagree with our patients. If we disagree with civility and objectivity we can continue having the privilege of patients trusting and valuing our advice. If we use hostility to convey opinions not founded in facts we will lose the opportunity and privilege of positively impacting our patients' lives. When you consider the 380% increase in the use of herbal medicines by patients since 1990 and the estimated 15 million adult patients who are having potential interactions between their prescription medications and OTC supplements (JAMA 1998;280:1569-1575) it becomes very apparent that we need to keep the lines of communication open!