After chilling out for part of the weekend, yesterday I became so engrossed in writing my part of a training grant for my postdoc that, before I knew it, it was way too late to provide you with the Insolence you crave for today. Oh, well. Tomorrow for sure; there’s a lot that has been waiting for my attention. Besides, I haven’t even really taken a vacation this summer; so I deserve a day or two (or three) off from time to time. In the meantime, I’ll post a couple of bits of “classic” (if you can call it that) Insolence. This particular bit of insolence dates back nearly four years, all the way back to November 2006. Remember, if you haven’t been reading at least four years, it’s new to you! Besides, it’s always fun (or disturbing) to me to see how well some of my older material has aged. See you tomorrow. Unfortunately, nothing appears to have changed since I first banged this out on my keyboard. Maybe I should do an update.
If you’re a physician, there comes a certain point in your career when you start caring a lot more than you did about the next generations of physicians in the training pipeline. While you’re in the middle of training, you are the next generation; besides, you’re too worried about just getting through medical school, residency, and Board certification to be all that concerned about those behind you in the pipeline, anyway. Then, when you’re early faculty, you’re concerned about establishing yourself, getting your career on track, and, if you’re in academics, getting promoted. True, physicians who aren’t interested in education wouldn’t be in academics in the first place, but most of us tend to be far more concerned about resident education, because these are the people who will be replacing us one day in our own specialties. At some point, however, one starts wondering about the next generation of doctors that will not just be replacing one’s own specialty, but will be becoming the next generation of primary care doctors, internists, and other specialties aside from one’s own. Part of this interest in self-interest. After all, we’re all getting older, and aging physicians will need doctors too. More importantly, though, most physicians like to think that their profession is improving and that the next generation of physicians will surpass the present generation, thus insuring continued improvements in the science and art of medicine. We like to see our generation leaving a legacy of improved patient care and part of that legacy is the training of medical students.
Unfortunately, I have seen what may be the future of American medicine, and now I’m very concerned. Dr. R. W. has shown it to me. The American Medical Student Association (AMSA), an organization that should be committed to advocacy of the finest training and the best scientific medicine, is deep into promoting woo among medical students.
Dr. R. W. was concerned about this pushing of pseudoscience as an instance of hypocrisy, given that AMSA is promoting a national “Pharm Free Day” on November 16, in which AMSA urges hospitals and medical schools to restrict access by pharmaceutical representatives to students, residents, and physicians, with a sanctimonious statement in which they seem to claim they are doing this in the name of evidence-based medicine:
AMSA members believe in providing the highest quality care through evidence-based medicine. Here’s how.
I’m less concerned with the hypocrisy (although Dr. R. W. is perfectly correct to point it out) and more concerned with the woo that AMSA is actively promoting among medical students. Indeed, AMSA publishes a Complementary Therapies Primer, which is full of credulity towards many forms of woo. It wouldn’t be so bad if it were just herbal medicine being promoted. After all, some herbs do indeed contain active compounds that definitely do have pharmacological activity and can be used to treat disease. (Just ask Abel Pharmboy.) It is almost certain that we will continue to find new natural products and plants that harbor substances that can be used as drugs to treat disease. The stuff on yoga, meditation, and other relatively innocuous woo doesn’t bother me too much either, as long as it doesn’t claim to treat disease. But AMSA goes way, way beyond that. Some examples follow.
Traditional Chinese Medicine (TCM) is an ancient method of health care that combines the use of medicinal herbs, acupuncture, food therapy, massage and therapeutic exercise. It has proven helpful for many conditions, including chronic degenerative disease, cancer, infectious disease, allergies, childhood ailments, heart disease and AIDS.
Really? How? Based on what evidence? AMSA doesn’t say. It simply goes on:
TCM also introduces a major component of the body, qi, that Western medicine does not even acknowledge. Qi is what is called the life force, and it is all inclusive of the many types of energy within the body as well as being essential for life itself. This vital life energy flows through the body following pathways called meridians. These meridians flow along the surface of the body and through the internal organs, with each meridian being given the name of the organ through which it flows, such as “liver” or “large intestine.” Organs can be accessed for treatment through their specific meridians, and illness can occur when there is a blockage of qi in these channels. Therefore it is essential in TCM to keep the qi flowing in order to maintain health. The healthy individual has an abundance of qi flowing smoothly through the meridians and organs. With this flow, the organs are able to harmoniously support each other’s functions.
Again, there’s no evidence presented for qi or any of the other mystical mumbo-jumbo discussed without skepticism. And, most outrageous of all:
TCM is well suited to anyone looking for safe healing, answers he or she can understand in everyday human terms, and involvement in and responsibility for his or her own healing.
On what studies or evidence does AMSA base these assertions, particularly the last one, in which AMSA explicitly states that TCM is “well-suited” to a certain group of patients? None whatsoever. The references are all books on TCM and acupuncture. There’s not a single peer-reviewed scientific study or clinical trial listed in the references for TCM. There’s not discussion of the lack of scientific evidence even for the existence of qi (and scientists have looked and continue to look; I’ve seen grant applications in which the applicants propose trying to measure qi without success or hope of success). Moreover, there is little or no skepticism or critical thinking. It’s all warm and fuzzy acceptance. Don’t believe me? You can read the whole thing yourself, or you could check out a couple of more examples.
AMSA on reflexology (p. 9):
Reflex areas in the hands and feet are believed to correspond to every part of the body, which may in turn be affected by stimulating the associated reflex areas. Reflexology is useful in relief of stress and tension, stimulation of relaxation, improving blood supply and unblocking of nerve impulses, thereby normalizing and balancing the entire body. Precise pressure is applied to release blockages inhibiting energy flow and causing pain and disease. Nerve endings in the feet are felt to connect with all areas of the body. Although medically unproven, there is a wealth of anecdotal evidence as to the effectiveness of this approach.
In other words, there is no good evidence other than the testimonials of the adherents of reflexology that it does any good treating disease. Certainly none of the references cited are in the peer-reviewed literature. They don’t even appear to be attempts at a critical evaluation of this technique. In fact, they don’t appear to be anything more than tomes written by advocates, and not even a single example of this so-called “anecdotal” evidence is cited or listed.
Before I go on, I can’t resist citing one more example from p. 18:
Fasting has been used as a means of physical, mental, and religious purification for centuries. Modern holistic medical practitioners are now recognizing its value in health maintenance and promotion.
Fasting eliminates the work required to digest and metabolize food, and allows the body to use stored fats as fuel. While fasting, fewer toxins are absorbed by the body, yet toxin elimination continues at the normal rate. Food allergens are eliminated, allowing the GI system to rest. After four days of fasting, serum fats are lowered, and the thinner blood circulates more effectively, leading to greater oxygenation and better immune function. Fat burning allows the release and elimination of fat-stored toxins such as pesticides.
Fasting has been used to benefit hypertension, headaches, allergies, arthritis, fibrocystic breast disease, schizophrenia, and, of course, obesity. Fasts may vary from two days to several months, depending on the condition to be treated. Fasting longer than a few days can be dangerous, however, and should only be done under the care of a health professional.
Fasters should consume an adequate amount of liquid. Experts are divided as to whether pure water or vegetable juice is the ideal replacement. Juice fasts are better suited to patients with poor dietary habits, who will undergo a vigorous detoxification phase of the fast. Patients may take a “detoxifying cocktail” of garlic, lemon, grapefruits and olie oil to flush out the liver at bedtime. Many practitioners encourage use of enemas while fasting.
I refer readers to the following old posts by yours truly for discussions of this sort of “detoxification” woo, which is an altie staple that is not only not supported by science but creates the appearance of “success” by producing the very “stones” that the “liver flush” claims to eliminate:
Even worse is, though, the credulous treatment of homeopathy on p. 19 (yes, I couldn’t resist just one more example):
The Law of the Infinitesimal Dose was formulated by Dr. Hahnmann when he experimented with dilute solutions, seeking to avoid toxicities, and found them to be more effective than full strength preparations. Homeopathic remedies are repeatedly mixed with water or alcohol and shaken (succussion), often diluting the substances to such a degree that no amount of the original medication can be found in the remedy. Some believe that the remedies retain their
effect because of electromagnetic frequency imprinting, changing the structure of the diluent subtly.
Initially, as a patient is treated by a homeopathic physician, he or she may actually worsen. This is know as a “healing crisis.” As the presenting, most recent, symptoms are treated, older, underlying disorders come to the surface. Dr. Constantine Hering, the father of American homeopathy, believed that healing progresses from recent diseases to chronic maladies, from emotional imbalances to physical disorders, from superior to inferior, and from the deep structures to the superficial. This is known as Hering’s Laws
of Cure. By following Hering’s Laws when treating a patient, a practitioner can successively unravel many layers of pathology, eventually recreating internal order and achieving a more permanent cure.
Homeopathy is used to treat diabetes, arthritis, asthma, epilepsy, rashes, allergies, mental and emotional imbalances, and the common cold, as well as many other conditions. Homeopathic remedies are very inexpensive and nontoxic, and many reports document their success in a variety of situations. Homeopathy, while popular in the early twentieth century, has lost favor with the medical establishment in the US.
There’s a reason that homeopathy has “lost favor” with the medical establishment. (Actually, it never really had much favor with the medical establishment in the first place.) That’s because it’s utter bunk. Indeed, even physicians of the 19th century, physicians like Oliver Wendell Holmes, could quite convincingly show why homeopathy is utter bullshit. (Sorry, there’s just no other word for it that describes homeopathy as well.) It makes me despair for our medical education system that AMSA, an organization run by medical students is publishing such a credulous treatment of pseudoscience like homeopathy. Didn’t they learn anything in undergraduate and medical school? Apparently not. Our medical schools seem to have failed to teach them basic chemistry, physiology, and pharmacology, leading to statements like this regarding the evidence supposedly supporting woo:
Proponents of CAM therapies argue that unconventional treatments often cannot be tested effectively by the traditional, double-blind, controlled format that is the hallmark of conventional scientific studies. According to Manuel J. Avancena, L.Ac., an acupuncturist in Reston, Virginia, acupuncture points are different for every patient. If five patients present with the same primary complaint, the treatment will be different for each patient depending on coexisting symptoms or problems. This holistic component of the treatment would not be effectively measured by a study that demands that each patient have the same points treated in order to control variability.
People more skeptical of CAM demand nothing less than the double-blind, controlled study with objective results before they consider CAM. To some, the very argument that CAM cannot be evaluated using the controlled, double-blind study indicates that CAM is equivalent to quackery. In addition, scientists and physicians often remain doubtful if a therapy works but little evidence is available regarding the mechanism of its effects.
Guilty as charged, with one exception. (I’m funny that way. I’m alway skeptical of treatments that don’t appear to have any physiological or scientific basis for “working.” In fact, I’m even more skeptical when the evidence that such treatments actually “work” is so flimsy.) The above is nothing more than a typical altie strawman that skeptics require “nothing less than the double-blind, controlled study with objective results.” True, that is the gold standard towards which we strive when evaluating a therapy, but evidence-based medicine does not demand only double-blind, randomized, placebo-controlled clinical trials before it will consider a treatment, as I have explained before. When weaker evidence is all that is available, evidence-based medicine must synthesize it as best it can and come up with recommendations. AMSA does get one thing right, though. If an advocate of a treatment claims that it can’t be evaluated by the scientific method, I become suspicious of quackery–and rightly so, I argue. Even if, as claimed, “every patient requires a different treatment” under this system, it should still be possible to determine using the scientific method exactly why and to identify the criteria upon which the “individualized” treatments should be based. Conventional medicine “individualizes” treatments too, but it doesn’t have the temerity to claim that such individualization can’t be studied scientifically. In conventional medicine, no treatment is assumed to be impossible to study scientifically, and CAM should be treated no differently than “conventional medicine.” It is true that certain treatments may be very difficult to apply the scientific method to, but that does not mean that we should throw up our hands, give up, and just take the alties’ word for it that their treatments work. We should treat their claims exactly the same as any claim by academic physicians or big pharma.
But AMSA’s promotion of woo goes beyond even this. AMSA is going so far as to hold what it refers to as a “Leadership Training Program for CAM.” Here’s the goal:
The LTP is an experience of a lifetime. 20 medical students from across the country will gather on the campus of the Omega Institute for a weeklong, intensive retreat dedicated to complementary and alternative medicine and leadership skills training. Our expectation is that these 20 students will go on to become the future generation of leaders in CAM education in their medical schools and beyond.
During the LTP, students will learn from expert facilitators about a number of CAM topics- everything from acupuncture to research to mind-body medicine to the latest in regulation and licensing standards for CAM. Stress reduction, wellness, and nutrition will also be emphasized throughout the week as students will enjoy healthy meals and will have opportunities to take classes in meditation, Yoga, and movement. To enhance leadership skills, LTP facilitators will host sessions on public speaking, interpersonal skills, teamwork, and other activities designed to make YOU a more effective advocate for CAM.
In addition, each participant will plan a project to increase CAM awareness at his or her school. The LTP facilitators will host sessions throughout the week to help you make your project a success!
Great. Just what we need, a project promoting the credulous acceptance of the claims of alternative medicine by future generations of doctors. But that’s not all. In April, AMSA is sponsoring a woo-filled four week elective in in communal living, alternative medicine, and activism. Yes, we’re talking about a group bonding experience largely based on the credulous acceptance of the claims of alternative medicine (plus a some left-wing activism thrown in for good measure) in future generations of doctors. (The left wing activism doesn’t bother me that much, but I do find the emphasis on woo highly disturbing.)
There are a couple of truly ironic aspects of this credulous support of alternative medicine by AMSA. Perhaps the most amusing is the frequent claim by alties that the AMA “suppresses” the “truth” about alternative medicine. Yet, here we have AMSA, the premiere organization for medical students, swallowing the altie line, hook, line, and sinker. True, AMSA is not a branch of the AMA. However, it is the largest organization representing medical students, and consequently the leaders of AMSA are likely to be the leaders in medicine in general in the next 10-20 years. After all, any medical student who would be willing to go through what it takes to become a leader in a national society like AMSA will also be likely to become a leader in various local, state, and national medical societies and organizations after he or she becomes a physician.
The most ironic aspect of all, however, is that, while a major medical student organization in the U.S. is accepting traditional Chinese medicine and medical schools themselves rush to embrace it, the Chinese themselves, particularly Chinese youth, appear to be early in the process of rejecting TCM in favor of scientific medicine:
Traditional Chinese Medicine (TCM) is losing out to western medicine in the popularity stakes in China, according to an online survey.
Only 28 percent of the 14,677 respondents to the survey by China Youth Daily and Tencent.com said they would turn to TCM first even though 87 percent said they still had faith in the centuries-old practice.
Half of the respondents who voiced their support for TCM believe it is an effective cure for many diseases but 27 percent only trust it because it is “the quintessence of China”. As for the future of TCM, more than 60 percent said they were not optimistic.
A nationwide debate erupted over TCM after an online proposal was submitted by Zhang Gongyao, a professor at Central South University, urging China’s health authorities to remove TCM practices from its national health service. It attracted both support and outrage from thousands of netizens.
Supporters of the proposal labeled traditional Chinese medicine “unscientific and untrustworthy” and opponents lambasted supporters for ignoring history.
Indeed, one prominent Chinese physician has dared to speak out:
Mr. Zhang, a professor at Central South University in Hunan province who has been studying medical history for more than 30 years, is urging the government to stop promoting traditional medicine. He has launched an online petition to seek its removal from the constitution and the official medical system. And he wants China’s traditional-medicine practitioners to get mainstream medical training.
“From the viewpoint of science, Chinese traditional medicine has neither an empirical nor a rational foundation,” he wrote in an article that ignited a furor when it found its way onto China’s Internet. “It is a threat to biodiversity. And it often uses poisons and waste as remedies. So we have enough reasons to bid farewell to it.”
Although he has been largely vilified, he has also garnered a surprising amount of support:
The professor won a surprising amount of support on some Chinese websites. One person commented that traditional medicine needs to prove itself scientifically, or else it should be dismissed as witchcraft. Another person, a medical student, said she wished her university would stop teaching traditional medicine, which she regarded as mythology.
Chinese newspapers pointed out that China has about 270,000 traditional-medicine practitioners today, far fewer than 800,000 in the early 20th century. Meanwhile, the number of physicians trained in Western medicine has soared from 87,000 in the early 20th century to about 1.75 million today.
“If the government wants people to trust traditional medicine, it must make a greater effort to prove the reliability and scientific basis of traditional medicine,” the respected newspaper Southern Daily commented. “Otherwise, traditional medicine will keep declining every day.”
So, in China, the number of practitioners of evidence-based medicine is increasing, while the number of practitioners of TCM is decreasing. The exact opposite seems to be occurring in the U.S. Wouldn’t it be sad if, just as China is starting to subject even its most deeply respected medical traditions to the scientific method and becoming willing to discard therapies that have no scientific basis, we in the U.S. start embracing the very same unscientific therapies that the Chinese are starting to reject in favor of evidence-based medicine? Yes, I will concede that parts of the literature on alternative medicine that AMSA publishes stresses that alternative medicine should be used in addition to conventional evidence-based medicine, but it doesn’t reassure me much. I’m still having nightmares in which I picture myself old and with cancer, faced with a chipper young doctor, fresh out of residency, assuring me that I’ll be just fine if I take the recommended homeopathic medicine and go through a “detoxification” regimen.
I fear for the future of my profession. My only hope is that AMSA is not representative of the vast majority of medical students. (I suspect that this is the case.) Even so, by claiming to be advocates of evidence-based medicine on the one hand while promoting unproven and unscientific therapies such as homeopathy and reflexology on the other hand, AMSA can’t help but have a pernicious effect on the education of the current generation of medical students.