Respectful Insolence

My recent post (coupled with similar posts by Dr. R. W. and Abel Pharmboy) about the American Medical Student Association (AMSA) and its credulous promotion of non-evidence-based alternative medicine while posing as being “skeptical” of big pharma brought this rejoinder from Joseph of Corpus Callosum, in which he took issue with one aspect of my suspicion of the promotion of woo in medical schools by AMSA. I have to strenuously disagree with nearly all of his points. Here’s the first, and most easily dismissed:

They [Dr. R.W., Abel, and I] raise some valid points, although I would not be quick to be entirely dismissive of ASMA’s efforts. There are several reasons for that.

For one, kids will be kids. While medical students are not exactly kids, probably most of them did not get to be very rebellious during their teenage years. Maybe they need to get it out of their system.

As a fellow physician, I’d say: So what? Being a doctor is serious business. Medical students are preparing for a profession in which they will literally be responsible for people’s lives and well-being. If a medical student feels the need to “rebel” by trying to get non-evidence-based medicine introduced into the curriculum, then maybe that medical student doesn’t belong in medicine. Harsh? Judgmental? Hell, yes! Medicine isn’t a game. Responsible physicians know what they are responsible for. For medical students, “kids will be kids” doesn’t bother me as far as playing pranks on each other (and, yes, a fair amount of that does go on during medical school) or dabbling in left wing politics, but I draw the line at anything that compromises patient care. The cardinal rule of medicine is, “First, do no harm.” In some cases, pitching woo may do no harm, but in many cases it does. (Just ask the Orange Man.) Maybe it’s just my specialty (surgery), where the therapies we use can do real harm when misapplied (and sometimes even when applied properly). Consequently, my attitude is not so forgiving towards actions that I perceive as potentially compromising the standard of care, and, I argue, the unabashed credulous promotion of woo by AMSA has the potential to do just that.

Joseph’s main objection to my thesis, in contrast, is not quite as easily dismissed, although I believe he is mistaken about this as well. After pointing out that AMSA is probably not pushing this woo as a replacement for evidence-based medicine (EBM), but rather something to be used in addition to EBM (probably true, for the most part, at least now), he makes the argument that understanding complementary and alternative medicine (CAM) can have a benefit:

However, looking at it from a biopsychosocial perspective, I am not confident that there is zero benefit [from a physician understanding CAM]. In fact, I think there is a benefit. What I am not clear about is how big the benefit is. I suspect that it helps some doctors, but not others.

Traditional medicine tends to focus or preventing or curing disease. It is hard to find fault with that. When the disease cannot be prevented cured, the focus shifts to stopping or slowing the progression. When that cannot be done, the focus shifts to minimizing the impact of the disease, by assisting with adaptation.

Patients, of course, want to be cured. Sometimes that is not possible, so the best thing for the physician to do is to help the patient accept the shift in focus. ICAM probably has a lot to offer in that area.

Again, I disagree. For one thing, CAM tends to do exactly the opposite. I argue that it actually impedes such a shift in focus. CAM therapies often promise the impossible: curing diseases that “conventional” medicine can’t cure, in particular. The patient often seeks alternative medicine because he believes that conventional medicine can’t help him or that it will cause too much discomfort or pain in doing so (patients who reject chemotherapy for tumors known to respond to it in favor of “less toxic” natural therapies that have no evidence to support their efficacy, for example). Even though most of us think that we are immune to it, physicians who begin to use CAM take the very real risk of falling into the same mindset as practitioners of woo who practice outright quackery. I’d be willing to bet that, for instance, Dr. Roy Kerry, the physician whose use of chelation therapy for autism killed a five year old boy, started out practicing EBM but now genuinely believes he is helping his patients when he gives them EDTA for their autism. No, in actuality, much of CAM shifts the focus of patients with incurable disease or chronic conditions that are not likely to change in exactly the wrong direction: towards a false hope that their condition can be cured, rather than simply managed or palliated.

Joseph’s other argument is that learning about woo can improve a physician’s bedside manner by helping him to understand what the patient’s conception of disease is:

The other area of potential benefit is a bit more obscure, more difficult to understand. Patients come to the clinic with a conception of what is wrong. To them, their conception of the disease is what defines the problem. usually, their concept of the disease is quite different from that of the physician.

In order to have the best chance of helping, it is necessary for the physician to make recommendations that are consistent with the patient’s concept of the disease. Education in ICAM can, at least potentially, help broaden the physician’s ability to understand the patients concept of the disease. This could facilitate communication, and the development of a therapeutic alliance.

Now, I am aware that the idea of a therapeutic alliance is pretty much restricted to psychiatry and allied disciplines. But the idea is an old one: every doctor knows about the concept of bedside manner, which is probably the single most important skill to have.

In fact, over the entire history of medicine, various concepts have come and gone. Probably the one concept that has endured over the entire history of medicine, is that of the centrality of the physician-patient relationship.

Part of the skill of bedside manner is the ability to understand the disease from the perspective of the patient. Increasingly, patients are coming in, having conceptualized their illness in terms borrowed from a variety of sources. Sometimes these are concepts from ICAM, sometimes they are from drug company ads, or Oprah, or Reader’s Digest; sometimes they are idiosyncratic. But whatever the origin, the doctor has to listen and understand.

Fair enough, but my rejoinder to this is that a doctor doesn’t really need to have more than a general understanding of what these concepts are order to accomplish exactly what Joseph considers important above. For example, a medical student does not need to take a series of courses as extensive as the courses at the University of Michigan to which Joseph referred. (Indeed, I’m actually quite disturbed to see my old undergraduate and medical school alma mater engaging in this woo, but that’s another matter. Suffice it to say that It’s unlikely that U. of M. will be getting any donations from me for the foreseeable future unless I can be somehow assured that they won’t go to help fund woo.)

My objection to Joseph’s argument is this; Just because medical schools have traditionally not been that great at teaching bedside manner, resulting in many doctors with less than stellar communications skills, is not a valid reason to teach them woo even if doing so would improve their communication skills with patients. ICAM and bedside manner are separate issues, and they do not have to be conflated to teach future doctors to learn how to forge a better therapeutic alliance with the patient. Just because, as Joseph correctly points out, the doctor-patient relationship can never entirely be evidence-based (being an interaction between two human beings) does not mean that practicing evidence-based medicine precludes the “human touch.” (Indeed, I’ve seen this in action at my own institution by oncologists with whom I work time and time again.) Joseph may have a point that it is useful for physicians to be familiar with multiple models of disease, but most CAM programs in medical school (and certainly AMSA’s credulous promotion of woo and even U. of M.’s program) go far beyond making students “familiar” with the tenets of CAM, which are numerous and often contradictory, depending upon which system.

Perhaps Joseph’s worst mistake, though, is this one:

Another potential benefit to inclusion of ICAM is that it provides opportunities to teach critical thinking skills. It is important for physicians to be able to critically evaluate the evidence supporting each treatment modality, regardless of whether it originated in New London or in Tibet.

In theory, yes, teaching CAM could provide opportunities to teach critical thinking skills. However, I’m afraid that in practice this is the last thing that CAM programs are generally good for. Indeed, as Dr. R. W. has so ably documented on his blog, critical thinking skills are most definitely not a primary concern in the vast majority of these programs, most of which teach credulous, nonjudgmental treatments of the major alternative medicine therapies and do not present much in terms of teaching what evidence there is or is not to support the use of these therapies. I note that even the program at the University of Michigan does not seem to provide much in the way of evidence-based teaching of CAM until the fourth year curriculum, and only then as an additional elective. (Heck, U. of M. even offers an elective that includes teaching on the utter quackery that is homeopathy! I could teach homeopathy in less than a half hour, with an explanation of the “law of similars” and “homeopathic dilutions,” followed by pointing out that homeopathy violates the laws of chemistry and physics and that there is no evidence that it does anything beyond a placebo effect. You can bet that U. of M. almost certainly doesn’t treat it that way.)

Also, my experience observing the proliferation of these programs is that they start out with good intentions of presenting an evidence-based approach to these modalities but then over time degenerate into credulous acceptance. I rather suspect that much of this is market-driven. Patients want CAM; to compete, medical schools introduce it into their hospitals and curricula. There is no real incentive other than good intentions to keep the programs strictly evidence-based, and the result is, all too often, a descent into woo. In short, woo sells, and medical schools are becoming all too willing to overlook the lack of sound scientific evidence for the vast majority of alternative medicine. I don’t have that much trouble with the teaching of herbal medicine, for instance, but when I start seeing Reiki, homeopathy, reflexology, and qi gong showing up in medical school, I become very alarmed indeed.

I rather suspect that Joseph doesn’t view the teaching of CAM in medical school to be as pernicious as I do because, unlike me, he perceives a mild benefit, no matter how ephemeral, and his perception of the cost to realize that benefit differs greatly from mine. One area where he and I agree is that teaching these modalities in medical school is “the potential to give certain treatment modalities more credibility than they deserve.” From my perspective that potential is very high–unacceptably high. When medical schools start teaching woo alongside EBM, it falsely elevates the woo as being on par with scientific medicine, and, worse, it takes time away from subjects that medical students actually need to know, to the potential detriment of their future patients. As far as I’m concerned, there should be no such thing as “alternative” medicine. There should medicine for which there is good scientific evidence of efficacy (it doesn’t matter where it came from or whether it was once considered “alternative” or not), and there is everything else that either doesn’t work or has no evidence to support that it works. Doctors-to-be should not waste too much time learning the latter.

Comments

  1. #1 Blake Stacey
    November 16, 2006

    Wait just a damn minute. When a pseudo-doctor drenched in woo gives his patient a quantum homeopathic treatment for the patient’s very real disease and the patient fails to get better, the pseudo-doctor will tell the patient that he, the suffering sick man, did not believe strongly enough. This is not good bedside manner.

  2. #2 ERV
    November 16, 2006

    Nonono I dont think it’s a ‘rebellious’ streak thats driving this garbage in AMSA. At least when I was in AMSA, the Humanistic Medicine students were the ones behind the woo. To be blunt, the HuMed kids are weird– in the cliche unwashed-Hippy-drum-circle sense.

    On the other hand, the rest of AMSA is made up of regular, nice, smart kids. The problem is, theyre too nice. They humor the HuMed kids because nice kids are supposed to be nice to the weird kids.

    I dont know if you all are appreciating the fact that this is one branch of AMSA that loves woo. Its the weirdos that sign up for CAM rotations. Yes, other students allow them to do it, but I think its out of ignorance of woo and wanting to be ‘nice’ and ‘welcoming’ to the weird kids.

    *shrug* Ill talk to my friends still in AMSA to see what can be done about this.

  3. #3 Interrobang
    November 16, 2006

    This tolerance for woo reminds me of the conventional wisdom that we atheists should be nice to people who do dumb things because of their religion, simply because it apparently isn’t polite to call out people for doing stupid things for stupid reasons.

  4. #4 The Loony Bassoony
    November 16, 2006

    And it isn’t polite, which means that it needs to be done carefully, diplomatically, and reserved for times when it’s really important. I mean, it doesn’t really matter if somebody wants to get down on the floor and pray to Allah five times a day. It *does* matter if someone wants to exterminate the Jews for crucifying Jesus. Similarly, it’s probably not worth alienating your Aunt Betty if she thinks multivitamins will help boost her memory, but if she’s taking vitamins to cure her breast cancer, then you might want to risk an intervention.

  5. #5 guerillahealer
    November 16, 2006

    It’s always interesting to me when the claim is made that there’s no evidence of CAM’s effectiveness.

    There’s actually abundant evidence, if one goes looking for it. But one has to consider the totality of the evidence … not just the culturally biased portion of it that, at least in the 20th century, was considered the best evidence.

    The problem is that when mainstream medical scientists talk about evidence, they’re referring to RCT and/or Cochrane review-type studies. There are a number of cultural biases embedded in these approaches that tend to produce false-negative results when analyzing the complex and individualized therapeutic techniques characteristic of CAM modalities. Assuming the primacy of western medical diagnoses, dismissing the effects of protein-turnover enhancing parasympathetic activation as “placebo”, hubristically slamming the quantum-effects of serially diluted substances, ignoring the synergistic action of multiple nutrient combinations titrated to a patient’s gastric competency and idiosyncratic requirements … it’s breathtaking when otherwise well-informed professionals refuse to educate themselves about the evidence that does exist.

    To drill down a bit into just one example of these biases: the body is a complex phenomenon dependent upon multiple inputs. Evidence has been presented, for example, that contemporary diets are deficient in a number of trace minerals as a function of the nutrient-mining effects of modern farming practices.

    RCT trials are thought to be the “highest” quality when they manipulate single variables; manipulating multiple variables is assumed a priori to produce “inconclusive” results. This is a little like the situation of someone who comes out of their house in the morning only to find that someone’s stolen the wheels from their car. If such a one goes about trying to determine which wheel is the one that needs replacing by putting one on at a time, trying to drive, and then taking that wheel off before replacing the next wheel … it’s going to be a long time before they’re mobile again.

    Patients in pain or with other disabling conditions don’t give a d*** about whether what helps them meets Cochran-level standards. They only care about what helps them regain their health.

    That’s why more than 30% of the population in the developed world reaches into their pockets to pay for CAM therapies … and awareness of that fact is why younger medical students, many of whom have had personal experience of CAM effectiveness, are seeking to integrate CAM study into their training.

  6. #6 quitter
    November 16, 2006

    Uggh, classic denialism from the alties again.

    Let’s see what’s wrong with these arguments guerillahealer.

    There’s actually abundant evidence, if one goes looking for it. But one has to consider the totality of the evidence … not just the culturally biased portion of it that, at least in the 20th century, was considered the best evidence.

    Where is this evidence again? I just know once I go looking for it I’ll end up on some message board listening to anecdotes about how aloe suppositories cured someone’s headache. Or explanations defying the evidence that Rife machines are more than just 2 dollars worth of electronic mumbo-jumbo. Do you have molecular evidence? A physiologic basis for the treatment’s effectiveness? A psychological explanation (probably related to the placebo effect)? Do you have an RCT on any of this garbage? Where is the evidence of which you speak, and remember, the plural of anecdote is anecdotes, not data.

    Assuming the primacy of western medical diagnoses, dismissing the effects of protein-turnover enhancing parasympathetic activation as “placebo”, hubristically slamming the quantum-effects of serially diluted substances, ignoring the synergistic action of multiple nutrient combinations titrated to a patient’s gastric competency and idiosyncratic requirements … it’s breathtaking when otherwise well-informed professionals refuse to educate themselves about the evidence that does exist.

    Again, where is the evidence for any of this? I’m a physicist, trust me, quantum mechanics does not say what you think it says. Where are your guidelines for this “titration” of nutrients? Are you sure those aren’t just pulled out of someone’s ass? What is “gastric competency”? This is just more mumbo-jumbo, slightly more jargonized, but still lacking any real evidence of efficacy.

    RCT trials are thought to be the “highest” quality when they manipulate single variables; manipulating multiple variables is assumed a priori to produce “inconclusive” results. This is a little like the situation of someone who comes out of their house in the morning only to find that someone’s stolen the wheels from their car. If such a one goes about trying to determine which wheel is the one that needs replacing by putting one on at a time, trying to drive, and then taking that wheel off before replacing the next wheel … it’s going to be a long time before they’re mobile again.

    Argument from analogy, irrelevant and just wrong. RCTs are multivariable if only because you’re studying humans, and beyond that often test multiple treatments at once for synergistic effects – like combined treatments for HIV, or hepatitis, or heart disease, etc. This claim is not only irrelevant but inaccurate.

    Patients in pain or with other disabling conditions don’t give a d*** about whether what helps them meets Cochran-level standards. They only care about what helps them regain their health.

    And that’s why altie medicine is so dangerous. It’s offering false hope and diverting them to treatments of questionable or non-existent efficacy and away from treatments that are known to be beneficial, even if only for a subset of patients.

    That’s why more than 30% of the population in the developed world reaches into their pockets to pay for CAM therapies … and awareness of that fact is why younger medical students, many of whom have had personal experience of CAM effectiveness, are seeking to integrate CAM study into their training.

    Argument ad populum, again irrelevent. I’m thoroughly unimpressed, as always. And I wouldn’t have even commented if I hadn’t been so unbelievable annoyed about this reference to “quantum effects”. That whole idea of molecular memory and quantum physics as a black box in which anything can happen is so annoying to someone who has actually studied it and for one simple reason. Planck’s constant is a very, very, very small number. Quantum mechanics is largely irrelevant even to macromolecules. Photons, electrons, subatomics, I’ll buy it, quantum mechanics becomes very important on those scales. But beyond the complete absence of evidence for these idiotic quantum theories, they don’t even make sense theoretically. So, stop reading Deepak Chopra and find a real scientist to follow.

  7. #7 HCN
    November 16, 2006

    Hmmmmm… could you post some studies that show which “alt-med” actually works? The cites from http://www.pubmed.gov are adequate (just remember that the spam filter here holds up your post for moderation if you post more than two URLs).

    For instance, let’s take one common remedy, and how to make it, Natrum Mur:

    Take 1 part salt and mix with 100 parts of water. Shake well. This is 1 C.

    Then take one part of the 1 C and put in 100 parts of water. Shake well. This is 2 C.

    Take 1 part of the 2 C and put it into 100 parts of water. Shake well. This is 3 C.

    Then Take 1 part of the 3 C and mix it into 100 parts of water. Shake well. This is 4 C.

    Then take one part of the 4 C and mix into 100 parts of water. Shake well. This is 5 C.

    Then take one part of the 5 C and mix it into 100 parts of water. Shake well. This is 6 C. A typical form that Natrum Mur (or Nat Mur, or Natrum Muriaticum) is sold as.

    Often, to get this remedy into pill form, a drop is placed onto a little sugar/lactose pill.

    What exactly is the percentage of “active” ingredient? How is it supposed to create any kind of reaction in the body to well do anything?

    A further discussion of the dilutions can be found at:
    http://badhomeopath.com/?p=12#more-12

    There is no real science behind homeopathy… yet is one of those alt-meds that have a large and vocal support group. Many claiming that there are studies showing it works, but when they are looked at more closely, the positive results seem to evaporate.

  8. #8 Justin Moretti
    November 16, 2006

    > Assuming the primacy of western medical diagnoses, dismissing the effects of protein-turnover enhancing parasympathetic activation as “placebo”, hubristically slamming the quantum-effects of serially diluted substances, ignoring the synergistic action of multiple nutrient combinations titrated to a patient’s gastric competency and idiosyncratic requirements … it’s breathtaking when otherwise well-informed professionals refuse to educate themselves about the evidence that does exist.

    I think you are talking a load of rubbish and you know it, even if you don’t want to admit it to yourself.

    What you are saying about the tendency of properly controlled trials to “incorrectly declare CAM erroneous” is analogous (if not equivalent) to fundamentalist Creationists (of any faith) alleging that God faked the existence of dinosaur bones in order to make fools of the paleontologists. Or are you one of those, as well?

    Are you going to tell a woman with a fungating carcinoma growing out through her mammary skin that there is a problem with the ‘primacy of western medical diagnosis’? Or a child with leukaemia tearing through their bone marrow and making them bleed through every pore and orifice?

    What mechanistic theory do you have for ‘protein turnover’ enhancing parasympathetic activity anyway? And what relevance does that have to the multitude of diseases that have nothing to do with the nervous system?

    When you talk of the ‘quantum effect of serially diluting substances’, are you simply stringing words together, or do you actually have a feasible, mathematically and theoretically based, quantum-mechanical mechanism – preferably one that has been demonstrated in the laboratory by independent analysts?

    “Synergistic action of multiple nutrient combinations” – what do you MEAN by this? How do you define “gastric competency”? How does this link in with the nutrient combinations, and with effects beyond the stomach? How do you analyse for the patient’s “idiosyncratic requirements”, and how often would two practitioners of this nutritional approach agree on the approach to the same patient?

    How do you prove that this is not just an excuse for saying “It’s all down to the individual patient; trials don’t work and we can ignore them”?

    I think you have a lot of questions to answer before I will consider that you have something worthwhile to say.

    “it’s breathtaking when otherwise well-informed professionals refuse to educate themselves about the evidence that does exist”

    We are well acquainted with the evidence. The evidence shows that your methods do not work. Your methods are all we had one to two hundred years ago, when EVERY woman with breast or cervical cancer died a lingering death; when EVERY child with leukaemia was dead within weeks; when appendicitis was still a killer; when osteomyelitis crippled children; when people in the most affluent and protected parts of society lost children to common illnesses as routine; when childbed fever, obstructed labour and even multiple births were a death lottery; and so on, and so on.

    The trials of efficacy have already been done; they are called ‘natural history of insufficiently treated disease’ and they took millions of lives. You might have had a claim to primacy when we docs had nothing better. Now we have plenty that is better, and you have to move on and accept that you are no longer ‘top dogs’, nor the least harmful.

  9. #9 anonimouse
    November 16, 2006

    I have a simple solution for all of this nonsense – no more stupid CAM clerkships. Let the fourth-year med students do what fourth-year med students traditionally do – sign up for the Marine medicine elective in Hawaii. They’d be better off doing that than learning about the best way to prepare a homepathic remedy.

  10. #10 HCN
    November 16, 2006

    An Australian known for wearing bright shirts attempts to commit suicide with supplies and instructions from a homeopath:
    http://www.skeptics.com.au/video/v/pbhomeo.htm

  11. #11 familydoc
    November 17, 2006

    When “alternative medicine” is proven by evidence (those inconvenient statistical double blind placebo control thingeys) to work we call it ………….medicine , until then we call it by it’s tried and trusted synonym……..”bollocks”

  12. #12 gaspass
    November 17, 2006

    Frightening. I went to a pretty darn openminded medical school just over a decade ago. The school was interested in exposing us to altimed, but I think mostly because we had quite a few patients in our population that used it and it was felt that we needed to learn to hear the patients out both to build rapport and to know what they were taking so we could make sure it wasn’t the cause of the problem or ran a risk of interfering with or creating an adverse reaction with actual medical therapy. I even got an assignment to go meet with some local naturopaths to hear directly from them about their theories. I hope never to get that close to a colon vaccuum again. I still routinely ask my patients if they are using any supplements or herbal preparations. Usually if I don’t think it will hurt them I just basically tell them that it’s their money and if spending it on woo makes them happy it’s probably better than spending it on McDonalds.

    A couple years ago the IM department at my hospital invited a professor from the medical school to lecture on altimed. I was teasing a friend about going and he summed it up nicely: “oh,” he said, “you mean the Introduction to Magic lecture.” That about sums it up for me.

  13. #13 RPM
    November 17, 2006

    Another potential benefit to inclusion of ICAM is that it provides opportunities to teach critical thinking skills. It is important for physicians to be able to critically evaluate the evidence supporting each treatment modality, regardless of whether it originated in New London or in Tibet.

    Sounds like an argument to teach creationism in science class.

  14. #14 Orac
    November 17, 2006

    My thought as well, but I refrained from writing it. ;-)

  15. #15 Lab Cat
    November 17, 2006

    I am concerned that CAM courses are taking away valuable time from medical students which could be better spent on topics they should know. For example, as I have a BS in Human Nutrition, I wish physicians got more training in that subject before learning about CAM.

  16. #16 familydoc
    November 17, 2006

    RPM – what is a colon vacuum and can I use my Oreck(TM)?
    Do you have to do a coffee enema detoxification first?
    Can you chelate with suction?
    Does chelation suck?
    Sigh , so much bollocks , so little time – back to double quantum general practice then and shilling for Big Pharma to pay for my house in Malibu next to Andrew Weil’s.

  17. #17 UK Community Pharmacist
    November 17, 2006

    4th year med students could do worse than to look at this series of articles published in the Pharmaceutical Journal in 2004/5:
    http://www.pjonline.com/noticeboard/series/complementarymedicine.html

  18. #18 The Solo Practitioner
    November 18, 2006

    As a physician, I find the anger with which this blog is written disturbing. The National Center for Complementary and Alternative Medicine was created by the NIH to provide grant money and motivation for research to be performed in these fields in order to apply evidence-based principles to CAM. I am trained as an Internist, but have gone beyond my training to specialize and apply acupuncture as a therapeutic modality. This has enhanced my practice of medicine and my relationship with and ability to help my patients with problems that fail other conventional modalities, such as physical therapy and epidural cortisone injections for pain. Western medicine doesn’t always get to the root of every matter, or provide the best options for the whole individual. I am not saying to accept all of CAM. Scrutinize it, but, come on, keep your minds open. You may be missing something through the veil of your anger.

    btw, to the commentator that called those HuMed kids “weird,” are they weird because they’re not like you? I thought they taught tolerance in medical school. I guess you missed that course.

  19. #19 familydoc
    November 18, 2006

    Acupuncture as a therapeutic modality for what?
    Does the word placebo mean anything to you – the HuMed kids should be at Straight Chiropractc schools and not medical school.
    Sorry back to shilling for Big Pharma and Western Medicine and its evil empire

  20. #20 Prup aka Jim Benton
    November 18, 2006

    I think that CAM should be taught in med schools — and that Creationism should be taught in science classes — for the same reason, to debunk them. (I would, as far as CAM, have you, Orac, and some of the SkepCirc crew, write the textbook.) In both cases, the advantage is that the students — and I would have each student be required to research a particular type of woo — would see for themselves how nonsensical the supposed ‘evidence’ for the ‘alternate explanation’ actually is, and the class, by criticizing the ‘research’ would learn a proper skepticism.

    Too often we see ‘real doctors’ (i.e., people with medical degrees) falling for this nonsense. Sometimes it is simple venality, or a desire to play into a patient’s belief system, but I would expect that more often it is simply that they’ve never been ‘inoculated’ against nonsense by having to try and defend it. (Similarly, with Creationism barred from science classes, too many students get into the bind of ‘teacher says this, preacher says that, both of them are lecturing me, how do I decide?’ But if they researched Creationism, and had to defend it — whether they believed in it or not — against a class of fellow students ready to challenge the assumptions, they’d ‘internalize’ their discovery that it really is totally unsupported by anything resembling a fact.)

    Of course, the difficult thing is to make sure the teacher understands this to start out with, and is capable of leading the debate properly.

  21. #21 Orac
    November 18, 2006

    Solo Practitioner:

    I wouldn’t characterize my reaction as “anger” so much as dismay and frustration. Modalities that I know to be without basis in science are being introduced into medical schools, and that concerns me greatly.

    You say that you’ve integrated acupuncture into your practice. Perhaps, then, you could explain to me what scientific evidence led you to believe that acupuncture has efficacy. I also wonder if you accept the basis of acupuncture, which is that somehow it alters the flow of qi along various “meridians.” (My perception is that acupuncture, if it does anything, functions as a placebo and/or counterirritant, and that if it has any efficacy at all it has absolutely nothing to do with the clearly religious/spiritual concept that is qi, which also turns out to be undetectable and unmeasurable by science.)

    Finally, you chose acupuncture, but apparently did not choose related modalities, like Reiki therapy, therapeutic touch, qi gong, and other forms of “treatment” based on a similar concept of manipulating the life force, or qi. Why not? Apparently you have some basis for thinking that acupuncture is useful and these other modalities are not; yet they all have a very similar basis in qi. On what evidence do you base your decision to incorporate acupuncture into your practice but not these other modalities?

    I’m not trying to bust your chops. Rather, I’m trying to get you to state explicitly the evidence upon which you’ve based your decision to offer acupuncture and the criteria which you use to decide which alternative therapies you will use and which you will not. In other words, if you have thought critically about it, I want to hear how. (Who knows? You might teach me something or show where I’m making mistakes.) If you haven’t thought critically about these issues, I’m hoping that, by asking these questions, I can get you to do so.

    Finally, regarding “tolerance,” be careful using that complaint. It’s a common plea that pseudoscientists of all stripes use, because most people think that it’s good to be tolerant.. In essence, they label the skeptic as “close-minded” and “intolerant” and tell him that he should be more “open-minded.” As we say in science, it’s good to be open-minded, but don’t be so open-minded that your brains fall out, and being open-minded does not preclude recognizing woo when one sees it (nor does it preclude properly labeling woo as woo). In other words, if a proposed treatment (like homeopathy, perhaps the best example of a totally ridiculous and scientifically unsupportable piece of woo) goes so obviously against the known laws of physics and chemistry and is so obviously without any evidence of efficacy, it’s not “close-minded” to reject it as woo. As we like to say in science, evidence talks, and bullshit walks. If holding these attitudes makes me seem “negative, mean, rude, ” or “arrogant” to you, that’s just a risk I’ll have to live with.

  22. #22 Joe
    November 18, 2006

    FYI, I don’t know if “solo practitoner” subscribes to this particular nonsense; but there is an American Academy of Medical Acupuncture that only trains medical doctors.

    “An Overview Of Medical Acupuncture”
    http://www.medicalacupuncture.org/acu_info/articles/helmsarticle.html
    [Accessed March 20, 2006]
    by Joseph M Helms, M.D.
    Modified from Essentials of Complementary and Alternative Medicine (Jonas WB, Levin JS, eds. Baltimore, Md: Williams & Wilkins; in press). Used with permission.
    “Diagnosis in acupuncture involves recognizing the level of manifestation of a disturbance. Premorbid symptomatology is organized according to the organs’ subtle spheres of influence, where early energetic and functional symptoms are linked to the organ that supervises the disturbed anatomical region or physiological function (eg, Kidney energy supervises head hair; premature graying or balding reflects a deficient Kidney vitality).”

    How can somebody go to medical school and believe this? I know the answer: as a former chemistry professor I can attest that we teach science poorly. Even professional scientists can subscribe to this nonsense because we don’t teach how to differentiate opinion from fact.

    I am sorry to read “solo practioner” refer to “western” medicine, as if there are other kinds. There is medicine, which is evidence based (or, at least, rational); and there is quackery, or stuff needing to be studied. Acupuncture makes hundreds (if not thousands) of claims, most are unsupported by research; a few have some provisional support, and are controversial.

  23. #23 guerillahealer
    November 18, 2006

    I’ll be back in a moment. I need to go rummaging around back in here for a sec.

  24. #24 guerillahealer
    November 18, 2006

    and BTW … don’t listen to me.

  25. #25 Joe
    November 18, 2006

    Further to “solo practitioner”

    The NIH did not create NCCAM, they were saddled with it by legislators who believe in woo (Sen. Tom Harkin, D IA; and Rep. Dan (The Loose Cannon) Burton, R IN., to name a few). NCCAM may be unique among our “scientific” agencies in having no scientific support. This causes actual harm to people who think NCCAM (via NIH) support means rational legitimacy for studies.

  26. #26 guerillahealer
    November 18, 2006

    OK. Here we go.

    One point at a time please. Some areas will be simpler than others.

    But again … don’t listen to me.

    Listen to these guyz & gals instead:

    Upon the changes in modern diets and their effects upon contemporary health status:

    Cordain L, Eaton SB, Sebastian A, Mann N, Lindeberg S, Watkins BA, O’Keefe JH,Brand-Miller J. Origins and evolution of the Western diet: health implications for the 21st century. Am J Clin Nutr. 2005 Feb;81(2):341-54.

    Frassetto L, Morris RC Jr, Sellmeyer DE, Todd K, Sebastian A. Diet, evolution and aging–the pathophysiologic effects of the post-agricultural inversion of the potassium-to-sodium and base-to-chloride ratios in the human diet. Eur J Nutr. 2001 Oct;40(5):200-13.

    Mann NJ. Paleolithic nutrition: what can we learn from the past? Asia Pac J Clin Nutr. 2004;13(Suppl):S17.

    Eaton SB, Konner M . Paleolithic nutrition. A consideration of its nature and current implications. N Engl J Med. 1985 Jan 31;312(5):283-9.

    Sebastian A, Frassetto LA, Sellmeyer DE, Merriam RL, Morris RC Jr. Estimation of the net acid load of the diet of ancestral preagricultural Homo sapiens and their hominid ancestors. Am J Clin Nutr. 2002 Dec;76(6):1308-1.

    Larsen CS. Animal source foods and human health during evolution. J Nutr. 2003 Nov;133(11 Suppl 2):3893S-3897S.

    Hulbert AJ, Turner N, Storlien LH, Else P. Dietary fats and membrane function: implications for metabolism and disease. Biol Rev Camb Philos Soc. 2005 Feb;80(1):155-69.

    Manz F. History of nutrition and acid-base physiology. Eur J Nutr. 2001 Oct;40(5):189-99.

    To drill down into one specific issue, magnesium … Mg is essential to the relaxation of both muscle and nerve tissue.

    The basic concept here is that once farmers get organized to a point where they succeed in stopping the regular flooding of their farmland, trace mineral content in human diets supplied by such farms steadily declines year by year thereafter as crops from the land are harvested. This takes place over generations.

    As if that wasn’t problem enough, some researchers and too many of the public rely on Mg oxide when running tests on / supplementing with Mg. Mg oxide doesn’t assimilate well … creating the possibility of false negative results in studies / personal trials of Mg supplementation.

    The grass tetany articles go into the effects of this on farmers … Ag journals are the one place some of this stuff gets discussed in depth and without the cultural biases sometimes apparent elsewhere … tho human studies have also been done. I’ll go rummaging summore. Back soon.

    Firoz, M, Graber, M. 2001. Bioavailability of US commercial magnesium preparations. Magnesium Research. 14(4):257-62,

    Robinson, D.L. et al. 1989. Management Practices to Overcome the Incidence of Grass Tetany. Journal of Animal Science. 67(12):3470-3484.

    Wilkinson, S.R. et al. 1987. Relation of Soil and Plant Magnesium to Nutrition of Animals and Man. Magnesium. 6(2):74-90.

    Worthington, V. 2001. Nutritional Quality of Organic versus Conventional Fruits, Vegetables and Grains. Journal of Alternative and Complementary Medicine. 7(2): 161-173.

    Marier, J.R. 1986. Magnesium content of the food supply in the modern-day world. Magnesium. 5(1): 1-8.

    Morgan K.J., Stampley, G.L. 1988. Dietary intake levels and food sources of magnesium and calcium for selected segments of the US population. Magnesium. 7(5-6): 225-233.

    Galan, P. et al. 1983. Dietary magnesium intake in a French adult population. Magnesium Research. 1997 Dec;10(4):321-328.

  27. #27 qetzal
    November 18, 2006

    guerillahealer,

    Thanks for the references “supporting” the efficacy of CAM, but I admit I’m still confused. Maybe you can help me out.

    Your first eight references talk about how much human diets have changed due to civilization and industry, and how that might affect our health. Your next seven references talk about how we might not get enough magnesium in our diets.

    So, the fact that we apparently don’t eat well these days proves that alt-meds work? That’s your evidence that “Western” medicine is wrong to be “dismissing the effects of protein-turnover enhancing parasympathetic activation as “placebo”, hubristically slamming the quantum-effects of serially diluted substances, [and] ignoring the synergistic action of multiple nutrient combinations titrated to a patient’s gastric competency and idiosyncratic requirements?”

    As Arthur said to the Black Knight, “You’re a looney!”

  28. #28 The Solo Practitioner
    November 18, 2006

    There can be no evidence if these modalities are not studied. Modern medicine has the advantage of being many years ahead in research. Let’s face it. If the NIH (by whichever means) did not fund research in CAM, it may not exist, as there is no patentable yoga, qi gong, or acupuncture therapy, etc… Medicine in this country up to this point has been largely driven by the financial interests of big pharma research.

    I ask you, Orac, have you ever had a massage? What evidence was there for seeking that modality for your specific complaint if you did? Have you ever tried any of those things you write off, such as qi gong or yoga? Perhaps it could mitigate some of your internal frustration with these issues. More and more people seek alternative care because modern medicine was losing touch with the spirit of the person. I say was because more and more medical trainings programs are seeing the importance of addressing these factors in their care of patients and training of future doctors. There is more to health than just the physical aspect, and there is more to one person than a statistic in a research study. EBM is not without fault as it may miss the tree for the forest. All things must be evaluated with scrutiny, including the studies done by big pharma that try to skew data to favor their drug, as we saw in the case of Vioxx. How did that make it past the FDA regulators? The data was already there, it was just presented differently to hide the facts. Case in point, scrutiny is needed in all directions before we swallow and accept facts — hook, line and sinker. And no, I do not accept all CAM at face value, but when I know there is no harm, and only possible added benefit, such as a program of yoga for stress reduction and relaxation, I’m all for it. I abide by the oath we all took: first do no harm.

    Since you insist, here are some things you can research yourself:

    Dr. Herbert Benson’s (Associate Professor of Medicine, Harvard Medical School) research on the relaxation response.

    Dr. Mehmet Oz’s (Vice Chairman, Dept. of Surgery, Columbia University Medical Center) integrative and complementary medicine cardiothoracic surgical program. Pubmed brings up multiple publications under his name.

    A review for you (regarding acup. mechanisms):
    The Role of acupuncture in pain management. Phys. Med. Rehab. Clin. N. Am. 2004 Nov; 15(4):749-72.

    Clinical research on acup. Part 1. What have reviews of the efficacy and safety of acupuncture told us so far? J. Alt. Compl. Med. 2004 Jan; 10(3):468-80.

    And evidence-based research on the use of acupuncture (sorry too lazy to write the authors today):
    Effectiveness of acupuncture as adjunctive therapy in OA of the knee: a randomized, controlled trial. Ann. Intern. Med. 2004 Dec 21; 141(12):901-10.

    Acupuncture in pts with OA of the knee: a randomized trial. Lancet 2005 Jul 9-15;366(9480)100-1.

    Acupuncture for peripheral joint OA: A systematic review and meta-analysis. Rheumatology 2006 Nov 45(11):1331-7.

    Acupuncture in patients with OA of the knee or hip: a randomized, controlled trial with an additional non-randomized arm. Arthr. Rheum. 2006 Oct 30;54(11):3485-3493.

    No doctor is infallible, and I certainly don’t claim to be. However, I am unyielding in my genuine desire to do good for each of my patients, keeping to the best possible practices in medicine.

    According to the Centre for Evidence-Based Medicine, “Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.” It involves the application of the scientific method to medical practice, including long-established existing medical traditions not yet subjected to adequate scientific scrutiny.

  29. #29 Bronze Dog
    November 19, 2006

    There can be no evidence if these modalities are not studied.

    Then pay for studies. Most of the time, alties love making excuses not to perform proper studies.

    Medicine in this country up to this point has been largely driven by the financial interests of big pharma research.

    You mean altruists and universities don’t exist at all?

    Perhaps it could mitigate some of your internal frustration with these issues.

    Nice way to sneak a subject change in there.

    More and more people seek alternative care because modern medicine was losing touch with the spirit of the person.

    That’s why I’ll never object to lessons on improving bedside manner.

    There is more to health than just the physical aspect, and there is more to one person than a statistic in a research study. EBM is not without fault as it may miss the tree for the forest. All things must be evaluated with scrutiny, including the studies done by big pharma that try to skew data to favor their drug, as we saw in the case of Vioxx. How did that make it past the FDA regulators? The data was already there, it was just presented differently to hide the facts. Case in point, scrutiny is needed in all directions before we swallow and accept facts — hook, line and sinker.

    That’s why I don’t object to most safety measures. I also realize that bad things happen despite our efforts to prevent them.

    The big problem I have with sCAM is that they usually aren’t interested in simple efficacy tests, much less safety.

    And no, I do not accept all CAM at face value, but when I know there is no harm, and only possible added benefit, such as a program of yoga for stress reduction and relaxation, I’m all for it. I abide by the oath we all took: first do no harm.

    The harm in that particular case comes mostly in the wallet and critical thinking abilities. Stress reduction and such are fine, but teaching them that it’s done by magic isn’t.

  30. #30 Bronze Dog
    November 19, 2006

    Oh, and thanks for the massive link love in that comment, Orac.

  31. #31 HCN
    November 19, 2006

    Why hasn’t an answer to my question:
    http://scienceblogs.com/insolence/2006/11/benefits_of_teaching_woo.php#comment-266156 … been addressed!

    Come on guerilahealer! Tell me what I want to know… don’t post studies of diet, tell me what proof diluting salt to some silly degree is an actual remedy!

    Not to be needling… but SoloPracticioner if I came into your office with a back sprain and you recommended punching me with needles versus telling me to do certain back strengthenig exercizes like my family doctor…. what would be better?

    My family doc recommended stuff like exercize and things like this:
    http://familydoctor.org/117.xml … which I did. After a year of exercizing from doing a kind of half leg lift in bed to working my way to swimming 2000 yards two to three times a week my back pain is no longer an issue.

    Would I have been better getting acupuncture instead of all the work I did?