Respectful Insolence

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.

Comments

  1. #1 Robin Peters
    November 19, 2006

    Orac, you mention that EBM treatments “often” need to be individualized. That isn’t 100%, and I’m afraid patients (myself excluded, as I am a believer in conventional medicine) want 100% individualization. In other words, every time a patient comes in to see a doctor, he or she wants treatments personalized to him or her – and yes, that’s true every single time. A hasty two-minute visit, or a treatment decision based on a protocol rather than on the results of a thorough physical exam, blood work and other tests, do not produce individualized treatments at the frequency we patients desire such treatments.

    My preferred solution is to change doctors when this happens, to someone using EBM and tincture of time to treat me, rather than my running to the nearest quack using CAM to treat patients. Unfortunately, in my opinion, people are running to the quacks because they are more willing to spend the time with patients to treat them as individuals.

  2. #2 Greg P
    November 19, 2006

    Louis Pasteur once said, “There is no such thing as applied science, only applications of science.” [Il n'existe pas de sciences appliquées, mais seulement des applications de la science.]

    Paraphrasing, we might say, “There is no such thing as alternative medicine, only medicine with various alternatives.”

  3. #3 Abel Pharmboy
    November 19, 2006

    With all due deference to you both as I am not an MD, I spent a leisurely afternoon examining some of the reference sources provided by The Solo Practitioner. Mind you, I share Oracian concerns that open-mindedness and tolerance be used in the most critical sense; I myself spend most of my professional days trying to make sense out of folk medicine claims.

    So, once I got past the name-dropping (Oz is an incredible doc but only one of his 16 current projects uses any CAM: omega-3s for post-cardiotomy depression) and references to meta-analyses (the least weighty of all statistical analyses), I took a look at the paper (acupuncture vs osteoarthritis of the knee) from the Annals of Internal Medicine; I misread the citation and came across another one with a similar title (Ann Intern Med. 2006 Jul 4;145(1):12-20.) The conclusion of this paper, one that illustrates the problem with sham acupuncture controls:

    Success rates were 53.1% for TCA [traditional Chinese acupuncture], 51.0% for sham acupuncture, and 29.1% for conservative therapy. Acupuncture groups [regardless of TCA or sham] had higher success rates than conservative therapy groups (relative risk for TCA compared with conservative therapy, 1.75 [95% CI, 1.43 to 2.13]; relative risk for sham acupuncture compared with conservative therapy, 1.73 [CI, 1.42 to 2.11]). There was no difference between TCA and sham acupuncture (relative risk, 1.01 [CI, 0.87 to 1.17]).

    Of course, I then realized that I misread the citation proffered by The Solo Practitioner, also from Annals (Ann Intern Med. 2004;141:901.) that showed positive benefit over sham using a similar endpoint (Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score).

    So what’s the difference between the two reports? The latter, positive-efficacy paper was led by an author who then was recognized the following year with a $100,000 prize from the Bravewell Foundation, presented by Sarah Ferguson, Duchess of York.

    Integrative medicine is no longer an evidence-based specialty; it is the medicine of the rich and famous and will be rewarded as such, by out-of-pocket bearing patients and celebrity “visionaries.”

    btw, I must however admit that I really like the Solo Practitioner’s castigation/frustration with health insurance companies at his/her blog; we’ve got a lot of common ground on that debacle.

  4. #4 Joe
    November 19, 2006

    Abel Pharmboy, Mehmet Oz must be (I hope) a technically competent surgeon. However, look at his book “Healing From the Heart,” (late 1990s). Just like “naturopaths,” he has not met a form of quackery that he can’t endorse. Seriously.

    Also, you wrote “Integrative medicine is no longer an evidence-based specialty …” “Alternative medicine” (the integrated part) has always been anecdote-based, not evidence-based. Maybe I misunderstand your point.

  5. #5 The Solo Practitioner
    November 19, 2006

    I’m honored to have made it to the top of your blog. I certainly didn’t plan to end up there, but since I’m out in the open, I might as well continue the dialogue. However, it will be brief as I have limited time.

    You want to talk about qi gong, Reiki therapy and therapeutic touch. Now your contention is that because it is not proven it should not be done. My contention is that if the patient wants to do it, they have every right to do something that will NOT cause harm (and only if it will not undo any other therapy they are undergoing) with the weighted reality check that this therapy is not a substitution for proven modes of treatment. However, like I said before, part of people’s dissatisfaction (as stated by Ms. Peters above) with insurance-driven medicine as it has evolved in this country is the lack of touch with the human spirit. This was something that was more instinctual to our physician forebears than it is now in the technological age. Now this has nothing to do with whether EBM or CAM is right — I know that — but it is a very important issue at the root of how care is administered in this country.

    I believe in integration, as do you; however, perhaps I am more open to exhaust non-harmful possibilities while guiding the patient away from treatments that have no proven basis. One example is that patients come in asking me to do acupuncture for weight loss. Now there is no study that has proven this, and that is what I tell my patients. It will be a waste of their time and money. And that should be the role of an integrative physician.

    Now, regardless of the studies (and I will address that in a minute), I can profess that in my hands the use of acupuncture for the treatment of pain has a greater than 75% success rate. Each case is individualized to the nature and degree of the problem. It doesn’t matter to me that the philosophical construct for acupuncture doesn’t jive with you or the patient. You don’t have to believe anything for it to work. What does have to be determined is what it works for and what it doesn’t work for. I know which problems I can help, and which problems I have less of a chance of helping, and I mitigate patient expectations with that knowledge. The same way a that a Uvulopalatopharyngoplasty has a 50% success rate in treating Obstructive sleep apnea — so the ENT who does surgery makes sure to choose (we hope) a carefully selected candidate so that perhaps the success rate goes up to 80%. That a procedure is not 100% successful does not prevent conventional doctors from proceeding, right? How many intra-cardiac stents stenose within the 1st 6 months? An intra-cardiac stent is followed by at least 6-9mo. of ASA + Plavix therapy to prevent restenosis. For me, Acupuncture is only one component of a multidisciplinary approach I use for pain management, which possibly gives me greater success rate. So, in spite of what the studies say, I have helped people overcome pain that was not solved by conventional medicine. If you want to call it placebo effect, fine. But ask the patient if they would do it again?

    Now as far as the acupuncture studies go: first of all, not all acupuncture is the same. The point selection and combination used in TCA (Traditional Chinese Acupuncture) differs from the point selection (even though the points are relatively in the same location) and combination used in Medical Acupuncture (yes, that one proposed by Dr. Helms which has some very poetic language in the description of acupuncture points and body physiology that is derived from ancient Chinese text — call it a history lesson in a 2000 yr. old tradition). There is also Neuroanatomical acupuncture, the Craig PENS technigue, hand/scalp acupuncture, and auricular acupuncture. I am not saying I practice all of these techniques, but I’m merely pointing it out for the readers to realize that grouping acupuncture under one terminology is erroneous. Now, I understand that you may argue that this creates more confusion and lack of standardization. However, I merely bring it up to address the issue of what type of acupuncture was done in these studies. You may not be able to compare all of them at face value. There is also the question of how sham acupuncture is performed. Perhaps breaking through the skin with an acupuncture needle in spite of location is not really a good sham/control group. In EBM drug studies, it’s very easy to give a placebo pill that looks the same as the active pill. However, functional MRI studies have shown that even sham acupuncture does activate loci in the brain. So, back to the study. Even sham performed better than conventional therapy. The other study I referenced done at the University of Maryland used a different type of sham acupuncture that involved taping the guiding tube to supposed acupuncture points in patients who had never had acupuncture before and did not know what it entailed. This study showed that the treatment group did better than the other groups. Many believe this to be a better way to test sham acupuncture against regular acupuncture as needling the body surface still creates an endorphin release mediated by local afferent nerve fibers that are sensing the needle insertion.

    I don’t promise the world with acupuncture, nor any other complementary therapy I may suggest to my patients, such as meditation. However, having educated myself in these modalities puts me in a unique place as an MD to guide patients in the right direction for their ails. Now, Orac, you also skirted one of my questions. Have you ever tried a program of yoga or Qi gong? Would you never try acupuncture just because it doesn’t have a full roster of EBM yet?

    How about all of those physicians that use medications off label (i.e. not according to their FDA-approved indications)? Usually these uses come into being through experience and talking with other physicians. The FDA has allowed this realizing that every medication cannot be fully evaluated for all of its possible uses. These observations usually lead to additional studies and the discovery of additional beneficial uses for medications that may have come into the market for one particular use. Perhaps this is the medical analogy of common law. EBM could not exist without empirical observation either. Usually these observations are what lead to more formal studies.

    Integration to me involves practicing medicine with prudence, addressing the whole person as an individual, and finding alternatives when everything else (evidence-based) has failed the patient. The selection of treatments should come from the realm of scientific understanding along with EBM. If I stopped at the end of the EBM line, I may not have anything to offer my patients. How about hope? Don’t cancer patients do better if they believe they will be cured?

  6. #6 Clark Bartram
    November 19, 2006

    How does one say “missed the point” in quack?

  7. #7 James
    November 19, 2006

    I believe its “quack quack … quack, quackquackquack.” Or is that “Don’t run, we are your friends” in martian, I always get them mixed up ;).

  8. #8 HCN
    November 19, 2006

    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?

    Come on, be truthful! You know we all want the easy way out!

    Also, did you know that Traditional Chinese Medicine (and that should include acupuncture) was losing favor in China? Real all about it here:
    http://english.people.com.cn/200610/30/eng20061030_316501.html

  9. #9 epador
    November 20, 2006

    I wuz gonna make an erudite observation, but after reading James’s last post, I think its moot, or quack, or something like that.

    Kinda made the qi run out of SP’s argument. Wait a minute, it wasn’t there to start with. I think there’s a metaphor there somewhere…

  10. #10 Catherina
    November 20, 2006

    I think the danger is that “Wellness” therapies are sold as “medicine”. I do feel significantly better after a massage, but I realize that that is not medicine. I did try acupuncture (against migraines – I was at a point where I would have done the “swing a black cat over a fresh grave at midnight” if someone would have recommended it) – acupuncture did not help (I was not surprised, but my doctor was very disappointed). After a lot of study in that sector, I will turn on my heels and find a new physician if one offers woo (of whatever taste).

  11. #11 dlamming
    November 20, 2006

    As someone who’s been suffering a lot from back pain, I only have this to say: if it makes patients feel better, who cares if we know how it works? It would be better if we found that out and could put it in a bottle, but if we can’t yet, so be it.

  12. #12 Bronze Dog
    November 20, 2006

    The key problem is finding out IF it works. Quacks are seldom interested in that question: They typically assume the answer is “Yes” and move on to making Star Trekky sounding explanations for how.

  13. #13 Paul
    November 20, 2006

    The mention of Vioxx interests me. If a complementary treatment, for example a herbal medicine, was responsible for a similar increase in heart attacks as observed for Vioxx, would we ever find out about it?

  14. #14 Orac
    November 20, 2006

    Guys, I’d ask that you stop it with the “quack” stuff with regard to Solo Practitioner. I don’t think it’s warranted in this case.

    To Solo Practitioner: I have to say that, although I disagreed with much of what you said, I was not at all hostile to what you were saying–until the end, that is. Then you lost me when you said, “If I stopped at the end of the EBM line, I may not have anything to offer my patients. How about hope? Don’t cancer patients do better if they believe they will be cured?”

    Frankly, as a cancer surgeon, I’m appalled at that statement for a couple of reasons. No, it’s not because I’m some hard-hearted automaton who doesn’t care when patients have incurable cancer. One reason quackery is so harmful is because it offers false hope to these people and in too many cases lures them away from effective palliation in the impossible quest for a cure that doesn’t exist. The quack clinics in Tijuana exist because they promise to cure cancers that conventional medicine cannot cure, leading Americans to head south of the border. When it’s someone like Steve McQueen, who was quite wealthy, it may not seem like such a big deal, but average working people go down there too. Some of them exhaust their savings between travel and paying the clinics. One clinic in Germany even charges $250,000 up front!

    Patients pursuing quackery don’t just die anyway; all too often they die after having exhausted their resources on quackery in a futile search for a cure.

    Giving false hope in these cases is also pernicious because quackery can make a patient’s last days miserable. For existence, look at the Gonzalez treatment for pancreatic cancer. It’s claimed to prolong survival (upon very dubious evidence), but it involves coffee enemas and taking up to 150 pills/supplements a day, among other things. Since patients with unresectable pancreatic cancer usually don’t survive much longer than a few months at best, it’s not a good thing to make what little time they have left miserable. Even if quackery doesn’t harm the patient or make his last days more miserable, it robs them of the most precious thing they have: Time. Dr. Jarvis put it well in an article:

    By offering false hope, quackery steals the most precious thing terminal cancer patients have — the best use of what little time that they have left. The notion that terminal patients have nothing to lose by turning to quackery is dead wrong. Most people faced with a life-threatening disease can make a reasonable psychological adjustment. Those who face reality experience five classical stages: denial, anger, bargaining, depression and acceptance. Those who accept their fate are in the best position to use their remaining time wisely.

    In the ABC-TV special “Who Will Love My Children” Ann Margret played an impoverished Iowa mother with cancer who spent her last few months finding homes for her ten children. I know of two similar cases. Quacks discourage people from making the difficult adjustment by reinforcing their denial. Such people usually die unprepared because preparation for death is an admission of failure.

    Hope is good, but false hope is most definitely not.

  15. #15 Orac
    November 20, 2006

    The mention of Vioxx interests me. If a complementary treatment, for example a herbal medicine, was responsible for a similar increase in heart attacks as observed for Vioxx, would we ever find out about it?

    No. We almost certainly would not.

    It wouldn’t matter anyway. Alternative medicine treatments rarely yield to evidence when shown to be ineffective. Evidence against homeopathy has not slowed its popularity. There are people out there who still advocate laetrile for cancer, even though multiple well-designed studies 20 years ago showed that it is ineffective. If an “alt-med” Vioxx were shown to increase the rate of heart attacks as much as the real Vioxx, you can bet that alties would blithely keep using it, all the while dismissing the study as being yet another manifestation of a conspiracy to suppress alt-med.

  16. #16 Clark Bartram
    November 20, 2006

    ORAC,

    What does qualify one as a quack? Based on the very limited information we have been provided, we are dealing with an MD who likes to think that EBM/rational thought only applies until he or she decides it doesn’t apply anymore because it makes the patients happy and keeps them coming back in. What might the next incursion of magical thinking into their daily practice be? What would it have to be in your eyes?

  17. #17 Solo Practitioner
    November 20, 2006

    You misunderstood my comment about hope. again maybe you’re blinded by the quackery veil with which you want to dismiss everything I say.

    If chemotherapy for say a given cancer is 40% successful in achieving 1-year survival. Then, what do you focus on to tell your patients? You have a 60% chance of dying in 1 year? Or you have a 40% chance of beating your cancer at 1 year? Hope is not necessarily based on false pretenses as you so want to dismiss, it’s based on focusing on the half-full part of the half-empty glass. It’s about having a positive mental attitude towards the stated outcome, because even if the cancer survival rate at 5-years is 25%, if the person makes it to that point cancer-free, then it’s 100% for them.

  18. #18 Solo Practitioner
    November 20, 2006

    Clark Bartram wrote above:
    “an MD who likes to think that EBM/rational thought only applies until he or she decides it doesn’t apply anymore because it makes the patients happy and keeps them coming back in.”

    Wrong assumption. You totally missed the boat on that one.

  19. #19 Andrew Dodds
    November 20, 2006

    SP -

    I’m not sure what your point is. What Orac was mentioning (and in another case in my local area) is the fact that ‘alternative’ practicioners will happile drain a cancer patient of their life savings with false promises of a cure, without giving then the reality of their position. That is not ‘maintaining a positive attitude’, it’s fleecing the dying and about as unethical as can be.

  20. #20 Mary
    November 20, 2006

    Here’s one tiny data point. I had a bad flare-up of plantar fasciitis last year and went to physiotherapy for several weeks. My therapist applied ultrasound and massaged my foot, but she also offered me the option of acupuncture. I was curious and enthusiastic, especially as she said others had found it really reduced the pain.

    Well, the procedure was mostly painless, apart from a couple of occasions where the needle hit something that fought back. But it didn’t relieve pain at all. If I sat on the table for 20 minutes getting needled, my foot was still very sore and tight, and it wouldn’t bear my weight properly when I got down from the table. But if my therapist massaged my foot, I felt immediate relief and could walk freely afterwards.

    The point is that acupuncture didn’t seem to work in any way for me, even though I felt very positive about trying it out. I’m highly suggestible and easily hypnotized, and I would think there would have been a very good chance for the placebo effect to kick in.

    (BTW, my therapist put me through a second round of acupuncture-free treatment that included vigourous massage of the sore areas with the hard rubber head of a reflex hammer. This dropped the pain to about 10% of what it had been. Getting my fibroids removed surgically a month ago took care of the remaining pain and swelling. Ten days of Naproxen after surgery did the trick.)

  21. #21 HCN
    November 20, 2006

    Bummer… All I got for my plantar fasciitis were directions to a shoe store for good inserts (something like “Mr. Goodfeet”?). My teenage son got the same “prescription” when he complained about knees during soccer season.

  22. #22 anonimouse
    November 20, 2006

    How about hope? Don’t cancer patients do better if they believe they will be cured?

    No, if it suggested they try quackery that has no chance of curing them in lieu of treatments that might. And as Orac said, it is often better to accept the reality of a situation and use palliative treatments when faced with incurable diseases – I would much rather live twelve relatively pain-free months than six months trying every disgusting treatment under the sun.

  23. #23 figmo
    November 20, 2006

    “It doesn’t matter to me that the philosophical construct for acupuncture doesn’t jive with you or the patient.”

    The word should be jibe whice means ‘to agree’. Jive derives from slang which originally meant to treat in a jazzy manner (“Jivin’ the Blues Away”) but also came to be associated with deception (“Don’t give me any of that jive”).

  24. #24 Troublesome Frog
    November 20, 2006

    I would argue that there is more to a treatment than the simple criteria of, “Does the patient want it?” and “Is it not dangerous?” I work in engineering, so I don’t deal with the specific problems that physicians have to deal with every day, but we are both in the business of being “experts” and finding solutions for non-experts in our fields. For me, taking money for a harmless but ineffective solution would be a breach of ethics if I did not make it abundantly clear that the solution was, in my opinion as a professional, without basis.

    If a client really wants me to attack a problem in some harmless but incorrect (usually wasteful) way, I feel it is my duty to inform the client that there is no benefit to that solution. If the client understands that I don’t endorse the solution but wants it anyway (and it won’t cause the design to fail), I’ll go with it with a clean conscience. Endorsing the solution without that caveat, though, adds my professional support to it, and I simply couldn’t accept that. It’s walking too close to the line of knowingly defrauding clients by selling them extra frills for extra cash.

    To me, it’s like a computer salesman selling a little old lady a $6000 workstation with a high end graphics card because she thinks it will help her email her grandchildren. Sure, it won’t hurt, but I’m taking a lot of extra money for something that won’t necessarily help her reach her goals, and if I don’t speak up about it, I’ll be profiting by lending an air of credibility to bad ideas.

    True, solutions aren’t as clear in the medical world as they are in designing circuit boards and bridges, but I think that we both have to be very careful about what ideas we put into the heads of people who rely on us–often quite blindly–for unbiased expertise in their best interests.

  25. #25 Renee
    November 20, 2006

    Reading through all the above comments, it seems that there are simultaneously two different subjects being discussed – a)acupuncture for pain due to chronic, non-life threatening conditions; b) alternative medicine for cancer treatment. I don’t see the value in a discussion that conflates ‘a’ with ‘b’.

    For a, if a person has exhausted all conventional treatments, trying acupuncture might be an option, as long as it is something that they choose to do in an informed manner. From what I know, it’s apparent after 8-10 treatments if accupuncture is going to work for a person or not. I do think it is wrong if a person is told that they have to go for 50 treatments or they have to buy expensive nutritional supplements, or told that acupuncture will be 100% effective for their problem.

    I know two people, one with neck pain, the other with back pain, who felt that acupuncture worked to significantly decrease their pain. I also know people for whom acupuncture didn’t work.

    I’m not going to comment on alternative medicine and cancer; there’s been enough said about it above.

  26. #26 Solo Practitioner
    November 20, 2006

    Orac wrote:

    “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.”

    Are you saying that massage is accepted as a treatment modality because it is part of “conventional” medicine? So is massage therapy excempt from an EBM evaluation? Isn’t massage claiming to do something if it is being used as a therapeutic modality? What if massage therapy only helps acute pain but not chronic pain? Does it work equally well for a lateral epicondylitis as it does for a sprained lower back? How effective is it? 45%? 55%? Wouldn’t knowing this benefit care from a medical as well as financial perspective? Also, how about what type of massage? Is all massage the same? Are they just as effective: shiatsu v. swedish v. deep-tissue v. fascia-release v. trigger point therpay v. rolfing? Is it really proven to work for the problems it is used to treat? What is it about massage that made you exempt it from an evidence-based evaluation? Any medical treatment is making a claim to do something.

  27. #27 Solo Practitioner
    November 20, 2006

    Andrew Dodds wrote:

    “I’m not sure what your point is. What Orac was mentioning (and in another case in my local area) is the fact that ‘alternative’ practicioners will happile drain a cancer patient of their life savings with false promises of a cure, without giving then the reality of their position. That is not ‘maintaining a positive attitude’, it’s fleecing the dying and about as unethical as can be.”

    And that practitioner should not be practicing medicine. That to me is a violation of ethics in medical care. Certainly, not what I was proposing in my statement. But, you’re right, you missed the point.

  28. #28 trrll
    November 20, 2006

    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.”

    I think that it is important to separate the question of efficacy from the theory upon which the therapy is based. As a pharmacologist, I know that there are many drugs that we’ve used successfully for decades with no understanding–or even an incorrect understanding–of how they work.

    I am particularly hesitant to dismiss qi based therapies simply because they are based upon a nonsensical pneumatic theory of physiology (qi meaning, in a literal interpretation, “breath”). After all, phenomena tend to be explained in terms of the prevailing paradigm whether they are real or imaginary.

    In the martial arts Tai Chi Chuan and Aikido (both of which regard ki/qi/chi as fundamental), there is a technique known as the “unbendable arm.” The way this is normally taught is by a ki-visualization exercise. The subject is instructed to envision a flow of ki through the arm, and this is then tested by attempting to forcibly bend the student’s arm. In the “control,” the subject is simply told to resist the attempt to bend his arm. The result is that in the control case, it is much, much easier to overpower the subject and bend his arm, whereas in the “ki” case, it is virtually impossible to overpower the subject unless the tester is much stronger than the subject. The subject reports that in the “ki” case, it felt almost effortless, while in the “control” case he was working very hard to keep his arm straight. Woo, the mystical power of ki!

    But it gets a bit more comprehensible if you actually feel the subject’s muscles during the test. In the control case, the triceps is hard–but so is the biceps. The subject is actually helping to bend his own arm, even though he believes that he is resisting with all of his might! Moreover, both muscles are hard even before the tester starts trying to bend the arm. In the ki case, biceps and triceps are initially flaccid, and as the tester starts trying to force the arm, the triceps tenses gradually, just enough to maintain the arm straight against the force, while the biceps remains completely flaccid. No wonder the subject seems so much stronger–he’s no longer helping the tester to bend his arm. And no wonder that it feels so much easier for the subject–he’s not expending most of his energy fighting his own muscles.

    So in the end, it has nothing to do with with any mystical energy or breath permeating the body–all the ki visualization exercise really does is give the conscious mind something to do so that it doesn’t try to override the unconscious mind, which is a lot smarter about knowing how to use the muscles. But nevertheless, it is a real, easily demonstrable phenomenon, and while it doesn’t actually require ki visualization (once you learn what it “feels like,” you can do it any time without the visualization), that is still the easiest way to learn it.

    All I’m trying to say is that we should judge these things based upon scientific evaluation of efficacy of the therapies themselves, and not allow ourselves to be distracted by our skepticism regarding the theory.

  29. #29 Orac
    November 20, 2006

    You misunderstood my comment about hope. again maybe you’re blinded by the quackery veil with which you want to dismiss everything I say.

    Incorrect, Solo Practitioner. I addressed what you wrote. You mentioned the whole probabilities thing at the beginning of your comment, went on to other topics for an extended length, then introduced the whole “hope” angle at the end out of the blue with no clear linkage between the two concepts. You’ll forgive me if I failed to see the link you were evidently trying to make between the whole probabilities discussion and your discussion of hope. There was a hell of a lot of verbiage in between. And I was clearly not alone in failing to see the link that you apparently were trying to make.

    Perhaps instead of whining about my supposedly not understanding your point, you should work at making your point (whatever it was) clearer. (I realize that I tend to be more verbose than necessary, but at least my point is usually pretty clear.)

    As for the general comment made by trrll about not being too concerned about the mechanism of action of acupuncture if it works because we have medicines that work whose mechanism we don’t really understand, I would simply say that you’d have a good point if acupuncture clearly did work. The evidence whether it does or does not work, however, is far from clear-cut. Also, we do not attribute mystical or religious explanations for the activity of drugs whose mechanism of action we do not understand. We assume that there is a plausible, entirely biological and physiological mechanism that we just haven’t unraveled yet. Not so with acupuncture, where mysticism is still the order of the day. When I see alternative medicine practitioners stripping acupuncture of the whole qi thing, even if it is to say that it works (whether I agree that it does or not) but that we don’t yet know how, I would have a lot less trouble with acupuncture.

  30. #30 Paul
    November 21, 2006

    Troublesome frog, I don’t think that you can assume that CAM is harmless. There have been cases where CAM has proved dangerous, for example inappropriate use of chelation therapy to “treat” autism and the interactions of some herbal medicines with some anti-cancer drugs. But this is not the only problem.

    If you look at some recent EBM failures, Troglitazone and Vioxx are good examples, the adverse effects only became apparent in post marketing studies after the drug had been used by hundreds of thousands on individuals, because the effects were rare in the case of Troglitazone and subtle (an increase in the frequency of heart attacks in a patient group already prone to them) in the case of Vioxx.

    Such rare or subtle effects are often only detected in phase III clinical trials or by post marketing surveillance, smaller clinical trials and animal testing involving tens or hundreds of individuals, may lack the statistical power to pick them up (though they certainly do pick up other serious problems).

    Some CAM techniques, such as Reiki, are very unlikely to have such adverse effects, but others such as herbal remedies, may be associated with ADRs (if they do have a biological effect). The trouble is that without large clinical trials or post marketing surveillance it’s highly unlikely that these ADRs will ever be identified.

    This by the way is also why the use of evidence based medicines “off label” differs from CAM, while there may not be strong stastically sound evidence for efficacy for “off label” use there will (or perhaps should) almost always be good safety data available, and often efficacy data for the drugs use in related disorders.

  31. #31 SP
    November 21, 2006

    Oh, there is a whole lot of anger I see out there. Isn’t that usually how fanatics express themselves? Don’t take offense guys, I just feel the need to defend myself.

    Just one last thing before I leave this witch hunt. Let’s talk about false hope. Apparently “conventional” medicine is immune from providing this to its patients; however, a study a few years ago found that less than 50% of terminally ill patients with cancer at one of the nation’s leading cancer centers, Memorial Sloan-Kettering Cancer Center, were approached with discussions about end-of-life issues, such as a DNR (Do Not Resuscitate) order and a Living Will. Furthermore, most of the therapies used for terminal cancer patients at MSKCC are not EBM, because there hasn’t been enough time to study the efficacy of these therapies, or perhaps because these “conventional” doctors have decided that there is little “harm” that can be done with potentially toxic chemotherapy if the person is going to die anyway (as long as the patient consents to a potentially toxic, life-threatening treatment. But what would make a patient consent to such an unproven treatment? Could it be that it provides some hope of a cure?). It seems these doctors believe that they can try experimental, unproven therapies because these patients come to them from other referral centers where their cancers were determined untreatable. These patients are coming for another answer and for HOPE. So are these doctors at MSKCC “quacks” for slipping outside the confines of EBM to try to help the terminally ill? According to Orac, it sounds like no other medicine should be practiced other than EBM.
    “Sorry, you’ve got Stage IV Ovarian CA, go home, get your affairs in order and die, because there are no evidence-based treatments that work,” is perhaps what they should tell their patients. That way we’re all living in realityland. How is it ok for “conventional” medicine to expose these patients to harmful, toxic treatments that are unproven? It doesn’t stand up according to Orac’s arguments.

  32. #32 Jess
    November 21, 2006

    (as long as the patient consents to a potentially toxic, life-threatening treatment. But what would make a patient consent to such an unproven treatment? Could it be that it provides some hope of a cure?).

    Perhaps. Or the hope of a cure for someone else down the road? Dying knowing you might have helped someone? I’m not saying hope for a cure isn’t in the mix, but I don’t think it would be the only reason.

    I would argue it was a matter of informed consent, but I’m not a medic so I’m not sure I have grounds to argue it.

  33. #33 trrll
    November 21, 2006

    Some CAM techniques, such as Reiki, are very unlikely to have such adverse effects

    I think that it is a safe assumption that anything that has a genuine biological effect carries some risk of adverse effects (although I agree that it is unlikely that Reiki will produce adverse effects). All the limitations related to statistical power of a study apply here as well.

    It’s worth noting that the Chinese martial arts tradition includes a malign version of acupressure that is intended to cause harm. The “rationale” for this makes as little sense as that for acupuncture, although based upon what I’ve seen of supposedly chi-based techniques in the martial arts (which sometimes seem to work in spite of the explanation being complete nonsense), I certainly wouldn’t volunteer as a test subject to prove these techniques harmless.

  34. #34 SP
    November 21, 2006

    trrll, thank you for injecting some balanced sense into this commentary. The extremes on both sides of the equation are dangerous.

  35. #35 anonimouse
    November 22, 2006

    SP,

    The only person on this thread who is taking things to an unhealthy extreme is you.

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