Respectful Insolence

I’m a cancer surgeon.

I started out as a general surgeon, but my passion and scientific interest goaded me into specializing in cancer. Ultimately, I ended up subspecializing even more, ultimately becoming a breast cancer surgeon, but through it all cancer, not just breast cancer, has remained my clinical and scientific passion. So has science-based medicine. Developed as a response to the concept of “evidence-based medicine” (EBM), SBM postulates that clinical care should be based on the best science available, including the consideration of basic sciences and prior probability. EBM relegates such considerations to the lowest rung of the ladder of data and elevates the randomized clinical trial to the highest form of data. This latter aspect of EBM is not what I generally have a problem with; rather it is how EBM treats randomized clinical trials as the be-all and end-all of evidence, which means that a single clinical trial of homeopathy that appears to be positive counts for more than all the hundreds of years of firmly founded chemistry, physics, and biology that say that homeopathy can’t work as homepaths claim it can. To overturn so much history and science requires far more than a barely statistically significant effect observed in a randomized clinical trial. The same holds true for other forms of magic that fall under the rubric of “complementary and alternative medicine” (CAM), such as reiki (which is faith healing that substitutes Eastern mysticism for Christianity as its religious basis) and therapeutic touch (which is not touch at all) that have managed to coopt EBM and claim to be “evidence-based.”

As Harriet Hall says, it’s Tooth Fairy science.

Not too long ago I wrote a post about something called “integrative oncology,” which I referred to as “quackademic medicine triumphant.” “Integrative oncology” is the oncology subspecialty of “integrative medicine” (IM), which is the latest incarnation of CAM that seeks to “integrate” pseudoscience into scientific medicine. In my post, the hallowed M.D. Anderson Cancer Center, whose faculty really and truly should know better given the incredible scientists and practitioners of scientific medicine who work there, received the majority of my ire. In particular, I singled out Lorenzo Cohen MD, PhD (whose latter PhD degree demonstrates conclusively that a PhD does not guarantee freedom from woo) for promoting “integrative oncology” at the University of Texas M. D. Anderson Cancer Center, and,, even worse, for promoting “energy therapies,” which include the aforementioned woo known as reiki and therapeutic touch.

He’s baa-aack.

A reader sent me a post that Dr. Cohen wrote for Cancerwise, the M.D. Anderson Cancer blog, entitled Integrative Medicine Versus Alternative Medicine: Why It’s Important to Know the Difference. All I can say (to begin with) is: Wow. The abuse of language and science to support magic is strong in this one. Very strong. One wonders if Dr. Cohen was–shall we say?–made aware of the criticisms coming his way from me, both here and at my other blog. One also wonders if someone mentioned to him that he was prominently featured in a talk I gave to the Chicago Skeptics about four weeks ago. Or maybe Orac is simply engaging in some of his usual hubris, to have the temerity to think that such a prominent and well-funded CAM researcher would even notice (much less give a rodent’s posterior about) two humble blogs and a talk to about 40-50 skeptics in a pub.

Whether he noticed me or not, whether I was the source or not, Dr. Cohen is not pleased at some criticism his precious integrative oncology has received:

People often do not make a distinction between the terms integrative medicine and alternative medicine. Below is the mission statement of the Society for Integrative Oncology (http://www.integrativeonc.org):

The Society for Integrative Oncology (SIO) is a non-profit, multi-disciplinary organization of professionals dedicated to studying and facilitating cancer treatment and the recovery process through the use of integrated complementary therapeutic options. Such options include natural and botanical products, nutrition, acupuncture, massage, mind-body therapies, and other complementary modalities. Our mission is to educate oncology professionals, patients, caregivers, and relevant others about the scientific validity, clinical benefits, toxicities, and limitations of state-of-the-art integrative therapies. SIO provides a forum for presentation, discussion, and peer review of evidence-based research in the discipline. We advocate for responsible public policy and the highest standards of practice in integrative medicine through appropriate training and the certification of health care professionals.

You will note that the word “alternative” is not contained in the mission statement because the SIO is not a proponent of alternative therapies in lieu of conventional evidenced-based medicine. This is also true of most academic organizations including MD Anderson, Memorial Sloan Kettering Cancer Center, Dana-Farber Cancer Institute, University of California, San Francisco, and others.

This is, of course, a massive straw man argument. Indeed, in this article, Dr. Cohen tilts at windmills with a ferocity that would alarm even Sancho Panza. The criticism, of course, that we supporters of SBM level is not that proponents of “integrative” medicine or oncology advocate using woo instead of real medicine. It’s that many of the nostrums they propose to use in addition to real medicine have no basis in science (and, in fact, are based on prescientific notions of disease), do not improve patient care, and, in fact, waste time and resources, as well as in some cases potentially cause harm. Even worse, they erode the scientific basis of medicine, as “integrative” medicine co-opts science-based modalities such as diet and exercise or the pharmacology of natural products (pharmacognosy), infusing them with pseudoscience and thereby making them into woo, too. Quackademic medicine blurs the lines between science-based medicine and pseudoscience-based medicine to the point that even many physicians begin to have trouble telling one from the other.

The straw men and deceptive (probably self-deceptive) language continue throughout the post. After assuring us that “integrative” oncologists only embrace “evidence-based” interventions and that they are “wholly committed to quality research in the area of integrative cancer therapies” (both points that no one, including myself, is arguing against), Dr. Cohen tries to point to the Society of Integrative Oncology’s “evidence-based” guidelines as evidence that there really, truly is good evidence for the efficacy of CAM therapies in oncology. What’s in those guidelines, though, is really mostly what I consider to be utterly conventional science-based medicine co-opted and rebranded as CAM, modalities such as diet, exercise, and relaxation therapies, with the real woo (such as reiki and “energy medicine”) seemingly tacked on as an afterthought. (You know, the 2009 “evidence-based” integrative oncology guidelines would make the basis for a good post; or maybe I should wait for the 2010 guidelines to come out.) He then proceeds with a tirade against his critics that includes gambits that wouldn’t be out of place on Mike Adams’ NaturalNews.com website in its more sane moments:

One of the other challenges of research in this area is that with the exception of the natural product clinical trials, it is difficult to develop studies using the gold standard double-blind, placebo-controlled design. However, even using single-blind designs, it is possible to at least determine if the patients remained blinded to group assignment and assess patients’ baseline treatment expectations. This can help to account for placebo effects. Often, in double-blind, placebo-controlled trials of conventional medicine patients are clearly “unblinded” when they experience negative drug effects and adverse events that are not experienced with the placebo treatment. Typically, it is unheard of to assess if patients remained blinded throughout a trial of conventional medicine. This unblinding is rarely questioned or even reported.

Well, that depends upon the trial, actually. Blinding is generally taken very seriously; that’s the default, and it’s simply assumed. For instance, in this trial, there was a slight difference in the labels that, if the labels were closely examined, could have led the pharmacists to be unblinded as to which vials contained placebo and which contained the study drug, leading to what was characterized as a “remote possibility that unblinding information…could have been revealed to the pharmacist.” Even the “remote possibility” that the first 130 patients recruited could have been unblinded to the pharmacists preparing the drugs because of a differences in the label led to those patients being excluded and a fresh batch of 130 patients being enrolled to replace them. The original 130 patients were included in the safety analysis but excluded from the efficacy analysis. To the extent that Dr. Cohen is advocating for more rigorous reporting I can’t criticize him, but to the extent that he comes across as complaining that a more rigorous standard is being demanded of CAM, I call him out on that because that is what he appears to be doing. In reality, what is being demanded of CAM is the same standard that should be and generally is demanded of SBM–and Dr. Cohen doesn’t like it.

This leads him to an amazing tu quoque argument:

It is uncommon to find scientists or practitioners who support evidence-based medicine unsupportive of well-designed clinical trials. However, this can sometimes still happen in designing, conducting, and publishing integrative oncology clinical trials. Scientific observation should never be trumped by a personal belief. In fact, substituting one’s own belief instead of supporting rigorous research and scientific observation is similar to what alternative medicine practitioners advocate – deliver or withhold treatments without evidence to support that action.

Even though it was very late when I wrote this because I was so exhausted that I fell asleep on the couch right after getting home from work and eating dinner, with the consequence that at 3 AM I’m wide awake hoping that blogging will tire me out enough to allow me to get some sleep (can’t sleep, clowns will eat me), I almost spit up my iced tea when I read this. It’s also a massive straw man argument, leading me to steal the phrase “pyromaniac in a field of straw men” to describe Dr. Cohen. Either that, or at the risk of becoming too repetitive, I could reuse one of my favorite images and describe Dr. Cohen as taking a flamethrower to a burning man-sized man of straw.

SBM is not “personal belief.” It is taking into account all the science, including the background basic science. No one–I repeat, no one–of whom I’m aware is opposing well-designed clinical trials. What I oppose is putting the cart before horse. Homeopathy, for instance, goes against so many well-established principles and theories in physics and chemistry that, for it to be true huge swaths of our very basic understanding of these disciplines would have to be not just wrong, but spectacularly wrong. A true scientist and skeptic never rejects the possibility out of hand that we are wrong about the science that declares homeopathy impossible, but, as Carl Sagan was fond of saying, extraordinary claims require extraordinary evidence, and homeopathy sure does make a whole lot of extraordinary claims. It is not “personal belief” to point that out, nor is it “personal belief” to point out that wobbly clinical trials in which placebo effects can easily result in false-positives are not enough to lead us to question hundreds of years worth of well-established science. Ditto reiki, acupuncture, therapeutic touch, and other forms of “energy medicine.” The bottom line is that one can always demand “more research.” That’s the default position of CAMsters when science doesn’t support their woo. If Dr. Cohen wants science to validate his woo, then he’d better cough up the evidence, rather than whining when skeptics point out that the CAMperor has no clothes.

Finally, Cohen uses the most tried and true gambit of CAMsters. Well, maybe the second most tried and true gambit after the pharma shill gambit. Yes, he pulls out the “science was wrong before” gambit:

If we simply followed people’s predictions and beliefs then the field of medicine would not be where it is today, as many medical discoveries went against what was commonly believed and/or predicted. A good historical example of this is the story of Dr. Ignaz Semmelweis who documented that washing hands with chlorinated lime solution prior to delivering a baby dramatically decreased the rate of puerperal fever. The germ theory of disease had not been developed at the time and Dr. Semmelweis was largely ignored, rejected or ridiculed.

Another good example in oncology is the late Dr. Judah Folkman who discovered angiogenesis and pioneered anti-angiogenic treatments. He also was initially dismissed and ridiculed by the medical community due to his ideas, which are now, of course, widely accepted.

Damn. Lots of woos invoke Semmelweis, but recently I’ve noted a new trend for them to invoke my scientific hero Judah Folkman in the same way. Dr. Folkman must be doing power backflips in his grave at the abuse of his good name. I suppose that Semmelweis is just too…1800s, and they need a more recent example of the alleged close-mindedness of scientists. Apparently building up the myth of Robin Warren and Barry Marshall’s supposed ostracism due to their proposal that H. pylori was the cause of peptic ulcers was not enough, and now they have to abuse Dr. Folkman. Of course, Folkman was never really seriously ostracized or marginalized for his ideas, although they were greeted with skepticism and criticized when he first published the hypothesis that angiogenesis is a target for cancer therapy in 1971. Rather, Dr. Folkman became one of the most revered figures in the field of surgery and remained so for over 30 years until his sudden and untimely death in 2008. More importantly, he proved himself to be right through 25 years of doing the hard work of science to test his hypotheses. His vindication came in the mid- to late-1990s, when he discovered the endogenous angiogenesis inhibitors angiostatin and endostatin and proved in mouse models that angiogenesis can be a viable target for anticancer therapy.

What Dr. Cohen is invoking, of course, is nothing more than the Galileo gambit. The problem is, as has been said so many times, that to wear the mantle of Galileo it is not enough to be criticized for ideas outside of the scientific mainstream. You must also be correct. Judah Folkman was correct, and he also did what true scientists do: He proved it through his research. That’s the way real scientists do it–scientists like Judah Folkman, who never publicly whined about how the scientific establishment wouldn’t believe him, which is in essence what Dr. Cohen is doing.

I’ve said time and time again that the co-opting of what should be science-based modalities by “integrative” medicine is a Trojan horse for the real woo, such as “energy healing” and homeopathy. Whether he realize it or not (I’m pretty sure he does not), Dr. Cohen concludes by making that explicit:

The field of integrative oncology continues its ascent as medicine shifts toward a more personalized care model. Delivering many common and accepted modalities such as diet, exercise, and stress management using a patient-centered, comprehensive approach is what distinguishes integrative medicine from reductionist and fragmented models of care. As more and more cancer survivors proactively participate in a patient-centered wellness approach, integrative oncology practitioners will continue to grow in numbers to meet this demand.

What, I ask, is “alternative” or CAM about diet, exercise, and stress management? Nothing. When done properly, it is SBM. Coopting it as “integrative” or “personalized care” is nothing more than marketing buzzwords. Of course, the unspoken but implied claim is that, if diet, exercise, and stress reduction are effective for improving health, which no SBM practitioner would argue, then the other woo advocated by Dr. Cohen (energy medicine) must also be effective.

The woo sits within the belly of the Trojan horse of diet and exercise, waiting to jump out and take over the fortresses of SBM. It’s already happening at M.D. Anderson.

Comments

  1. #1 mad the swine
    September 15, 2010

    The woo sits within the belly of the Trojan horse of diet and exercise, waiting to jump out and take over the fortresses of SBM.

    Which would make you Cassandra, I suppose, and Dr. Cohen the wily Odysseus? Beware of Greeks bearing CAM. But I don’t think Jenny McCarthy is quite pretty enough to be Helen.

  2. #2 Todd W.
    September 15, 2010

    Lots of woos invoke Semmelweis

    When I read the quote, the same thought occurred to me. It’s silly, really.

  3. #3 christophe-thill.myopenid.com
    September 15, 2010

    I think we need a new acronym. One for all the non-wooish methods such as nutrition, exercise, massages, physical therapy (not chiropraxy!) and psychological support. I suggest RCT for “rational complimentary therapies”. Clearly opposed to CAM.

  4. #4 Mu
    September 15, 2010

    mts, Jenny’s role is for ever to be cast as Pandora.
    As for the “energy healing” stuff, I have no beef with it as long as it’s clearly presented as a “supportive therapy” based on placebo effects. 30 min massage might be better, but if the patient feels better after 30 min hand waving, so be it. I only get upset when the practitioner demands we have to believe in the magic parts.

  5. #5 lenoxuss
    September 15, 2010

    Is the following sentence basically true? “EBM and SBM converge into the same thing when the threshold for evidence overturning established models is set high enough, given the high prior evidence for those models.”

    I mean, there is a sort-of-logically-possible amount of experimental evidence which raises the probability of homeopathy works” being true. It’s just that this amount of evidence is insanely high!

    Thought problem: What if homeopathy suddenly started working unequivocally in the year 2011? And quantum and chemical experiments suddenly showed a material basis for water memory? Would scientists tear our hair out in madness or excitedly investigate the new frontier? I think the sanest answer is “both”. (Also, it would be a good time to ask the universe for a pet dragon.)

    christophe-thill @ 3: Speaking of acronyms, “pyromaniac in a field of straw men” ought to become an initialism-based neologism, because it happens to be pronounceable: piafosm. (“PIE-uh-fozz-im”).

  6. #6 Gopiballava
    September 15, 2010

    The article lets you post comments, although they are moderated. You can also vote on how many stars the article deserves. We’ll see if my comment gets posted:

    “”As a matter of course, they embrace only the utilization of viable evidence-based treatments”

    I’m trying to resolve the contradiction between this statement and the SIO’s “strong recommendation” for energy therapy such as Reiki.

    Reiki is not a “viable evidence based treatment”. While it is very good that Dr. Cohen encourages patients to continue to receive evidence-based medicine, I think it is wrong to encourage non-evidence-based medicine.

    Some of what SIO wants to integrate is science. Some of what SIO wants to integrate is pseudo-science. I am disappointed to see respectable medical establishments officially encouraging pseudo-science. I fully support research. The topic here is not research, but rather clinical care.”

  7. #7 William
    September 15, 2010

    I wouldn’t want a cancer surgeon operating on me who has a sleep disorder. Better to have someone whose neurological system is functioning well. But for Orac, I would recommend he experience Reiki, Therapeutic Touch or Healing Touch, especially in the evening, as they may help him improve his sleep quality. This may in turn help him begin to think more clearly about complementary therapies. (We didn’t know how aspirin works until just a few years ago…)

  8. #8 Orac
    September 15, 2010

    I hasten to add that today is not a clinical day for me. Rather, it’s one of my research days.

    I do not operate or see patients in clinic on Wednesdays. Trust me, if I did, I would have tried a lot harder to get more sleep and I would have been a lot more careful about letting myself fall asleep early in the evening and screwing up my sleep-wake cycle.

    Of course, my getting up to blog was actually my attempt to tire myself out in an hour or two so that I could still get some more sleep. The problem was that I shouldn’t have allowed myself to fall asleep on the couch. That was stupid.

  9. #9 MikeMa
    September 15, 2010

    @William,
    What horseshit.

    By what mechanism, exactly does ‘healing touch’ work? If you cannot describe the mechanism, you cannot design a test to see if the thing has value. On the other hand, aspirin has mechanisms which can be (and have been) tested and proof made available.

    Quoting Dara O’Briain, “Get in the fawking sack.”

  10. #10 LovleAnjel
    September 15, 2010

    @William

    Maybe we didn’t fully understand the mechanism underlying different effects of aspirin, but we knew it actually worked– double blind controlled trials ‘n’ all. Reiki, TT and HT, if they are ever even subject to proper trials, do not show a significant effect. (I believe TT practitioners were shown to be wholly unable to determine the presence of a body part, much less alter any “energy” it might have.)

  11. #11 Angela Sodee
    September 15, 2010

    @William you are joking I hope?

    Nice post Orac!

  12. #12 Dangerous Bacon
    September 15, 2010

    “Which would make you Cassandra, I suppose, and Dr. Cohen the wily Odysseus?”

    Dr. Cohen actually is Mary Poppins, singing about how “just a spoonful of woo-ness helps the medicine go down”.

    How sad that he evidently thinks that “personalized care” must involve non-evidence-based modalities – as if proven, quality treatment is incompatible with caring.

  13. #13 DrWonderful
    September 15, 2010

    @Christophe- let’s not clump all chiro’s or PT’s together on one side of your wall or the other. Myself and many of my colleagues practice completely woo-free chiropractic physical medicine while the PT group down the road (one of the largest in the state I might add) have Reiki, Acupunture and Reflexology practitioners on staff.

    The new world order is that PT’s are becoming more holistic and woo-full while at the same time my profession is shedding it like an old skin. Just for the sake of accuracy please do not stereotype based solely on your own personal bias…in other less snarky worlds that would be called discrimination.

  14. #14 Militant Agnostic
    September 15, 2010

    LovleAnjel

    I believe TT practitioners were shown to be wholly unable to determine the presence of a body part, much less alter any “energy” it might have.

    Indeed they were, by Emily Rosa when she was 9 years old. Sort of like the child in the Emperor’s New Clothes.

  15. #15 MikeMa
    September 15, 2010

    DrWonderful:

    The new world order is that PT’s are becoming more holistic and woo-full while at the same time my profession is shedding it like an old skin.

    Took you at your word and checked the top chiropractic results on the web in my area.

    Quoting from their sites, I find things like “Balance your brain”, “Flu vaccine alternative”, “Breakthrough… Koren Specific Technique” followed by a list of all the body parts that adjusts and fixes including the cranium, “Biofreeze”, “Nutrametrix”, etc.

    Only one of the top sites missed all the woo but their site was very sketchy altogether. They want you to come in and experience, well, whatever.

    Your opinion of the woo-shedding chiropractor is off a bit I’d say.

  16. #16 robopox
    September 15, 2010

    The “spoonful of woo-ness” is a vicious slur against evidence-based medicine!
    The song refers to Richard Sherman’s son getting his Sabin oral polio vaccine.
    Since a “[small cube] of sugar” was a crap lyric, they changed it to “spoonful”.

  17. #17 Pablo
    September 15, 2010

    MikeMa – I find the whole comment kind of funny, since DrWonderful is a major woo. So if chiropractors are shedding woo like crazy, they must have started with lots and lots of layers, because he is still covered deep in it.

  18. #18 jenbphillips
    September 15, 2010

    @Dr. Wonderful,
    and I’m N=2. Of the top four hits for chiropractors in my city:
    Two are straight up chiropractic, with no adjunct health care workers on site. Of these, one offers a lengthy explanation of ‘subluxation’ and speaks extensively of ‘nervous system blockages’ that can presumably be ameliorated by chiropractic adjustments. The other presents a long list of conditions he treats with chiropractic, including: addiction, asthma, allergies, high blood pressure, lung problems, and pregnancy care. He also offers nutritional counseling and markets a number of supplements on his website. Both of these promote chiropractic treatments for children and infants.

    The other two offer a broad range of ‘woo-full’ services, including naturopathy, acupuncture, reiki, and biofeedback.

    Perhaps, though, we need to clarify what you consider ‘woo-free’. I see plenty of woo in the ‘chiropractic only’ practitioners described above. Perhaps you disagree?

  19. #19 mcsnebber
    September 15, 2010

    Perhaps the ultimate PIAFOSM should be THE WICKER MAN, as in the original movie from 1975, not the laughable, ridiculous remake a couple of years ago. I won’t spoil the ending if you haven’t seen it (maybe I already have) but in short he is a great structure built of flammable materials, dedicated to an ancient Celtic god of fertility, (as good as WOO) with a little extra thrown in. Watch it, but not if you’re trying to fall asleep!
    Thanks for all you do..it is SO important. (as a doctor, and a patient with breast cancer on medical leave *hair currently becoming scarcer*). :) :) :)

  20. #20 MetaEd
    September 15, 2010

    The phrase “SBM states that” is cdesign proponentsisted in the first paragraph.

  21. #21 Dangerous Bacon
    September 15, 2010

    DocWonderful: “The new world order is that PT’s are becoming more holistic and woo-full while at the same time my profession is shedding it like an old skin.”

    Would that this were true. Chiropractors in general appear more than ever wedded to woo – bogus nutrition advice, dubious supplements, “detoxification”, homeopathy, an array of impressive-looking but useless machinery and of course the biggest woo of all – using chiropractic manipulation for treatment of nonmusculoskeletal complaints. Nearly every chiro’s website I’ve visited offers one or more of these “services”. One typical example (I wonder, can you combine therapies so that you get your Thought Field Technique while soaking afflicted parts in the Ionic Foot Bath and simultaneously being administered a homeopathic tincture?).

    The snake may shed its skin – but underneath, it’s the same old stuff.

    Poor Dr. Wonderful. “Not As Crazy As Some” does make for a nice business motto, though. :)

  22. #22 DrWonderful
    September 15, 2010

    Most chiropractors do not have web sites, including myself. Don;t need one. I am busy all day, every day, with absolutely no advertising. The one’s who do have sites seem to have bought pre-packaged formats using the same few templates that are out there. Also the chiro’s that have web sites, with that type of marketing schtick, tend to be the ones that also do Mall screenings, which again is the minority of the profession. You’ll need to find a better way to measure the sample. If a full 80% of the profession (at least) you are sampling is not even present in your study group how can call that a fair assessment and dare to make general statements? Your sample bias is extraordinary.

    For example, there are 28 chiropractors in my city and only 3 have the distasteful full page Yellow Pages ads we all hate and they are the ones you’ll see at Mall shows. The other 25 chiro’s in my town can’t stand those guys but have no way to “control” them as many of you have suggested. Of the 28 chiro’s in my city, the last I looked I think something like only 6 had web sites with hit volume that would come on Google.

    Look at claims data or something truly representative and you’ll see the overwhelming majority of the chiro’s treat basic musculoskeletal conditions. Look at diagnosis codes and procedure codes. Basic physical medicine nearly across the board. Rarely are the subluxation codes even used nowadays. That is the data that would be considered hard and representative.

    That data also shows fewer visit used and less overall cost than other “acceptable” modalities, which is why we are being used increasingly to treat NMS conditions in Medicare, VA, DoD, etc. If you want to look at what chiro’s are actually treating look at the billing and treatment records, not the web sites, duh. Shall I judge all breast cancer surgeons solely on the few that have web sites? Of course not.

  23. #23 DrWonderful
    September 15, 2010

    Also, I should clarify. I did not ask that no assignment of woo guilt be placed on my colleagues. There is plenty of it still out there but less and less each decade.

    The fact is that woo has steadily been draining out of chiropractic for the past 25 years while it is gaining in popularity in places like PT and Osteopathy. I just ask that you not put all chiro’s on the bad side of your woo wall of execution and all PT’s on the good side of your woo wall of acceptability.

    The fact is the chiro’s are improving their standards while the PT’s are getting worse and falling prey to wooey marketing shticks because their fees are plummeting like stones. You are self anointed judges and juries with very little understanding of what you discuss here.

  24. #24 MikeMa
    September 15, 2010

    DrWonderful

    Most chiropractors do not have web sites…

    If that is true there are an amazing number chiropractors out there based on a count of those that do.

    Claims data only focus on things that the insurance companies will pay for, correct? Vitamins, naturopathy, homeopathy, they are all cash & carry, maybe. No trail of woowoe.

  25. #25 locklin
    September 15, 2010

    “While additional research is needed in the area of integrative oncology, there is nonetheless a sizeable and growing body of well-designed, high-quality science that clearly supports specific interventions as evidence-based (http://www.ncbi.nlm.nih.gov/pubmed/19706235). Locating well-conducted randomized trials of integrative therapies in oncology is not a difficult matter.

    As funding for this area of research is relatively new and not supported by big pharma, many of the trials are small Phase II studies and lack appropriate control groups (often just usual care). As more positive Phase I and II trials are completed, we will start to see the larger, necessary, better-controlled Phase II and III trials to know the true benefits of some of these treatments. “

    Emphasis mine. Talk about glaring contradictions!

  26. #26 DrWonderful
    September 15, 2010

    @Pablo- I would appreciate it if you could explain your comment that I am a “major woo.” I am a chiropractor and I practice basic musculoskeletal physical medicine. Unless you have evidence otherwise maybe you should not try to to persuade your colleagues with dishonest comments? I was fairly certain you place a rather high standard on anyone who dares to comment here. Do you have the same level of evidence you demand of others. Or is it not necessary? Typically you are the snarkiest and most self righteous of the people who comment here and tend to attack with ferocity, but I guess you don’t hold yourself to very high standards?

  27. #27 DrWonderful
    September 15, 2010

    @MikeMA- yeah you raise a good point I did not consider. I sell no supplements and as far as I know the other docs I hang out with probably don’t either. If you care, a PT approached me a few weeks ago about selling $45 bottles of mangosteen juice as part of her downline in a multi-level marketing company. My dentist tried to get me involved with the same product earlier this summer. So far no chiro’s have approached me to sell it, though. My own anecdote.

    As far as billing is concerned the carrier data is likely is skewed based on pre-determined knowledge of what is covered although in my office I bill for everything I do and do everything I bill for.

    But seriously though, very few chiro’s have web-sites with any traffic. The one’s who do have the bigger sites buy from pre-fab templates where marketer loads the content and gets you at the top of the Google searches. It’s all garbage but not representative of the majority.

  28. #28 JJM
    September 15, 2010

    @Mr/MsWonderful,

    Your handwaving about woo content in chiro is belied by a recent survey of chiros by chiros “How chiropractors think and practice” William P. McDonald et al “Seminars in Integrative Medicine” 2004 V.2 #3 92-98. Ninety percent of chiros still believe in subluxations (and many who deny it, simply rename them; there are more than 300 synonyms in use). One could say that more than 90% of you make the rest look bad.

    Also, the Assoc of Chiro Colls official position is that the subluxation is the central idea of your trade http://www.chirocolleges.org/paradigm_scope_practice.html . Think about it, how much time and money did you spend studying a fairy tale? Would you have done that if you could recognize woo? I think you will find that no chiro believes he is a quack, not just yourself.

    Finally, if you are trying to be a “rational” practitioner, then you are trying to substitute for a PT. If I needed a PT, I would go to one who has studied and gotten real clinical education in the subject.

  29. #29 Dangerous Bacon
    September 15, 2010

    DocWonderful: ” I did not ask that no assignment of woo guilt be placed on my colleagues. There is plenty of it still out there but less and less each decade…The fact is that woo has steadily been draining out of chiropractic for the past 25 years…The fact is the chiro’s are improving their standards…”

    Cite?

    I was probably a bit hard on DocWonderful, who according to his comments here runs a relatively evidence-based practice including support for vaccination (something a hefty proportion of his colleagues will not do). What got me was his claim that woo is losing its grip on chiropractic, something that runs counter to the evidence I see every day. It’s not just the websites (which vary widely in format; only the types of woo are often similar), but the storefront promotions and newspaper ads as well (we have one local chiro who must spend a fortune on big ads in the paper; his latest focus is on convincing women that they’ve had their thyroid problems misdiagnosed and should come to him for advice and presumably treatment (is hypothyroidism a T6 subluxation, or is it L4? I forget).

    And individual chiros do have limited scope in policing their profession. What they should definitely do is get their professional organizations involved in speaking out against woo and turning up the heat on the worst offenders. Even the non-batshit crazy groups (such as the A.C.A.) are enabling the problem by turning a blind eye to abuses.

  30. #30 Pablo
    September 15, 2010

    I think you will find that no chiro believes he is a quack, not just yourself.

    This is a very important comment.

    No chiropractor or anyone is going to admit to being a quack. If you ask them, THEY are all acting rationally, and it is everyone else who is doing it wrong.

    That’s why I don’t take DrWonderful’s protestations that he/she is doing things properly and is not a woo too seriously. We’ve met DrWonderful before. Nothing he/she says about his/her practice makes me think that it is anything but your typical chiropractic office.

  31. #31 Gopiballava
    September 15, 2010

    Is this a good short summary of the article?
    “As long as the patient continues to receive the primary therapy recommended by their oncologist, we can safely lower the standard of evidence so low that we integrate what is, effectively, magic.”

  32. #32 Scott
    September 15, 2010

    No chiropractor or anyone is going to admit to being a quack.

    Not only will they not admit it, in most cases I think quacks don’t believe themselves that they are quacks. Generally they believe that their woo du jour really works – they’re just mistaken.

    There are some who are knowingly defrauding people, but they seem to be relatively scarce.

  33. #33 Pablo
    September 15, 2010

    Generally they believe that their woo du jour really works –

    Indeed, they all believe they are relying on sound science and using scientifically based methods. Despite the fact that there is no scientific basis at all.

  34. #34 william
    September 15, 2010

    So let me get this straight… when we didn’t know the mechanism of aspirin, we still knew it worked because of randomized controlled trials. But even though we have double blind randomized placebo controlled trials showing an effect from homeopathy, they must be fraud because we don’t understand the mechanism? Sounds like a double standard to me…

  35. #35 Todd W.
    September 15, 2010

    @william

    The problem is that the studies showing an effect of homeopathy beyond placebo are riddled with flaws. The greater the controls and the more rigorous the study, the less of an effect the homeopathic treatment has to the point of being indistinguishable from placebo.

    However, if you feel that there is a properly designed study that supports the efficacy of homeopathy, by all means, please let us see it.

  36. #36 Scott
    September 15, 2010

    So let me get this straight… when we didn’t know the mechanism of aspirin, we still knew it worked because of randomized controlled trials. But even though we have double blind randomized placebo controlled trials showing an effect from homeopathy, they must be fraud because we don’t understand the mechanism? Sounds like a double standard to me…

    The situations were not analogous. With aspirin, we didn’t know the mechanism, but we had no reason to doubt it could work, and there was a large amount of quality data supporting the fact that it did, with little indicating it did not.

    With homeopathy, there is a small amount of equivocal data suggesting that it works, a very large amount of solid data indicating that it does not, AND very strong reasons to doubt it could work.

    Put another way, the preponderance of the evidence indicated that aspirin worked and there was no basic science reason to question that. The preponderance of the evidence indicates that homeopathy does not work, and there are strong basic science reasons to question whether it even might.

  37. #37 Composer99
    September 15, 2010

    Care to point us to some of those trials, william?

  38. #38 JJM
    September 15, 2010

    So far, the article has 5 stars from 7 votes. I see Gopiballava’s comment was published; so far, the only one. I left one that is, hopefully, acceptable. Gopiballava pointed out they should not encourage use of energy medicine because there is no evidence base. I objected to renaming reiki from “alternative” to “complementary” and calling nutrition etc. “complementary.”

    Maybe someone could venture to post a link to this article, I thought it might kill the chances of my comment being accepted.

  39. #39 Morwyn
    September 15, 2010

    FYI: reiki has nothing to do with faith or religion. Might I suggest more research into the subject matter? Or, better yet, experience it for yourself.

  40. #40 Composer99
    September 15, 2010

    Morwyn @38:

    The introductory Wikipedia article describes Reiki as being a “spiritual practice developed in 1922 by Japanese Buddhist Mikao Usui” and “Through the use of this technique, practitioners believe that they are transferring healing energy in the form of ki through the palms.”

    Both the person who originated it and the importance of ‘ki’ (or ‘qi’ in China) in general in various Asian philosophical, spiritual or religious systems leads one to conclude that reiki does, in fact, have something to do with faith/religion.

    If you have any specific recommendations for further research, please feel free to cite them. Sources from the peer-reviewed literature are preferred.

  41. #41 DrWonderful
    September 15, 2010

    Aaaah@Bacon- hey buddy, long time no jousting. It is hard to argue your very well stated points.

    Never once in my career have I tied a non-musculoskeletal condition to a specific musculoskeletal lesion. At no time in my chiropractic education was the connection between a specific spinal segment and a specific condition such as a thyroid problem ever presented to me. What you saw is the product of a horrific marketing scheme or, imagine this, the chiropractor is not going to treat the thyroid condition with any specific manipulation. You again tie all chiropractic treatment to one procedure…spinal manipulation.

    For example…can I treat Type 2 diabetes? You betcha. It is a lifestyle disease. I would never take person off their meds or away from their PCP but I certainly can counsel on nutrition, exercise, psycho-emotional conditioning, etc. Can treat that without ever touching the patient and still practice legally in my scope and yes, bill for it! Same for many ailments. The semantics of “cure”, “treat” and “co-manage” need to be worked out in some cases but yes, chiro’s can treat and/or co-manage patients for all sorts of things and never actually adjust them, the same way an MD can (except w/o prescriptions). Are you insinuating that the only way to treat any condition is always with drugs or surgery? It would be quite revealing if you were.

    @JJM- it’s ok. You can call me doctor. My state recognizes me as a chiropractic physician and the Fed Dept of Education credentialed my doctorate degree.

    Also, I am in no way substituting myself for a PT. My DC education has provided me with more basic science, anatomy, physiology, clinical pathology, physical examination, and differential diagnosis, including radiology and blood, than any PT walking on this earth (other than those who later went on to MD, DC or DO programs). You should look closer at the chiro education, you might be clued in a little better.

    You also might be interested in knowing that the majority of the modalities PT’s use today, including rehab and proprioceptive re-education, were in fact developed by DC’s long before PT ever existed. If anyone is mimicking anyone it is the PT’s who are trying to be DC’s, even now more than ever.

  42. #42 mcsnebber
    September 15, 2010

    @Dr. Wonderful:
    Could you post your chiropractic school curriculum including clinical service time? This would go a long way to establishing whether or not you can say you are qualified in pathophysiology, differential diagnosis, testing (radiology and blood tests, among others) and treatment of disease. Also, do you do any post-graduate work prior to obtaining your license? MDs must do at lease one year of training to be licensed to practice independently of supervision. This WOULD be educational for me, and as you say, would “clue me in” a little better–thanks.

  43. #43 JJM
    September 15, 2010

    @Mr/sWonderful,

    Your degree is not academic and accreditation has nothing to do with the legitimacy of your field. There are (were?) accredited schools of astrology.

    If your “DC education” is good, why do your ilk believe in, and (officially) promote, the fairy tale of subluxation (and all of its euphemisms)? It is also well known that your “clinical education” is a joke, see http://www.chirobase.org and, more particularly http://www.dynamicchiropractic.com/mpacms/dc/article.php?id=53681&MERCURYSID=9ac341fe894c032f3c98ee00405aa420 which is written by a chiro.

    You really must supply evidence that PTs are merely copying people in your trade. You also thought that most chiros are adopting a rational practice (despite the McDonald survey I cited). Your beliefs are not reliable.

  44. #44 Dangerous Bacon
    September 15, 2010

    As is evident from DocWonderful‘s last post, even self-professed non-woo chiros retain some degree of cluelessness about what they should and shouldn’t be treating.

    In Doc’s case, he should not be a treating a disease he does not understand (type II diabetes, while strongly linked to obesity, has a significant genetic component and is not purely a “lifestyle disease”. Nonobese individuals may develop it). It would be interesting though to see what his nutritional and “psycho-emotional conditioning” advice is, and how much insurance providers might be shelling out for said advice.

    You can find plenty of chiros advertising that they can sucessfully treat diabetes (and other chronic medical complaints) through manipulation. Here’s one chiro practice that believes in “gentle” upper cervical manipulation relating that they can successfully treat both diabetes and cancer in this way (though there’s a quack Miranda warning of sorts).

  45. #45 DrWonderful
    September 15, 2010

    @Jenbphillips- you seem to be making the assumption that chiropractors only perform spinal manipulation. The conditions you mentioned can all be treated, or helped, with many different natural therapies including basic lifestyle counseling, nutrition, etc. These services are rarely offered by primary care and pediatric physicians, not very well at least, and can go along way toward helping patients. Chiropractors do a lot more than manipulate specific spinal musculoskeletal lesions. No matter how hard you try to avoid it, the truth remains he truth.

    As far as children and pregnant patients are concerned I fail to see your point. Both respond very well, and very safely, to chiropractic treatment for a variety of issues. There is a large Ob/Gyn practice in my city that use to refer at least 3-4 pregnant patients a month to me until they finally hired their own chiropractor who practices much the way I do. That chiro only treats in-house pregnant patients now and treats musculoskeletal conditions and counsels on gestational diabetes, blood pressure, exercise, sleep positions, ergonomics, nutrition, etc. I play golf with the principle OB in that practice 2-3 times a year and she told me the chiro is by far the most popular person in their practice of 8 OB’s, 3 PA’s and several nurse practitioners. To them it is a phenomenon. To us it’s SOP for more than 100 years.

    I have a pediatrician patient who sends many kids to me, including her own, on a regular basis. Your fear, no terror, is not shared by the medical professionals who actually treat those classes of patients themselves. Only the blind snarky skeptics who have an agenda and axe to grind.

    Like it or not chiropractic has integrated with mainstream medicine and the practitioners who work with us directly are typically very impressed.

  46. #46 DrWonderful
    September 15, 2010

    Bacon – you can skirt around the truth all you want…are you trying to convince us lifestyle is not a major factor in type 2 diabetes and no one can help anyone with that condition without drugs and surgery? Making lifestyle changes will not in the vast majority of the cases impact the life of a type 2 diabetic whether a genetic pre-dispositon exits or not? Are you serious? Any science at all behind drinking green tea and helping diabetes?

    With regard to that chiro you were able to pull out of your ass you’ll need to find 35,001 more just like them to even call it a majority position, let alone representative of the entire profession.

  47. #47 DrWonderful
    September 15, 2010

    @JJM- omg you cited chirobase? Was that peer reviewed and indexed? Hah! It’s known to be complete fiction. I love it when people cite their own manipulated and biased stuff as “proof.”

    Yes, the DC education is much stronger in basic science, anatomy, physiology, pathology, radiology, diagnosis, neuro pathology, etc than every single PT program in the world. Even the worst chiro school is better..it has to be because most of this is never covered in PT programs. PT’s have no differentially diagnosis skills or training in disease pathology, none, ever, zero, zilch. Not even in their DPT programs. This is not even an argument worth having, read the catalogs and licensing requirements.

    Now PT’s are talking and marketing like chiro’s used too…leg length discrepency, pelvic tilt, orthotics, and even high velocity low amplitude manipulation are becoming mainstream in PT. They absolutely are trying to mimic chiro’s.

  48. #48 mcsnebber
    September 15, 2010

    Sorry to make a simple request to justify your claims of adequate training. Perhaps I should have done my research.
    The services you provide sound like some sort of PA/NP/PT hybrid without the abiity to prescribe and without the need to be supervised. Even if it is confined to musculoskeletal conditions.

  49. #49 DrWonderful
    September 15, 2010

    @mcsnebber- I think you have come up with adequate anaologies. With much more experience working with medical groups than most of my colleagues I was would say we fit in around the mid-level provider level when it comes to diagnosis of non-musculoskeletal conditions. Even less so when it come to co-management. My friends would shudder at my saying that but I do believe it is true. If we obtained prescription rights that wpuld improve dramatically. Let’s face it…pharma’s make a huge difference.

    We do fill a nice triage, differential diagnosis, portal of entry, natural management niche that is autonomous. Responsible DC’s recognize their strengths and weaknesses and should co-manage most non musculoskeletal conditions wih their medical counterparts. When it comes to musculoskeletal diagnosis and treatment I honestly think chiro’s are on par if not supoerior to every discipline out there including PT’s and Ortho’s.

    The woo is draining out but the residue remains, of course.

  50. #50 jenbphillips
    September 15, 2010

    Dr. W:

    you seem to be making the assumption that chiropractors only perform spinal manipulation

    Not at all. I am inferring that the conditions I listed will be treated with spinal manipulation at this particular practice, based on the declaration on the website that states that these conditions are treated *with chiropractic*. I’m sure plenty of DCs do include nutritional counseling etc. as part of their practice model, but such therapies cannot reasonably be defined as “chiropractic”. Do you define them as such?

    Moreover, (as is pointed out repeatedly on this site), nutritional/lifestyle counseling is NOT in any way alternative. Primary care and pediatric MD practices do it routinely, contra your claim in #44.

    There is a large Ob/Gyn practice in my city that use to refer at least 3-4 pregnant patients a month to me until they finally hired their own chiropractor who practices much the way I do. That chiro only treats in-house pregnant patients now and treats musculoskeletal conditions and counsels on gestational diabetes, blood pressure, exercise, sleep positions, ergonomics, nutrition, etc. I play golf with the principle OB in that practice 2-3 times a year and she told me the chiro is by far the most popular person in their practice of 8 OB’s, 3 PA’s and several nurse practitioners. To them it is a phenomenon. To us it’s SOP for more than 100 years.

    Um, what was the topic of the original post here? There are, regrettably, many MDs who endorse woo. Such endorsements do not give any scientific weight to quackery, although they do seem to enrich the quacks.

    Your fear, no terror, is not shared by the medical professionals who actually treat those classes of patients themselves.

    My, what a sweeping generalization. See above.

  51. #51 DrWonderful
    September 15, 2010

    @jenbphillips- I fail to see your point. Are you stating that the chiro that practices with the OB group is practicing woo simply by virtue of the fact that she is a chiropractor? You say this with no knowledge of what she does on a daily basis? This does not strike you as blindly discriminatory and unfair to her?

    Again, despite my efforts to explain otherwise you simply must insist that the word “chiropractic” is interchangeble with a singular procedure, spinal manipulation. You do this as if you are somehow more of an authority in my field than I am? Wow, you just take a pre-determined thought and stubbornly cannot let go of it, huh? You make the stakes so high for yourself in the case that you might be wrong. That’s not skepticsm, that is fundamentalism and takes you over the line toward an unhealthy mental state.

  52. #52 Dangerous Bacon
    September 16, 2010

    DocWonderful: “Making lifestyle changes will not in the vast majority of the cases impact the life of a type 2 diabetic whether a genetic pre-dispositon exits or not? Are you serious?

    Of course lifestyle changes can be quite helpful in type II diabetes. My point was that you can’t blame all incidence of this disease on lifestyle. Nor can chiropractic claim credit for promoting weight loss in managing this condition. It’s just another example of how alties try to appropriate mainstream medicine’s non-drug approaches to health and argue that they invented them.

    “Any science at all behind drinking green tea and helping diabetes?”

    Good question. What’s your evidence that drinking green tea is a proven method of glycemic control? If that’s your big gun in dietary/supplement management for diabetes, I fear for your patients.

    “With regard to that chiro you were able to pull out of your ass you’ll need to find 35,001 more just like them to even call it a majority position, let alone representative of the entire profession…The woo is draining out (of chiropractic) but the residue remains, of course. “

    We have only your assertion that the woo content of chiropractic is declining. Examples to the contrary are easy to find (here’s another of your colleagues providing “Nutritional Wellness Consulting” in addition to various forms of woo such as homeopathy and Bach flower therapy. We’re supposed to trust his qualifications in nutrition, because he learned his stuff not only in chiro school but in a naturopathic college as well). What evidence can you provide that chiropractic is becoming more evidence-based?

  53. #53 Damien
    September 16, 2010

    I would not dare to speak about someone’s specialty in a general fashion. I’d rather let themselves speak on it. And they have. And 90% believe in the bullshit.

    DrWonderful, does it occur to you that perhaps you are in the tiny minority of chiros that aren’t essentially witch doctors? In trying to do a documentary recently on chiropractic, I called almost every chiropractor in my area, which was seriously, seriously time-consuming. I asked each of them on the phone if they worked with the subluxation therapy. Most of them did. In fact, I’d have to look at my notes, but I’m pretty sure all of them did.

    Just saying, maybe you should stop attacking us for pointing out that the vast majority of chiros are complete quacks. If you’re at a party and everybody’s walking like ducks and quacking like ducks, I would recommend you admit they’re ducks, and not pretend they’re people just like you.

  54. #54 hibob
    September 16, 2010

    @DrWonderful

    Look at claims data or something truly representative and you’ll see the overwhelming majority of the chiro’s treat basic musculoskeletal conditions.

    That has more to do with the types of claims insurance companies are willing to pay than which conditions chiropractors are willing to treat; the same goes for the reduced numbers of visits.

    Which conditions, outside of lower back pain, have chiropractic-specific techniques been proven to treat? Citations, please.

  55. #55 mcsnebber
    September 16, 2010

    @Dr.W
    “If we obtained prescription rights that wpuld improve dramatically. Let’s face it…pharma’s make a huge difference.”

    AMA Mission Statement (Pertaining to Evidence):

    The Council on Science and Public Health (CSAPH), formerly the Council on Scientific Affairs, works to represent the AMA’s core belief that scientific evidence is the basis for improving the quality of patient care, promoting medical progress and enhancing the health of the public. The council prepares reports on a wide range of public health and medical issues. Council members represent the full spectrum of the medical and public health continuum, bringing diverse expertise to their recommendations to the AMA House of Delegates.
    Mission Statement
    The mission of the Council on Science and Public Health (CSAPH) is to assure the position of the AMA as the national leader in advancing the science of medicine as the primary mechanism for improving the quality of patient care, enhancing medical progress, and enhancing the health of the public. The key objectives of the CSAPH are:

    Promote the scientific basis of medical practice
    Promote the betterment of public health
    Enhance the quality of medical care
    Be a leader in science and public health advocacy
    Enhance the profile and priority of science and public health within the AMA and the Federation*
    *Editor’s note: The term “Federation” is used to describe the state, county, and specialty medical societies represented in the AMA House of Delegates that work together to advance the agenda of physicians and their patients.

    American Chiropractic Association Mission Statement:

    “The ACA, as the profession’s preeminent leadership organization,
    strives to preserve, protect, improve and promote the chiropractic
    profession and the services of Doctors of Chiropractic for the benefit
    of patients they serve. The ACA provides lobbying, public relations,
    professional and educational opportunities for doctors of chiropractic,
    funds research regarding chiropractic and health issues, and offers
    leadership for the advancement of the profession.”

    American Academy of Chiropractic Physicians Mission Statement:
    “The mission of the American Academy of Chiropractic Physicians is to preserve, protect, improve and promote the chiropractic medical profession and the services of Chiropractic Physicians for the benefit of the patients they serve.
    The Academy advocates for direct access to chiropractic medical care, by advancing the training and competencies of chiropractic physicians.”

    I think it would be scary to give prescribing capabilities to members of professional societies without the word “science” in their mission statements. I realize this is a simplification of the issue however illustrates to a degree the concerns regarding the fundamental philosophical differences in the two professions. I agree with a previous commenter that your passion and energies could well be focused on changing these societies to reflect your personal approach; you seem to be purporting to be more focused (in an elevated manner above some/many/most of your colleagues) on evidence and science based learning that began in graduate school and has continued. I don’t believe there will ever be prescribing privileges ever granted to your profession without evidence of “evidence and science-based” medicine being paramount in the mission of your societies and curricula (as a start!).

    “The services you provide sound like some sort of PA/NP/PT hybrid without the abiity to prescribe and without the need to be supervised. Even if it is confined to musculoskeletal conditions.”
    I was merely describing a hypothetical professional by what it seems you are stating of the services you provide; it doesn’t mean that you have the same training as all of them, or if they sum to your training. But PAs and NNPs who write prescriptions are supervised by a physician, and PTs don’t prescribe medications. The combination still would not be able to function without a physician. And the imaginary combo would force the PT component be very evidenced and science based. This is more thinking out loud, trying to get at the basis of your claims of adequate training, knowledge base, and science. Maybe such a curriculum combining PA/PT or NP/PT would create professionals who provide the services that you personally do without the “woo” part found so frequently in your profession.

  56. #56 JJM
    September 16, 2010

    Sorry about the derail, in which I participated.

    I just left another post at Cohen’s article suggesting that readers should come here.

    Joe

  57. #57 Bob Stone
    September 16, 2010

    Looks like someone might want to consider being more objective. There are many prominent Integrative Medicine Programs that can not me simply dismissed as woo.

    Integrative Medicine Programs

    * M. D. Anderson Cancer Center’s Complementary/Integrative Medicine Education Resources (CIMER)
    * Dana-Farber Cancer Institute’s Zakim Center for Integrated Therapies
    * Johns Hopkins Center for Complementary and Alternative Medicine
    * Integrative Medicine Service at Memorial Sloan-Kettering

  58. #58 Scott
    September 16, 2010

    Please provide evidence that these programs “cannot be simply dismissed as woo.” An argument from authority based on the prestige of the institutions involved does not qualify.

  59. #59 Pablo
    September 16, 2010

    Looks like someone might want to consider being more objective. There are many prominent Integrative Medicine Programs that can not me simply dismissed as woo.

    Integrative Medicine Programs

    * M. D. Anderson Cancer Center’s Complementary/Integrative Medicine Education Resources (CIMER)

    So wait a minute…

    Orac is not being objective in criticizing the UT-MD Anderson Cancer Center’s quackademic medicine because there are prominent Integrative Medicine Programs that cannot be dismissed as woo, such as the one at the MD Anderson Cancer Center?

    So Bob, where did you cut and paste this from? Clearly, it was not written in response to this post.

  60. #60 jenbphillips
    September 16, 2010

    Are you stating that the chiro that practices with the OB group is practicing woo simply by virtue of the fact that she is a chiropractor?

    No, I’m stating that the affiliation of any practitioner of CAM with an MD-run practice is not sufficient evidence that said CAM practitioner is not a woo. I am not making any judgement about the specific people in your anecdotes, merely expressing that the imprimatur conferred by MD referrals to/collaborations with CAM practitioners doesn’t make CAM any more valid. Scientific evidence of efficacy would really be the only thing that would convince me otherwise–and I could genuinely be convinced with sufficient data. If this strikes you as ‘fundamentalist’, I think your definition of the word lacks precision.

    Speaking of which:

    Again, despite my efforts to explain otherwise you simply must insist that the word “chiropractic” is interchangeble with a singular procedure, spinal manipulation.

    Again, no. ‘Chiropractic’ is a fairly specific term. While, as stated earlier, I accept that chiropractors do more than spinal manipulation in their practices, it is needlessly confusing and misleading, based on the public understanding of what ‘chiropractic’ means (see, e.g. these definitions), to characterize diet and exercise advice (for example) AS ‘chiropractic’. If you are indeed on the leading edge of a profession-wide movement to drive out the woo, practice evidence-based medicine, and redefine what it means to be a chiropractor, I certainly wish you well. But until such efforts are well on their way to completion, it’s nonsensical to pretend that your definition *already* means something else entirely than what has been routinely defined as ‘chiropractic’ since Palmer.

  61. #61 Scott
    September 16, 2010

    DrWonderful:

    A question occurs to me, to which I would be interested to know your answer. Taking as given your points that chiropractors provide (e.g.) counseling on getting enough exercise and eating a healthy diet, in what way is this superior to the same sort of counseling provided by MDs? (Or for that matter, RNs.) And unless it is somehow superior, in what way does it justify the continued existence of chiropractic as its own discipline?

  62. #62 JJM
    September 16, 2010

    It looks like my comment on Cohen linking this blog has been rejected (it has been 7 hours and is noon (or past) anywhere in the 48 states). I also note that the rating of the article in “stars” (which was 2 out of 5) has been completely eliminated. It was at 2 of 5 when I voted, yesterday. Also there were no positive comments.

    Since Gopiballava and I have the only (accepted) comments taken together with the low value (in stars) given by readers (now censored), one must doubt the impact of Cohen’s ideas.

    Joe

  63. #63 DrWonderful
    September 16, 2010

    @Scott- Chiropractors have long emphasized the “natural” healthy lifestyle (over 100 years) and still take the time to do it on a regular basis. MD’s, NP’s, and PA’s are obviously capable but it really still is not emphasized, or done very well, in mainstream medicine. I suspect because it is not part of a viable revenue stream for most practices and this stuff takes time. Educating takes time, lots of time, and most mainstream medical offices do not schedule adequate time. Probably because it really isn’t their niche and it really does not pay well in the medical model. Can’t blame them but it’s true that chiro’s tend to do more of it, more often, and at a higher level of competency as it stands now.

    With regard to your other question I first have to ask you why a discipline must be completely unique? Why do we have podiatrists vs ortho’s or optometrists vs ophthalmologists? Psychologists vs psychiatrists? The medical model alone has ample discipline crossover and overlap within itself, does it not?

    I would say chiro’s, when best utilized at their optimal level, are portal of entry, differential diagnostic, musculoskeletal based physicians who also perform their own therapeutic protocols. An excellent chiro will refer to ortho’s, neuro’s and PT’s when indicated (I do) and of course utilize all medical specialties when needed. I personally spend my time treating musculoskeletal conditions, which is the norm in my field, but chiro’s can adequately cross over and function as mid-levels in primary care settings. A great woo-free model is being developed in the VA system as we speak.

    Let’s face it choices and competition drive innovation and performance in the world. Y’all seem to be very anti-competitive here.

  64. #64 Scott
    September 16, 2010

    Chiropractors have long emphasized the “natural” healthy lifestyle (over 100 years) and still take the time to do it on a regular basis. MD’s, NP’s, and PA’s are obviously capable but it really still is not emphasized, or done very well, in mainstream medicine.

    I must inquire as to your basis for this statement. In my experience (and those of everyone I’ve ever heard opine on the subject), mainstream medicine emphasizes lifestyle factors very heavily indeed.

    For instance, can you provide evidence that chiropractors know things about nutrition and exercise that MDs do not? Or that chiropractors achieve better compliance with recommendations than MDs? After all, let’s be honest here. Essentially everyone knows the important principles of diet and exercise (it’s not like they’re complicated). It’s compliance that matters, not education per se.

    With regard to your other question I first have to ask you why a discipline must be completely unique?

    I do not so require, though I do require that it provide SOMETHING unique. You presented the diet/exercise thing as a reason chiropractors are needed. It would only BE such a reason if chiropractors did a better job with that than MDs.

    I would say chiro’s, when best utilized at their optimal level, are portal of entry, differential diagnostic, musculoskeletal based physicians who also perform their own therapeutic protocols.

    Are chiropractors able to do this as competently as MDs? Particularly given how much less training is required for a DC than an MD?

    Let’s face it choices and competition drive innovation and performance in the world. Y’all seem to be very anti-competitive here.

    Straw man; another MD is just as much competition as a DC.

  65. #65 Jenbphillips
    September 16, 2010

    [healthy lifestyle education] really still is not emphasized, or done very well, in mainstream medicine.

    [citation needed]

    An excellent chiro will refer to ortho’s, neuro’s and PT’s when indicated (I do) and of course utilize all medical specialties when needed.

    The fact that you consider this a sign of ‘excellence’ rather than, say, ‘competence’, is rather alarming.

    Let’s face it choices and competition drive innovation and performance in the world. Y’all seem to be very anti-competitive here.

    Hello, straw man! Our objection isn’t to the emergence of an equally effective (and thus competitive) alternative treatment methods to conventional medicine. It’s that there are no equally effective alternative treatment methods to conventional medicine. Anything that claims to be, absent objective supporting data, is a sham.

  66. #66 william
    September 16, 2010

    Anyone sincerely interested in objectively exploring the scientific evidence regarding homeopathy can go to Pubmed at
    http://www.ncbi.nlm.nih.gov/pubmed
    Enter “Homeopathy” and be sure to click on “Limits” and for “Type of article” select “Randomized controlled trial”.

    When you read the abstracts you will see a mix of positive and negative studies. Obviously there are many remedies and many possible dosages in homeopathy, so it is impossible to make blanket statements about the efficacy of this approach like “Homeopathy doesn’t work” or “Homeopathy works.” That would be like saying “Allopathy works” or “Allopathy doesn’t work.”

    Skeptics should be careful not to assume that all positive studies are fatally flawed but the negative studies are not.

    On another note, it is curious that some skeptics assume that for something to work there has to be a “plausible” explanation according to current scientific knowledge. This would mean that if we don’t know of a plausible mechanism, the data must be erroneous. Of course, a little humility might help here…

  67. #67 Militant Agnostic
    September 16, 2010

    That would be like saying “Allopathy works” or “Allopathy doesn’t work.”

    Thanks to the scientific method, we know “allopathy” doesn’t work and that is why it was abandoned a long time ago. SBM/EBM based doctors aren’t recommending mercury* and lead based medications. Next straw man please.

    *Cue the thimerasol trolls.

  68. #68 Chris
    September 16, 2010

    william:

    This would mean that if we don’t know of a plausible mechanism, the data must be erroneous. Of course, a little humility might help here…

    It works both ways. If you put the word “homeopathy” in the search window of this blog (upper left hand corner of this page) you will see many discussions, several on many of those papers. There are also several discussions on this Skeptical Forum.

    The general trend in those studies is the rigorous the study is done the less likely homeopathy is going to work.

    Two questions that you need to find the answers (and they are discussed in detail in the discussions in the forum linked to above) to are:

    1) Find a well documented case with third party verification that homeopathy (and only homeopathy, nothing else) cured a non-self-limiting disease. This means a disease that will not get better on its own.

    2) Be able to distinguish between two homeopathic remedies without labels, and from the solvent (water or alcohol) or base (lactose pill). Bonus: there is actually a cash reward for doing that task.

    Once you have answered both of those two questions, you can discuss how it works, and that it is plausible.

  69. #69 Fuzzzone
    September 16, 2010

    “and many possible dosages in homeopathy”

    Indeed. Although they all really boil down to varying levels of zero, don’t they?

  70. #70 DrWonderful
    September 16, 2010

    @Scott- Wow. If MD’s are highly skilled at educating patients on natural healthy lifestyle issues in an effort to prevent and manage disease and also have a high level of competency in diagnosing and managing musculoskeletal conditions then they really must hiding it very well. The reason why patients fill chiro offices obviously is because the medical community has failed miserably in those two areas, plain and simple. Like i said I understand why but let’s not pretend they are good at either.

    So what is so unique about a podiatrist or optometrist? I believe every service offered in those offices are also offered by their medical counterparts, no?

  71. #71 Science Mom
    September 16, 2010

    @Scott- Wow. If MD’s are highly skilled at educating patients on natural healthy lifestyle issues in an effort to prevent and manage disease and also have a high level of competency in diagnosing and managing musculoskeletal conditions then they really must hiding it very well.

    Not really, my practise, for example has a lifestyle clinic staffed with their physicians, registered dieticians and trainers. They are also extremely competent clinicians. I simply fail to see where chiropractors fit into the healthcare model except to be willing to spend more time with hypochondriacs.

  72. #72 DrWonderful
    September 16, 2010

    @ScienceMom- hypochondriacs as well as just about every professional and Olympic athlete too, I guess. The more you discriminate, the greater attention this all gets, the more people pay attention, and the greater the conversion of patient care from failed PT/ortho models toward chiropractic. So, I mean, you know, whatever.

  73. #73 augustine
    September 16, 2010

    Mr. Wonderful,

    It’s pathetic watching you beg for professional acceptance from a group of people who will NEVER accept you. What is even more sad is to see you throw all the other “woo” practitioners under the bus for your own self-serving aggrandizing purposes. At least the SBMers truly believe in what they stand for. You on the other hand act purely out of EGO.

    “See science bloggers, I’m one of you guys, I don’t practice that other woo. My woo is legit. Please oh please let me in your club. I’m qualified. I even have “Dr.” in front of my name. If you want I’ll even throw a sack of turds on the door of a woo office.”

    No one respects you for a reason.

  74. #74 JJM
    September 17, 2010

    Mr. Wonderful’s claim that chiros are no longer quacks is belied by the 2004 McDonald study (cited above). Wondy’s assertion that he has studied basic sciences is belied by the fact that he believes in chiro subluxations. (In actuality, what they learn in those courses is “conversational science” so they can sound educated to the gullible.)

    Now, Wondy wants us to think chiro popularity among athletes is evidence for efficacy. That’s a well-known fallacy, among the educated. But, tell us Mr. Wonderful- what do chiros do that health professionals and masseurs cannot?

  75. #75 dinkum
    September 17, 2010

    Many professional athletes also swear by their lucky underwear.

  76. #76 Scott
    September 17, 2010

    ow. If MD’s are highly skilled at educating patients on natural healthy lifestyle issues in an effort to prevent and manage disease and also have a high level of competency in diagnosing and managing musculoskeletal conditions then they really must hiding it very well. The reason why patients fill chiro offices obviously is because the medical community has failed miserably in those two areas, plain and simple. Like i said I understand why but let’s not pretend they are good at either.

    Doesn’t follow that chiropractors do it any better…

    So what is so unique about a podiatrist or optometrist? I believe every service offered in those offices are also offered by their medical counterparts, no?

    Optometrists are cheaper than opthamologists, which is at least some justification. I have insufficient knowledge of podiatry to comment, so on that point I’ll refrain.

  77. #77 mcsnebber
    September 17, 2010

    Please. Ophthalmologists (always with 2 h’s) are also eye surgeons. They are have a variety of specialties within the field–neuro-ophthalmology, retinology, pediatric ophthalmology.. and many others. They do many more sophisticated tests, AND they fix eyeballs using lasers, replacement parts, and KNIVES. There is a reason these services cost more. And, optometrists REFER to them, and do perform a good screening role in their field while helping people see better. They are NOT interchangeable. C’MON MAN!
    Now for podiatrists, I have a thing on the bottom of my foot. That is what I would consider them a starting point for, which I believe they would be expert at addressing (I think it is a corn). They perform important functions for diabetics with wound and neuropathy issues, and do minor surgery.

  78. #78 Vicki, pouring my tea from Russell's teapot
    September 17, 2010

    The problem with all sorts of patient education is that it’s easier to tell people something than to get them to change their lifestyles in significant ways because of it.

    The rate of tobacco use is strong evidence of that: if someone smokes, and has any contact with the medical profession, they have been told to quit. (If they don’t have that contact, they’ve been told by ads, relatives, and random strangers.)

    Given the choice, most people would rather take a pill than change their diet significantly, or exercise significantly more than they do already. At least some would also rather go sit in an office or clinic where someone else will do something to/for them, and go home and make no other changes.

    The something else might be inherently useful—I eat quite a bit of sugar, so it’s a good thing that I see my dentist for regular cleanings in addition to brushing and flossing, and it would be useful to get those cleanings even if I didn’t floss. Or it might be irrelevant to the problem (massage can be very pleasant, but it doesn’t cure everything), or complete quackery: it’s still tempting to go somewhere once a week, or month, or year, and then put the matter aside until the next visit.

    Physical therapists can teach all sorts of useful exercises and stretches for a person to do at home (in addition to applying heat, massage, and so on). Some people go home, don’t do them, and just come back next week. More go home, do them more or less diligently until the PT says “great, you’re fine now, keep doing these so it doesn’t get better” (or the insurance company says they’ve hit their cap on number of visits), and then stop. Those exercises and stretches are boring even if not difficult; I’d rather read a book or go for a walk. Most days, I do at least some of them. Unfortunately, “most days I do at least part of it” is better than average.

  79. #79 james gaulte
    September 17, 2010

    The following is intended to neither detract from or amplify your comments regarding the apparent invasion of woo to MD Anderson, although I agree with your comments. You indicated that Lorenzo Cohen has both the MD and PHD degrees.As best I can he has only the PhD in medical psychology.On the faculty page of the MD Anderson website he is listed as Lorenzo Cohen,PhD. Under education the site reads “Uniformed Services University of the Health Sciences, Bethesda, MD, PHD, Medical Psychology”. The MD after Bethesda is the state and PhD is the degree. Further, there is no reference to an MD with his name on the AMA physician’s listing nor on the Texas Medical Board’s listing of licensed physicians in Texas.

    Your comments stand-I just didn’t want Dr.Cohen to get more academic credit that he deserves.

    By the way your concise explanation of the difference between EBM and Science Based Medicine is worth the price of admission and beautifully expresses a theme I have ranted about for a while even though some time ago a blog commentary of mine was apparently so poorly worded that the prolific Orac swooped down like a fury on my comments mistaking my anti-EMB thoughts as anti-academic. All is forgiven.

  80. #80 JJM
    September 18, 2010

    Dr. Cohen responds:

    Lorenzo Cohen | September 16, 2010 4:10 PM | Reply

    So that there is no misunderstanding, MD Anderson does not offer Reiki, Healing Touch, Therapeutic Touch, or other forms of “energy medicine” to patients. The evidence-base does not exist for these modalities and, as such, they are not offered. Moreover, the SIO does not make a “strong recommendation” for these treatments. At our annual meeting we “allow” people to present their research on this topic, as we support research in all areas. In the SIO Clinical Practice Guidelines (http://www.integrativeonc.org/index.php/sio-publishes-2009-practice-guidelines) energy therapies are not endorsed per se, the evidence for and against in simply presented and the reader, whether physician or patient, can make their own decision on how to proceed clinically.

    The inclusion of nutrition and dietary counseling, physical activity counseling, stress management, social support, etc. within the integrative medicine model is based on the philosophy of providing these approaches in a comprehensive fashion under the direction of a medical oncologist. This is what distinguishes integrative oncology from how these treatments are often delivered within most conventional medical systems – if they are offered at all.

  81. #81 JJM
    September 18, 2010

    So I asked Cohen if all he offers is medicine, why call it “integrative?” Maybe that comment has been censored, or maybe it is just the weekend.

  82. #82 squirrelelite
    September 18, 2010

    @JJM,

    Thanks for the link to the SIO Clinical Practice Guidelines.

    I downloaded the pdf and gave it a quick skim, but didn’t have time to plow through all 36 pages. Perhaps orac or one of his friends at SBM could give it a look if they haven’t done so already. (It has been out for a year now.)

    I did notice a few oddities and will try to give them a more careful response soon.

    They try to emphasize the “distinction” between complementary medicine and alternative medicine, but then go on to just use the term CAM repeatedly.

    They give acupuncture a 1A recommendation, their highest.

    The comments on energy medicine are pretty wishy washy. Sort of along the lines of “there’s no good evidence that it works, but if you want to try it, go ahead.”

    They state that there is good evidence for several CAM treatments. Strange that the NCCAM after 10 years and a few billion dollars hasn’t found them yet.

    They completely glossed over some real dangers of some treatments, like infection from unsterilized or improperly handled acupuncture needles.

    Several of the treatments mentioned, such as exercise, massage, meditation, nutrition, music therapy, etc. probably have very little effect on the long term outcome for the patient. But, IMHO they can at least be helpful for patients trying to cope with the pain, discomfort, emotional distress, and other side effects of a prolonged cancer treatment regimen.

    However, they seem to be used as sort of a flag carrier or Trojan Horse to shoehorn everything else in.

  83. #83 Gopiballava
    September 18, 2010

    Energy medicine is in two categories that are both “strong recommend”. My reading of the clinical guidelines contradicts Dr. Cohen’s. I submitted a comment pointing out the categories. We shall see what the response is.

    I think it’s ridiculous to conflate providing all evidence-based therapy and expanding the acceptable definition of conventional therapy. It really feels like the woo mindset is permeating them.

    I think, IMHO:
    I don’t expect an oncologist to tell a stage IV cancer patient that they’re a fool for trying Reiki.
    However, when determining clinical guidelines, there have to be three categories:
    Strong evidence based
    Plausible / weak evidence based
    Magic

    If you are trying to educate clinicians and expand their scope of treatment, and you are unwilling to state clearly and un-equivocally that Reiki and all other energy therapies defy multiple fundamental laws of physics and have only weak evidence of efficacy, you are encouraging belief in woo.

  84. #84 Vicki
    September 19, 2010

    The other side of that is that if I develop cancer, I don’t want my oncologist pushing something like reiki, which would waste both money and finite time.

  85. #85 Drew
    September 20, 2010

    I’ve been reading your posts with interest and enthusiasm for the debate. As a student trying to make sense of the conflicting information and passions, could someone please explain “evidence based”? According to JAMA, 2009:

    Reported levels of scientific evidence were reviewed and the degree of scientific support for 2711 specific practice recommendations was assessed and placed in one of three categories:

    Level of evidence A-recommendation based on evidence from multiple randomized trials or meta-analysis

    Level B-recommendation based on evidence from a single randomized trial or non-randomized study

    Level C-recommendation based on expert opinion, case studies, or standards of care

    results of that study showed that only 11% of 2711 recommendations are based on level of evidence A-muliple randomized trials. Of the remaing recommendations, 41% are based on level of evidence B-a single randomized trial or non-randomized studies and 48% are based on level C-expert opinion or case studies.

  86. #86 JJM
    September 20, 2010

    Drew,

    How about enough information so I can look up the article.

  87. #87 Drew
    September 20, 2010

    Of course!

    Tricoci P, Allen JM, Kramer JM, Califf RM, Smith SC Jr. Scientific evidence underlying the ACC/AHA clinical practice guidelines. JAMA. 2009;301(8):831-841.

  88. #88 Gopiballava
    September 20, 2010

    I wonder what the usage frequency is for the 2711 recommendations. I expect that a small percentage of recommendations are used for most treatment. I should see if the paper is freely available.

  89. #89 ian.monroe
    September 22, 2010

    Maybe my memory from high school Spanish class is a bit hazy, but I think Sancho Panza was alarmed by the attack on windmills. Don’t drag that old skeptics name through the mud. :)

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