A couple of days ago, I wrote a criticism of the increasing tendency to teach woo in American medical schools and then later followed up with a post questioning the contention that teaching woo has the benefit of improving the doctor-patient relationship. A physician going by the ‘nym Solo Practitioner took umbrage:
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.
My initial response was thus:
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.
Solo Practitioner responded with what was in essence the usual criticisms by alternative medicine afficianados against big pharma and EBM, coupled with a list of some articles for the efficacy of acupuncture plus a couple of names of physicians involved with CAM in other areas. I think he deserves a more formal response than just me writing him another comment in my blog, where few will see it (and where few will follow the link to his blog), and so he shall have one! This one’s for you, Solo Practitioner:
First off, let me assure you that I never impugned your dedication to patients; I was merely asking you upon what evidence you base your decisions regarding what CAM modalities you will or won’t incorporate into your practice. It just so happens that I’ve read a fair amount of the literature on acupuncture. My synthesis of it is that, if there is efficacy, it’s either due to either counterstimulation, endorphin, release, or placebo effect, or some combination of the three. That’s “if.” I’m not fully convinced that it does much at all. Similarly, massage is a fine thing that’s used by physical therapists in “conventional” medicine; so I don’t even really consider it to be CAM unless claims are made for it for which there are no evidence, such as when massage is combined with “therapeutic touch” and marketed as a way of doing anything more than improving relaxation, helping with musculoskeletal pain, etc.
I note that you’ve for the most part neatly sidestepped my main question, though, which was: Upon what evidence do you decide which CAM modalities you will or will not incorporate into your practice? You threw out a standard rant at big pharma and deficiencies in clinical trials for standard drugs. OK, fine. EBM isn’t perfect, and yes even EBM treatments often need to be individualized. I’ve never claimed otherwise. However, the deficiencies of EBM do not constitute evidence for the efficacy CAM, and at least conventional medicine usually addresses such deficiencies. It may take longer than we would wish, but eventually the truth will out–as with the example of Vioxx that you cited.
But back to acupuncture. My problem with acupuncture is only partially over the lack of solid evidence for its efficacy. My main problem is the belief system upon which acupuncture is based, which states that acupuncture “works” by altering the flow of qi through certain “meridians” via “acupuncture points.” The problem is, acupuncture is nonspecific; I suspect that even you would agree that in well-designed trials using sham acupuncture, it’s been found that whether the needles are inserted in the “correct” acupuncture points or not generally doesn’t matter. It may or may not relieve pain, but it’s pretty nonspecific.
That’s why I asked you whether you accept the validity of CAM modalities related to acupuncture that also claim to manipulate qi, such as qi gong, Reiki therapy, therapeutic touch, etc., and if you don’t I requested an explanation about why you don’t accept them when you do accept acupuncture? You basically dodged the question and inserted a screed against EBM and big pharma, plus some references about acupuncture. You see, to me the biggest threat to scientific medicine and the critical thinking of physicians who engage in CAM is not necessarily whether or not these therapies have efficacy. That can be determined scientifically. Rather, it’s the whole religious/spiritual belief systems that accompany them, belief systems rife with magical, rather than scientific, thinking. It’s this magical thinking that I don’t want to see invading medicine. When you open the door to these therapies before science shows that they have any efficacy, then you open the door to this sort of religious/spiritual thinking, which in my opinion has no place in being used as a basis for medical or surgical therapies. That’s also part of my problem with NCCAM, which is not a scientific construct at all, but rather the result of powerful legislators with a fondness for woo forcing the NIH to create first an Office and then a Center to study it. Worse, a lot of the studies that I see being funded by NCCAM lack even a rudimentary scientific plausibility, and to me scientific plausibility is the minimum necessary precondition for a study.
Once again, I’ll repeat it: There should be no such thing as “alternative” medicine. Medicine or treatments that have scientific evidence to show that they work, be they from big pharma, universities, or shamans should be incorporated into our armamentarium. Those for which scientific evidence shows no efficacy should not be used to treat disease. And those for which there is not any evidence yet should not be used outside of the auspices of a clinical trial in most cases–just as “conventional” therapies for which the evidence is not yet there should be treated. It’s really very simple.