Respectful Insolence

I’ve complained on multiple occasions about the infiltration of non-evidence-based “medicine” (a.k.a. woo) into every level of medicine in the U.S.. Worst of all, it’s infiltrating medical education in a big way, starting with the pro-woo activism of the American Medical Student Association (AMSA), to various educational programs in various medical schools, to even the mandatory medical curriculum in at least one prestigious medical school. This is more than just teaching what various “alternative medical” therapies are, so that new physicians know what their patients are referring to or about various potential interactions between herbs and pharmaceutical medications, something that I wouldn’t have any objections to. However, it goes far beyond that, to encompass uncritical teaching of woo as though it had a scientific basis.

Of course, it doesn’t help that there’s now a $120+ million/year bureaucracy ensconced in the very heart of the bastion of scientific medicine, the NIH. This is, of course the National Center for Alternative and Complementary Medicine, whose support for the study of utter woo I have bemoaned. After hundreds of millions of dollars over a decade and a half of its existence, NCCAM has been utterly unable to demonstrate the efficacy or lack of efficacy of a single “alternative” therapy. Despite that, I had always thought that there remained one beacon of scientific medicine, one place where woo did not hold sway, and that place is the NIH Clinical Center, the hospital on the NIH campus where many cutting edge experimental therapies are first tried in patients.

Dr. R. W. has shown me that I was wrong. Woo has now widely infiltrated the NIH Clinical Center:

The National Center for Complementary and Alternative Medicine (NCCAM) has established an Integrative Medicine Consult Service at the National Institutes of Health (NIH) Clinical Center, the world’s largest hospital devoted to research. This service will provide physicians, nurses, and other members of the Clinical Center health care team the ability to discuss complementary and alternative medicine (CAM) therapies with knowledgeable medical staff from the consult service and learn how various CAM practices might complement or interact with a patient’s care as a research participant at the Clinical Center.

Lovely. After the usual boilerplate about how supposedly more than one-third of American adults use some form of CAM, the press release tries to justify this decision:

Since patients at the Clinical Center are participating in research studies, it is important to know what CAM therapies are being used and how they might affect the treatments being studied.

“Volunteers who participate in clinical research at the NIH Clinical Center are partners in medical discovery. We are committed to providing excellent care for them,” said John I. Gallin, M.D., Director of the Clinical Center. “This new consult service will help enhance the care they receive and the research conducted here.”

While I agree that it is absolutely essential to know what CAM treatments are being used by patients participating in clinical trials, I don’t see how it follows from that that providing woo to them at the clinical center as a consult service will improve their care. I suppose if all such a service did was to advise researchers and physicians on CAM treatments that patients may already be taking, it might be reasonable, but no consult service could ever limit itself to that. The very purpose of a consult service is to recommend treatments to the primary physicians. Worse, this new service is not a new phenomenon. Apparently woo has been entrenched in parts of the Clinical Center for a while now:

CAM is not a new concept at the NIH Clinical Center. The Clinical Center’s Pain and Palliative Care Service and the Rehabilitation Medicine Department offer acupuncture, Reiki, hypnosis, guided imagery, massage therapy, acupuncture, tai chi, and qi gong training. The Pharmacy Department consults on herbals and herb/drug interactions and has conducted research in these areas. The Integrative Medicine Consult Service will coordinate the resources of these existing services to meet the needs of the Clinical Center staff and its patients. In addition to offering clinical consultation regarding CAM therapies, the service will establish a research program embedded in NIH”s clinical and translational research structure and provide CAM education for NIH staff, patients, and their families.

Reiki? Qi gong? I had no idea that life energy woo is being offered to patients as if it had a basis in science in the hospital that is at the very heart of scientific medicine in the U.S. Truly, evidence-based medicine is doomed. Consider the background of the new director of this consult service:

The director of the consult service will be Patrick J. Mansky, M.D., a clinical oncologist and researcher at NCCAM. Dr. Mansky received his medical degree from Witten/Herdecke University Medical School in Germany, where he also gained experience and received instruction in Anthroposophical Medicine including herbal therapies, art therapies, and physical applications. After a postdoctoral research fellowship in immunogenetics at Memorial Sloan-Kettering Cancer Center, New York, NY, he completed clinical residency training in pediatrics and internal medicine at Case Western Reserve University in Cleveland, OH. Dr. Mansky joined NIH in 1997 as a clinical and research fellow in pediatric hematology/oncology and medical oncology at the National Cancer Institute.

Anthroposophical medicine? Rudolf Steiner‘s woo? You know, the guy whose philosophy was responsible for the concepts behind biodynamic farming, where various parts of dead animals are buried on the farm to “strengthen its life force”? Sure, Dr. Mansky apparently has experience in “conventional” medicine, but if he accepts Anthroposophical medicine as anything other than spiritual woo I have serious doubts about his critical thinking skills. After all, Steiner’s medicine postulates the causes of illness are not primarily physical but spiritual; that good health is achieved when the physical organism is properly ‘aligned’ with three nonphysical bodies that manifest during a human’s lifetime, the ‘etheric body,’ the ‘astral body,’ and the “I,” a spark of divine selfhood or ego that separates true humans from animals and subhumans. Bad health, on the other hand, comes from this;

Bad health, on the other hand, often reflects the working out of one’s “karmic destiny.” If one enters this world carrying spiritual impurities resulting from sins and errors committed in previous lives, disease can serve as a rite of passage, purging evils from one’s bodily/spiritual system. Thus, medical intervention is often a bad idea: A doctor who cures a patient with drugs, etc., may be blocking the patient’s karmic self-healing process.

How is this different from religion?

Moreover, Anthroposophical medicine has a distinctly antivaccination cast to it. Perhaps I’m being unfair to Dr. Mansky, and perhaps his later training at, among other places, the institution at which I did my general surgery residency, purged the woo that is Anthroposophy. Perhaps. Or perhaps it doesn’t even really matter who’s in charge of this new consult service at the NIH Clinical Center. Given the mentality of CAM advocates, no matter who’s in charge this new initiative will be, as Dr. R. W. put it, “taking woo to a whole new level.”

In retrospect, I suppose that this further infiltration of woo into the NIH was inevitable once NCCAM had been established. After all, NCCAM is a full Center in the NIH. Given that, in the eyes of the NIH bureaucracy there is no logical reason that NCCAM shouldn’t be allowed into the NIH Clinical Center and no reason there shouldn’t be a CAM Consult Service there. Moreover, it doesn’t matter that the real purpose of NCCAM is, more than anything else, to promote the use of CAM by giving it a veneer of scientific respectability. Remember, the NIH did not take the initiative in forming NCCAM. Rather, it was woo-loving legislators such as Senator Tom Harkin (D-Iowa) who foisted NCCAM upon the NIH and resist all attempts to cut its funding. I used to be of the opinion that NCCAM served a useful purpose, but no more. In recent years, it has become abundantly clear to me that it wastes money studying therapies with no scientific plausibility or basis in science such as Reiki or homeopathy as though they worked.

How long can evidence-based medicine endure in the face of this relentless assault? I used to think that EBM was the wave of the future. Now I fear that woo is the future of American medicine.

Comments

  1. #1 Miguelito
    May 22, 2007

    My wife was watching Oprah and it was an episode with Dr. Mehmet Oz. He was talking about accupressure (I’d also seen an episode where he endorsed some form of woo massage).

    Anyhow, he was talking about “energy” and how we’re composed of atoms that all have “energy”. He explained that it’s not that ridiculous to extend the concept and that we have “energy” lines or paths in our body.

    I couldn’t believe what I was hearing. It ran against everything I knew about, well, the physical world.

    My wife was defending him, “But he’s a cardiac surgeon! He has to be smart!”

    My response, “There are lots of surgeons who are creationists. He may be smart, but it doesn’t mean that he isn’t deluded. Where is the clinical evidence?”

  2. #2 SLC
    May 22, 2007

    Re Miguelito

    Le’s remember that noted heart surgeon Dr. William Frist, former senator from Tennessee endorsed the teaching of intelligent design in public school science classes and contradicted the findings of board certified neurologists in the Terri Schiavo case (based on edited video tapes).

  3. #3 AnnR
    May 22, 2007

    People who suffer from lymph edema go to massage therapy.

    People with node removal are often saved from a cancer death, but that doesn’t mean they should live with swollen, stiff, possibly infected limbs afterwards.

    Let’s not be so quick to throw everything out here. You are lumping treatments for “spiritual imbalances” in with things that are on the edge or substitutes for physical therapy.

  4. #4 MarkH
    May 22, 2007

    Because my mind is shaped by 17 years of Simpsons episodes, all I can think of is when Grandpa is in the hospital for some made-up malady and someone shouts, “Quick, this man needs a quack!”

    Then doctor Nick shows up…

  5. #5 Orac
    May 22, 2007

    Let’s not be so quick to throw everything out here. You are lumping treatments for “spiritual imbalances” in with things that are on the edge or substitutes for physical therapy.

    What am I throwing out? I’m primarily throwing out energy woo (notice I singled out Reiki and qi qong). Also, although I’m unaware of good evidence that massage is useful for lymphedema, I could just be unaware of it. The usual treatment for lymphedema is physical therapy, custom-made compression stockings, and sometimes machines that “milk” the lymphedema out of the limb, whose action, I suppose, could be mimicked by massage.

    Point two: I never denigrated massage therapy. I’ve only come down on it when it’s associated with energy woo (which, alas, it all too frequently is), as in therapeutic touch, for example.

  6. #6 sailor
    May 22, 2007

    We do have a problem. On the one had some of these therapies may be quite effective in reducing anxiety and thus promoting healing. In particular, any therapy (such as guided imaging and I suspect in this case hypnosis depending on how it is done) and I would include meditation and relaxation, that gives the patient a feeling he can do something to help his problem, is likely to be beneficial in terms of reducing his anxiety and so speeding up his healing.

    These should be cheap and simple and maybe available along with nursing care. But they should be sold as what they are – not some kind of mystery medical care. Nothing that promotes ficticious lines of energy, or alignment of the planets has any place in modern medecine.

  7. #7 Sid Schwab
    May 22, 2007

    It’s hard not to feel doomed. It seems at some level recognition of the fact that we’ve (us humans) so polluted the world (literally and figuratively) that it’s beyond repair and the reality of it is too much to take. So woo is everywhere on the rise. It’s like throwing in the towel.

  8. #8 Francis
    May 22, 2007

    Anyhow, he was talking about “energy” and how we’re composed of atoms that all have “energy”. He explained that it’s not that ridiculous to extend the concept and that we have “energy” lines or paths in our body.

    I couldn’t believe what I was hearing. It ran against everything I knew about, well, the physical world.

    The problem with statements like that is that chi works. I’m serious. If I stand with my arm outstretched and visualise my chi as a column of water heading towards the far wall, my arm becomes almost unbendable. Until I turn it off or it gets disrupted – when my arm is as easy for a strong person to bend as you would expect.

    Now I know perfectly well that what’s actually happening is relaxation of my arm – but when visualising the chi actually helps and has a measurable physical effect, it’s very easy to see why people fall for it.

  9. #9 Dr. Nick Riviera
    May 22, 2007

    See this smudge that looks like a fingerprint? No – that’s trauma!

  10. #10 outre
    May 22, 2007

    Of course, it doesn’t help that there’s now a $120+ million/year bureaucracy ensconced in the very heart of the bastion of scientific medicine, the NIH.

    That’s upsetting, $120+ million? …and here I sit watching the funding for NF research go from $25 million in 2005 down to $10 million for 2007. I know for a fact that there’s a PI in the peds oncology branch at NIH who’s been trying to get an approval for a NF drug trial using a targeted drug used for other cancer/tumor indications. I’m pretty sure she’s been trying for over an year…

  11. #11 Terrence
    May 22, 2007

    As a friend of mine once responded to a wooster: “Did this cure your cancer before or after the chemo?”

    At least if woo starts getting administered as primary care, the problem should be eminently self-correcting.

  12. #12 Koray
    May 22, 2007

    There should be a society of physicists who are tasked to smack doctors who talk about atoms and energies in such manner.

  13. #13 Nat
    May 22, 2007

    Sailor Said

    “We do have a problem. On the one had some of these therapies may be quite effective in reducing anxiety and thus promoting healing. In particular, any therapy (such as guided imaging and I suspect in this case hypnosis depending on how it is done) and I would include meditation and relaxation, that gives the patient a feeling he can do something to help his problem, is likely to be beneficial in terms of reducing his anxiety and so speeding up his healing.”

    OK then so instead of calling this therapy and essentially lying to our patients why don’t we just be nice to them. Being nice to people works. It reduces their anxiety about being in a medical setting. I wouldn’t call it therapy and sell it per consultation though. I just call it good manners.

  14. #14 Science Avenger
    May 22, 2007

    In my days as a massage therapist, I was amazed at the woo. “Energy” was an especially prevalent term, even though no one could ever really tell you what it was. Asking a woo-wizard to specifically define “energy” is the fastest way to paralize them.

    And apologies to everyone I’m about to offend, but I met a lot of woo-woos and I never met one that wasn’t a little…off…in other ways. The most common attribute in my experience is a steadfast, unshakable, frankly irrational certainty in their perceptions and interpretations of their experiences. Don’t bore them with talk of placebos. They can FEEL its real. They can TELL. They KNOW what they saw/felt/experienced, and no amount of contrary double-blind data can cause them to believe otherwise.

    The thing is that they do seem to get real effects from some of the treatments, when those effects are completely subjective of course. I wouldn’t be surprised if someday in the future, there was a psychological disorder identified that causes people to misinterpret their body’s “health signals”, for want of a better term, and which was reversed by alternative therapies for reasons unrelated to their stated “efficacy”. In a real sense, it’s all voodoo – it only works if you believe.

  15. #15 AnnR
    May 22, 2007

    No, manual lymph drainage – which is a specialized type of massage is used for lymph edema.

    I see the NCCAM has a trial comparing massage alone to massage/bandaging.

    No doubt this is the result of a small group of people with this malady lobbying like crazy so they can get some proof about what the most successful treatment is. Those bandages get pretty hot.

  16. #16 Dr. T
    May 22, 2007

    Many healthcare professionals now believe in the efficacy of nonsense “therapies,” a bleak situation that I attribute to declining standards of science education in grades 6-12 and in college. I was astonished and disappointed when I learned that many of my medical school classmates (class of 1983) failed to use (or even understand) the scientific method. They had taken science survey courses in huge classrooms (>250 students), spent minimal time in college science labs, and memorized their way through multiple choice exams.

    But nurses are worse. Every nursing school I know of walls its students into the College of Nursing where every subject is taught by nurses: no anatomists, biochemists, physiologists, pathologists, pharmacologists, etc. can enter the sacred nursing classrooms. Thus, I was unsurprised to read of a survey showing that >30% of nurses believed in therapeutic touch.

    We will never get rid of the plague of nonsense therapies until we require healthcare professionals to understand and use the scientific method, logical analyses, and sound medical decision-making.

  17. #17 Dr. T
    May 22, 2007

    Many healthcare professionals now believe in the efficacy of nonsense “therapies,” a bleak situation that I attribute to declining standards of science education in grades 6-12 and in college. I was astonished and disappointed when I learned that many of my medical school classmates (class of 1983) failed to use (or even understand) the scientific method. They had taken science survey courses in huge classrooms (>250 students), spent minimal time in college science labs, and memorized their way through multiple choice exams.

    But nurses are worse. Every nursing school I know of walls its students into the College of Nursing where every subject is taught by nurses: no anatomists, biochemists, physiologists, pathologists, pharmacologists, etc. can enter the sacred nursing classrooms. Thus, I was unsurprised to read of a survey showing that >30% of nurses believed in therapeutic touch.

    We will never get rid of the plague of nonsense therapies until we require healthcare professionals to understand and use the scientific method, logical analyses, and sound medical decision-making.

  18. #18 Science Avenger
    May 23, 2007

    It’s a shame Dr. T’s nurses don’t know that therapeutic touch was debunked years ago by a 4th grader.

  19. #19 Jo
    May 23, 2007

    Take it from someone who is finishing her last semester of nursing school for a BSN, energy fields are alive and well and being taught by many nursing school faculty. The majority of my textbooks have sections regarding this completely bogus therapy. It is sooo hard to sit in class and not laugh in the face of professors that appear to take this crap seriously. In addition, my current clinical instructor has told us that her energy field is so strong that she shorted out 3 different PDA’s and the man at the store refused to replace the device again, giving her a full refund and referring her to a different electronics store. On a positive note, within my program there is a strong adherence to evidence-based practice and learning to interpret research findings in a critical and scholarly manner. Unfortunately, Ms. Energy Field, as I like to call her, flat out admitted to us “I think research is a waste of time and when something works I just know it.” What a role model!! It’s going to be a long semester.

  20. #20 Ky Sanderson
    May 23, 2007

    The problem, of course, is that the average patient (consumer) has lost faith in conventional medical care.

    According to Lazarou, about 106,000 Americans die each year from prescription drugs.

    According to Starfield, one can reasonably add about 119,000 deaths/year from hospital errors and infections.

    That’s 225,000 iatrogenic deaths/year in America.

    These 2 papers are peer-reviewed in JAMA — so they can’t be dismissed out of hand.

    This massive death caused by doctors and hospitals has, in my view, either given rise to or fortified the pre-existing notions of those disposed to “woo.”

    Woo may be quackery, but it doesn’t typically kill you (at least not to the tune of 225,000 deaths/year).

    Until these figures go down, I think “woo” will continue to emerge.

  21. #21 steppen wolf
    May 23, 2007

    What is reported here is scary to say the least. I am not surprised then that there can be people like Dr. Egnor buying into things such as intelligent design – scientific/critical thinking does not seem to be much part of the curriculum in medical schools after all.

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