Respectful Insolence

Yesterday, inspired by a post by fellow ScienceBlogger Martin, I had a little fun discussing the evolution of “alternative” medicine (a.k.a. “complementary and alternative medicine” or CAM), specifically speculating about the possible selective pressures, positive and negative, that have influenced the course that its evolution took. Essentially, the discussion centered around whether, by its very nature CAM undergoes negative selective pressure for having as little effect as possible, positive or negative, a point I found somewhat, but not entirely, convincing. Although the post inspired a bit of a troll invasion (well, one troll, anyway), the discussion in the comments was rather interesting. It also led me to believe that perhaps I hadn’t considered more recent developments in the history of CAM sufficiently in applying the principles of evolutionary biology.

As I pointed out before, the very terminology used to describe the hodge podge of non-evidence-based remedies has undergone considerable evolution to bring us to the politically correct term that seems to be used the most frequently, CAM. Originally, the term “alternative” medicine, under selective pressure to appear more mainstream, morphed into “complementary” medicine; i.e., medicine that was used alongside or in addition to conventional medicine. The problem, of course, is that many people do use these remedies largely instead of conventional medicine. Hence, the fusion of the two terms occurred, to “complementary and alternative medicine” (CAM). There’s a reason for this, and it has to do with the relationship between scientific medicine, as epitomized by academic medical centers, and CAM.

So what is that relationship? My first thought was that CAM was adopting an evolutionary strategy not unlike that of dogs or cats. In other words, it was subsuming itself to its more successful competitor, conventional medicine, in much the same way that ancient wolves were domesticated by humans and ultimately started to speciate into dogs. The problem with that analogy, of course, is that both human and dog gain benefits from their relationship. Humans gain companionship and work from dogs; dogs gain protection and a reliable source of food. It could be argued which species gains more, human or dog (probably humans early on and dogs now), but there is little doubt that both species benefit. So, in the relationship between CAM and conventional, who benefits?

The answer is obvious: CAM. Scientific medicine does not need CAM, but these days CAM appears to need scientific medicine. Indeed, the very name CAM was adopted to allow alternative medicine to seem more palatable to practitioners of conventional medicine and ease its ability to insinuate itself into academic medicine, which, as I’ve documented extensively, is having increasing success in doing so, even to the point of finding its way into the curriculum of various medical schools.

What this tells me is that we’re looking at a “speciation” event in alternative medicine. There is a strain of alternative medicine that fits in with the whole movement towards CAM in medical schools, and there is a strain of alternative medicine that does not. Now here’s where Martin’s idea of selective pressures favoring placeboes in alternative medicine comes in. The strain of alternative medicine that either excessively credulous or cynical academicians embrace falls under exactly the sort of selection pressure that Martin discussed that favors minimal effects. The reason is simple. The two most common justifications used for including CAM in academic medical centers are (1) the patients want it and (2) the perception among academic physicians that it won’t do any harm anyway and seems to make patients feel better. Consequently, the most common varieties of CAM in such settings are massage therapy, meditation, acupuncture, yoga, and nutrition-based therapies. Oddly enough, arguing against Martin’s idea is that seldom will you see homeopathy in academic medical centers, at least in the U.S. I speculate that that is because in such settings, there is also a negative selective pressure against extreme scientific implausibility–at least upon the initial incursion.

So what term best describes the relationship between CAM and academic medicine? Certainly CAM advocates would argue that it’s a symbiotic relationship. I would counter that it’s a parasitic relationship, and here’s why. Parasitism is defined as a relationship where one organism benefits and the other is harmed. CAM is indeed parasitic. It benefits from its association with academic scientific medicine by obtaining a level of plausibility and respectability that it could never obtain on its own, while it arguably harms academic medicine in the process. True evidence-based medicine is what academic medical centers are ostensibly built to promote, applying the scientific method to medical therapies in order to find more effective treatments. What academic medical centers should be doing is to educate the new generation of physicians in the scientific method, to better prepare them to be able to evaluate claims for treatment, whether they come from conventional medicine or elsewhere. This is how medicine has advanced so rapidly over the last 60 years. Blurring the line between science and non-science, evidence-based medicine and woo, through the enthusiastic promotion of CAM in medical school curricula, harms that endeavor, both by degrading the ability of physicians to think critically (thus preparing them to accept even more implausible treatments) and by wasting money and resources to study obviously highly implausible gobbledygook before there’s any good evidence that it does anything at all beyond the placebo effect that could be better used to study more promising science-based modalities. It would be one thing if CAM were being studied from a truly scientific perspective. I don’t object to that; indeed, I encourage it. A true scientific examination of the vast majority of CAM will likely find it useless, while a few gems might be pulled out of the dirt. Unfortunately, though, as I’ve mentioned before, that’s not what usually happens. What almost invariably happens is that CAM is used as a marketing tool.

As is often the case, Panda Bear, MD gets it right in describing this parasitic relationship:

Suppose I were to actually build a house. Along with a foundation it would require framing of the walls and floors, siding, wiring, glazing, plumbing and a dozen other skilled trades coordinating their efforts. The practioners of Complementary and Alternative Medicine would be like your Aunt Mildred telling you how to hang the toilet paper in the finished bathrooms and then trying to claim credit as an essential part in the construction. Complementary and alternative medicine only exists because real medicine does all of the heavy lifting leaving a risk-free enviroment in which it may ply its patent remedies. At best it’s an afterthought, something that legitimate hospitals add to their services to attract the kook money. At worst it’s a cynical ploy to fleece a little extra from the desperate, many of whom are dying and will gladly pay for another straw to grasp. In no way is it an essential part of medical therapy except that it provides entertainment to the patients and their families while medicine and nature run their courses.

Precisely.

Conventional medicine fights the real battles and faces the real danger of failure, while increasingly CAM attaches itself to conventional medicine, much as the parasitic roundworm Ascaris lumbricoide finds its way into the small intestine of its host. CAM benefits from its association, but its host, conventional medicine, most definitely does not. At best it is not harmed; at worst, grave harm to scientific medicine is possible.

All this speculation leads me to believe that the form of CAM that increasingly thrives in academic medical centers is indeed developing into a new “species” of woo, so to speak. It’s wraps itself in scientific-sounding terminology and, for the most part, discards the more outrageously silly religious and supernatural elements that it can, all in order to become seemingly inoffensive enough that academic physicians, although they may not approve of it, remain insufficiently sufficiently alarmed by it to rise up and purge the system of this parasite. Meanwhile, the parasite grows in number and strength, continually weakening the body of academic medicine the longer it stays. Eventually, like the roundworm, it spreads its eggs where more and more academic medical centers can pick it up until it is so entrenched and self-perpetuating that it can’t be dislodged without resulting in severe injury or death to the host.

MORE DISCUSSION OF THIS CONCEPT:

  1. Orac: Selective pressures and the evolution of alternative medicine
  2. Steve Novella: Alternative Medicine and the Evolution Analogy

Comments

  1. #1 Benjamin Franz
    November 13, 2007

    That sounds an awful lot like mimetic parasitism. That might be a more useful evolutionary model of what is happening.

  2. #2 The Crack Emcee
    November 13, 2007

    Sounds about right to me – so what’s the cure for parasites?

  3. #3 Infophile
    November 13, 2007

    Sounds about right to me – so what’s the cure for parasites?

    I’d think the answer would be obvious: Critical thinking skills and skepticism.

  4. #4 N.B.
    November 13, 2007

    So what’s the cure for parasites?

    critical thinking skills and skepticism

    No, it’s obviously ColonBlow!

  5. #5 Sastra
    November 13, 2007

    It’s interesting. Alternative medicine is starting to infiltrate scientific medicine by getting mainstream physician approval through courses in medical school; creationism is trying to infiltrate scientific biology by even making its way into college classes and universities.

    Has anyone seen any examples of vitalism being taught in physics curriculums? It looks like the next logical step.

  6. #6 N.B.
    November 13, 2007

    I believe I’ve heard that commonly referred to as the “wedge strategy.” I think it would be difficult to get vitalism into physics, though. ID is a good wedge because it already has supporters–notably Fundamentalist Christians–who want to see it suceed because it gets their foot in the door for more proselytizing against evil materialistic atheist scientists. CAM is a good wedge because even medical practitioners often remark that medicine is more of an art than a hard science, whether that particular fact is true or not; the seed that we “don’t need evidence or the scientific method” is hypothetically already there.

    Vitalism, by contrast, is unnecessary to the extreme in physics. ID can be pushed because “evolution has flaws.” CAM can be pushed because “medicine is an art.” What straw man can be set up to wedge vitalism into physics? Garbage about the second law of thermodynamics? The IDers already co-opted that schtick.

  7. #7 Michael Suttkus, II
    November 13, 2007

    FYI, although the word is almost invariably misused in public, “symbiotic” actually includes parasitism. A symbiotic relationship is any close living arrangement between two organisms. Parasites are certainly close to us!

    There are three classical forms of symbiosis: Mutualism, Commensalism, and Parasitism. Mutualism is a relationship where both organisms benefit (such as E. coli in your intestines helping you digest your food). Commensalism is a relationship where one organisms benefits, but the other gets nothing much (such as spanish moss growing on trees, the tree gets nothing, but the moss benefits greatly). Parasitism is, of course, where the benefit one organism gains is at the expense of another. The lines between these forms aren’t always clear (for instance, we now know that mistletoe offers some aid to it’s tree, but does far more damage).

  8. #8 The Crack Emcee
    November 13, 2007

    Sounds about right to me – so what’s the cure for parasites?

    I’d think the answer would be obvious: Critical thinking skills and skepticism.

    No, come on you guys – one step at a time:

    What do you do to get rid of an actual parasite?

  9. #9 Chris Noble
    November 13, 2007

    So what’s the cure for parasites?

    Hulda Clark?

  10. #10 James
    November 14, 2007

    Interesting comparison to the pressures of evolutionary biology. However, what strikes me about the article is that the author could be quite so narrow-minded and pompous, perhaps a surgeon who feels tragically under threat from a paradigm shift (in Europe and America at least) in modern prevention and treatment methods? An area in which he is tragically under-informed and therefore scares him?

    The author sets up a real us (the medical old-boys network of traditionalists) and them (CAM), when what really should be the focus is the health of the patient by the most effective means. The author infers that by research into CAM treatments, and the mounting body of evidence to support the effectiveness of some (not all) of CAM treatments, CAM is somehow cheating!!

    Unfortunately, the narrow perspectives and protectionist ideas of like-minded people within the medical community is the main stumbling block for a more holistic approach to medicine. Fortunately, there is a new generation of medical practitioners who don’t have as much to lose as the old-guard and are prepared to take the brave leaps forward (in the West at least, this discussion is largely irrelevant for India and China) that are required to keep a patient’s health at the forefront of what medicine is all about.

  11. #11 Orac
    November 14, 2007

    Funny you should mention China “keeping patient’s health at the forefront.” While the U.S.embraces woo more and more, there’s evidence that the Chinese increasingly choose Western medicine and drifting away from traditional Chinese medicine. This is not surprising. TCM was generally something that was promoted to the masses when China couldn’t afford more modern medical care for its citizens. Now that China is becoming an economic powerhouse, it can afford better health care.

  12. #12 Bronze Dog
    November 14, 2007

    The author infers that by research into CAM treatments, and the mounting body of evidence to support the effectiveness of some (not all) of CAM treatments, CAM is somehow cheating!!

    What research? It tends to be uniformly shoddy in nature. That universal shoddiness tends to allow “cheating,” like not accounting for natural healing, confirmation bias, regressive fallacy, etcetera, which is why we insist on rigorous standards to eliminate those cheating methods. We just ask that sCAM be given the same treatment as any other claim.

    Far too often, though, sCAM promoters resist that and yell that they’re special, that science shouldn’t apply to them, and we shouldn’t question anything, ever.

    Oh, and love the old “paradigm shift” thing. Nice to offer Galileo-ish platitudes as a distraction, rather than this evidence you speak of.

  13. #13 danielle
    March 25, 2008

    Medicine is medicine. Whether the pills are made from plants in the garden or in a lab, we all know that, in this day and age, it’s important to know if something is safe and works. CAM included. Science is science as well and it’s applicable across the board. We use research for everything. I’ve been referring to a site lately http://www.rvita.com for my research into alternative therapies (conventional medicine has no solid treatment for my condition) BECAUSE it gives scientifically trial data and grades. I don’t think I would believe anything worked, conventional or alternative, unless I KNEW what the research has said. This isn’t a matter of piggybacking. It’s a matter of intelligence.

  14. #14 danielle
    March 25, 2008

    Medicine is medicine. Whether the pills are made from plants in the garden or in a lab, we all know that, in this day and age, it’s important to know if something is safe and works. CAM included. Science is science as well and it’s applicable across the board. We use research for everything. I’ve been referring to a site lately http://www.rvita.com for my research into alternative therapies (conventional medicine has no solid treatment for my condition) BECAUSE it gives scientifically trial data and grades. I don’t think I would believe anything worked, conventional or alternative, unless I KNEW what the research has said. This isn’t a matter of piggybacking. It’s a matter of intelligence.

  15. #15 danielle
    March 25, 2008

    Medicine is medicine. Whether the pills are made from plants in the garden or in a lab, we all know that, in this day and age, it’s important to know if something is safe and works. CAM included. Science is science as well and it’s applicable across the board. We use research for everything. I’ve been referring to a site lately http://www.rvita.com for my research into alternative therapies (conventional medicine has no solid treatment for my condition) BECAUSE it gives scientifically trial data and grades. I don’t think I would believe anything worked, conventional or alternative, unless I KNEW what the research has said. This isn’t a matter of piggybacking. It’s a matter of intelligence.

  16. #16 danielle
    March 25, 2008

    Medicine is medicine. Whether the pills are made from plants in the garden or in a lab, we all know that, in this day and age, it’s important to know if something is safe and works. CAM included. Science is science as well and it’s applicable across the board. We use research for everything. I’ve been referring to a site lately http://www.rvita.com for my research into alternative therapies (conventional medicine has no solid treatment for my condition) BECAUSE it gives scientifically trial data and grades. I don’t think I would believe anything worked, conventional or alternative, unless I KNEW what the research has said. This isn’t a matter of piggybacking. It’s a matter of intelligence.

  17. #17 danielle
    March 25, 2008

    Medicine is medicine. Whether the pills are made from plants in the garden or in a lab, we all know that, in this day and age, it’s important to know if something is safe and works. CAM included. Science is science as well and it’s applicable across the board. We use research for everything. I’ve been referring to a site lately http://www.rvita.com for my research into alternative therapies (conventional medicine has no solid treatment for my condition) BECAUSE it gives scientifically trial data and grades. I don’t think I would believe anything worked, conventional or alternative, unless I KNEW what the research has said. This isn’t a matter of piggybacking. It’s a matter of intelligence.

  18. #18 danielle
    March 25, 2008

    Medicine is medicine. Whether the pills are made from plants in the garden or in a lab, we all know that, in this day and age, it’s important to know if something is safe and works. CAM included. Science is science as well and it’s applicable across the board. We use research for everything. I’ve been referring to a site lately http://www.rvita.com for my research into alternative therapies (conventional medicine has no solid treatment for my condition) BECAUSE it gives scientifically trial data and grades. I don’t think I would believe anything worked, conventional or alternative, unless I KNEW what the research has said. This isn’t a matter of piggybacking. It’s a matter of intelligence.

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