In Defense of Dr Perry Wilson, Socrates, and Donald Rumsfeld

This transcript has been edited for clarity.

Hello and welcome. I'm Dr George Lundberg, and this is At Large at Medscape. Today, I'm speaking in defense of Dr Perry Wilson, Socrates, and (ugh) Donald Rumsfeld.

During July 2019, Yale associate professor of medicine and gifted communicator, Dr Perry Wilson, published a piece on vitamins and supplements in his generally excellent weekly multimedia Medscape column named Impact Factor.^[1]

Over 300 readers chose to comment, and the bulk of the comments were critical.

Not that he needs it, but I rise to his defense.

Presenting a column intended to be evidence-based from recent literature, on a topic interesting to a broad swath of medical readers, is a hard job. Been there, done that. Dr Wilson, keep up the good work.

Experience is the best teacher for most people, and that includes physicians. That truism prompted the great Canadian pathologist, Dr William Boyd, who also was a first-rate textbook writer, to speak about cause and effect in a lecture to our second-year medical school class in Birmingham, Alabama (where he wintered from Winnipeg; smart man).

Boyd pointed out that one may encounter a certain situation, A; perform a certain action, B; observe what happens, C; and conclude...exactly what? Did B done to A produce C? Maybe it did; maybe it didn't. That is an anecdote. But if it is your anecdote, it resonates.

Sorting out cause and effect is the biggest issue in modern medicine. The entire disciplines of epidemiology and biostatistics are intended to answer that kind of question.

There is a huge propensity for ordinary people to draw conclusions based on their personal experiences. With physicians, this is called "clinical experience" and "clinical judgment," breeding expert opinion. These days, this is sometimes termed "real-world evidence."

There are many obvious situations where one does not need controlled clinical trials, such as outcomes from jumping out of an airplane without a parachute or life after amputating a gangrenous extremity. In less obvious situations, it has rightly been said, "Just because the frogs come out after it rains does not mean it rained frogs" and "The outcome of a rain dance depends a lot on timing."

How about vitamins and other supplements? Are they parachutes, amputations, or a waste of money? Many people take them and somehow believe that what follows is cause and effect. Maybe. Maybe not.

No one knows for sure. I have read that because Socrates talked a lot but did not write, Plato, his reporter, may have credited him with coining the phrase "It is what it is" or "res ipsa loquitur"—the thing speaks for itself. Many people say, "I took my daily calcium and vitamin D yesterday, and my hip feels fine today. Voilà!"

I need to throw headline writers into this messed-up mix. The Impact Factor commentary is titled, "Vitamins and Supplements Are a Waste of Money." My English professor spouse corrected my use of that kind of language many decades ago.

The implication is "all." Had it read "many," or "some," or even "most," some of the reader uproar might have been prevented. Maybe the title was simply clickbait in our modern world. If so, it seemed to work.

During George W. Bush's ill-conceived and tragic Iraq War, Defense Secretary Donald Rumsfeld became famous for his jousts with the press about the fog of war. One that stuck with me is [about the unknowns]: "[W]e don't know we don't know."

There are many vitamins, minerals, and other supplements that have not yet been thoroughly studied, the benefits of which are highly touted by many users. The esteemed Annals of Internal Medicine cannot publish articles that are not submitted. Most investigators cannot study reasonable questions about some such topic without money—often a lot of money—to do the studies right.

Much more research is needed. I, for example, swear by my daily magnesium. It has hugely improved my life—perhaps even sustains it. I also take vitamin K₂. It is tough to measure, but it seems beneficial.

Neither of these was included in the Annals paper,^[2] perhaps because doctors manage what they measure, and accurately measuring body stores of magnesium and K₂ are nonstarters.

If you find it difficult to obtain trustworthy information in this field of vitamins and supplements from your usual sources, you are not alone. I find that Consumer Lab does as good a job as any one source.

This field remains a work in progress.

That's my opinion. I'm Dr George Lundberg, and this is At Large at Medscape.

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