Let's face it, Dr. Andrew Weil is a rock star in the "complementary and alternative medicine" (CAM) and "integrative medicine" (IM) movement. He is one of its founders, at least a founder of the its most modern iteration, and I am hard-pressed to think of anyone who did more in the early days of the CAM/IM movement, back before it ever managed to achieve a modicum of unearned respectability, to popularize CAM. In fact, no physician that I can think of has over the course of his lifetime done more to promote the rise of quackademic medicine than Dr. Weil. The only forces greater than Dr. Weil in promoting the infiltration of pseudoscience into academic medicine have been the Bravewell Collaborative and the National Center for Complementary and Alternative Medicine (NCCAM). Before there was Dr. Mehmet Oz, Dr. Dean Ornish, Dr. Mark Hyman, or any of the other promoters of IM, there was Dr. Weil.
And why not? Dr. Weil looks like an aging 1960s rock star, and, operating from his redoubt at the University of Arizona, is quite charismatic. For all the world Dr. Weil has the appearance of a kindly, benevolent Arizona desert Santa Claus, an ex-hippie turned respectable, dispensing advice about "natural" medicines, writing books, and making himself ubiquitous on television and radio whenever the topic of alternative medicine comes up. Before Dr. Oz told Steve Novella that "Western" science and medicine can't study woo like acupuncture, Dr. Weil was there, paving the way for such arguments, previously considered ludicrous, to achieve a patina of respectability.
In fact, he's still at it, too, doing it far better and far more subtly than the ham-handed Dr. Oz. Unfortunately, it's the same anti-science message and the same appeal to other ways of knowing built upon tearing down straw men versions of evidence-based medicine (EBM) with gusto. This was brought home last week when Dr. Weil co-authored an opinion piece with Drs. Scott Shannon and Bonnie J. Kaplan for the journal Alternative and Complementary Therapies entitled Safety and Patient Preferences, Not Just Effectiveness, Should Guide Medical Treatment Decisions, an article that was noted at the blog Booster Shots in a credulous, fawning post entitled Dr. Weil says there's a better approach to evaluating clinical drug trials. In contast, Steve Novella put it far more succinctly (and accurately) in the title of his post: Andrew Weil Attacks EBM. That's exactly what Weil and company did in this article.
While Steve is absolutely correct, I also see it more as Dr. Weil demonstrating once again that, upstarts like Dr. Oz aside, he is still the master of CAM/IM apologia, much as, even though both were Sith Lords, Emperor Palpatine remained master over Darth Vader until just before Vader turned on him and threw him down the energy shaft. You'll see why in terms of the arguments, both subtle and not-so-subtle, that Dr. Weil and his acolytes make. Moreover, even though his disciple Shannon is granted the coveted first author position, the arguments presented leave little doubt that it's Weil who's driving the bus.
Efficacy, effectiveness, and safety, oh, my!
Shannon et al begin by emphasizing that there is a difference between "efficacy" and "effectiveness," and from the very beginning take pains to separate their definitions of the two, pointing out that they will not use the terms interchangeably. Specifically, they refer to the definition of "efficacy" as "demonstration of benefit under ideal conditions, typically in randomized controlled trials" and "effectiveness" as "demonstration of benefit in real-life conditions." These are relatively new concepts, comparatively speaking. Even so, they are nothing "alternative," being instead firmly within the bailiwick of EBM. This doesn't stop Shannon et al from presenting these concepts as though EBM and science-based medicine (SBM) don't consider questions of whether treatments work under real-life conditions. As you will see, it is also the opening volley in a rather complex set of fallacious arguments designed to support the watering down of scientific rigor in order to allow CAM/IM modalities that can't stand up under close scientific investigations to be labeled as "effective" (or at least acceptable).
First of all, let's see a bit more what Weil and company are up to when they compare "effectiveness" with "efficacy." Mostly, it's meant to attack the reliance of EBM randomized clinical trials (RCTs) in order to set the stage for proposing something else more to their liking:
The value of efficacy lies mainly in its ability to indicate potential for effectiveness accurately. Sadly, in the drive to emphasize the importance of delineating clearly sound measures of clinical effectiveness, modern medicine has come to equate RCTs as the final arbitrators of clinical decision making. As discussed below, RCTs are but one tool to sort out these complex questions. In integrative medicine (IM), particularly, with its emphasis on patient variables and practitioner participation, evaluation of efficacy is not sufficient.
In all fairness, I actually do agree that one major value of efficacy in RCTs is that they indicate the potential for effectiveness in the real world. I also even partially agree that EBM overemphasizes RCTs as the final arbiters of clinical decision-making, although, I note, not for the same reason as Weil and his acolytes. I've made the argument before that plausibility based on science should be a much more important consideration in evaluating treatments than it currently is in EBM. Indeed, this is a major reason that the term science-based medicine, as opposed to evidence-based medicine, was coined in the first place. EBM emphasizes RCTs with minimal, if any, consideration of prior plausibility, relegating basic science considerations that conclusively demonstrate CAM/IM modalities like homeopathy to be so implausible as to be not worth studying in humans to its lowest rung in its scale of evidence. So, while I agree somewhat that EBM overemphasizes RCTs, I most definitely do not agree with Dr. Weil about how it does so. Whereas Dr. Weil seems to think that RCTs are overemphasized because they are too standardized and do not adequately take into account real-world conditions, he most definitely would not like SBM's plea to EBM to consider scientific plausibility, because doing so would relegate modalities like energy healing, homeopathy, and acupuncture to the hopelessly implausible.
Dr. Weil also does a very clever thing with his argument. While he correctly points out that evaluation of efficacy is not sufficient to determine whether a treatment is effective, as Steve Novella pointed out, Dr. Weil conveniently neglects to acknowledge that it is at the very least necessary. If RCTs indicate that a therapy is not detectably more efficacious than a placebo, which is the case for the vast majority of CAM/IM modalities, then there is no point in doing trials in "real world" conditions because there is no reason to expect the to be effective. Basically, RCTs serve as a screening test to identify promising therapies that are likely to be effective in real world use. In essence, Dr. Weil is echoing the same two-pronged attack that CAM/IM advocates make against RCTs, the first being the claim that "Western science" can't study his woo, which is the same fallacious argument that Dr. Oz made regarding acupuncture. The second prong of the attack is to point to what Weil calls "alternative sources of valid information" as demonstrating that his woo works when RCTs do not support its efficacy. Although Dr. Weil is careful never to state this explicitly or even use the term "pragmatic trial," his emphasis on "effectiveness" over "efficacy" is in essence a plea for relying much more heavily on observational trials, in particular pragmatic trials.
But what are "pragmatic" trials? They are trials that seek to determine if a treatment is effective outside the confines of an RCT, in other words, out there in the "real world." RCTs, because they seek to determine efficacy, need to control for as many potentially confounding factors as possible, which makes them inherently artificial to one extent or another. Once efficacy is established under controlled conditions, it is sometimes then useful to determine whether this efficacious treatment is effective under usual circumstances in the "real world," where patient compliance might be poor, either due to side effects, cost, or difficulty in adhering to the therapy; where complicated protocols might be more problematic to follow compared to academic medical centers; and where use of the treatment will inevitably be expanded to patient populations not represented in the RCTs used to approve the drug.
Pragmatic trials can go one of two ways. In the case of treatments demonstrated efficacious in RCTs, most commonly pragmatic trials demonstrate a lower level of effectiveness than the efficacy measured in RCTs might indicate. As Harriet Hall discussed a couple of years ago, a classic example of a treatment that was shown to be efficacious in RCTs but potentially more dangerous in pragmatic studies of actual use in community hospitals was the clot-busting drug t-PA, which was effective for ischemic strokes in RCTs but resulted in a higher death rate. For efficacious interventions, the "real world" is almost always less hospitable than the "ideal world" of RCTs. There is one case, however, where the "real world" can make a treatment seem more effective than it is by any objective measure, and that's for treatments that are essentially placebos. Outside of the rigorous, carefully controlled world of RCTs, placebo medicine can seem to have effectiveness, which is exactly why proponents of pseudoscientific medicine absolutely love pragmatic trials. The populations aren't as well-defined; often there is no placebo control; and they are almost always unblinded. There is a good reason why, after well-designed RCTs have demonstrated acupuncture to be no more efficacious than placebo or sham acupuncture, acupuncturists have returned to pragmatic studies; Harriet Hall even calls them Cinderella medicine. The hospitableness of pragmatic trials to placebo medicine is also behind much of the attack on RCTs by advocates of pseudoscience, and Shannon et al certainly engage in such attacks with gusto:
RCTs have dominated decision making about efficacy in health care for almost 50 years. Many researchers have explored the difficulty of subjecting IM treatment approaches to RCTs. There are some characteristics of IM interventions that make RCTs particularly difficult to carry out, and perhaps even less relevant, than for conventional allopathic medicine. As Fønnebø pointed out, the gap between published studies of integrative approaches on the one hand, and the clinical reports by practitioners on the other hand, may partially result from the fact that placebo-controlled RCTs are designed to evaluate pharmaceutical interventions.
Or, more likely, they result from the biases and lack of adequate controls for placebo effects inherent in "clinical reports" by practitioners. Also note the Oz-like argument that RCTs can't evaluate Weil's favored woo.
Granted, uncontrolled clinical reports from practitioners can, if carefully documented, represent one form of pragmatic trials; more often they are at best preliminary data and at worst nothing more than anecdotes. To support their attack, Shannon et al cite a prominent New England Journal of Medicine study, namely Concato et al, which found that well-designed observational studies often produce the same results as RCTs, meaning that placing observational studies lower on the rung of the EBM hierarchy might not be justified. Unfortunately, the authors failed to note that Concato et al only looked at studies of clinical questions with objective outcomes, including the Bacille Calmette-Guérin vaccine and tuberculosis, mammography and mortality from breast cancer, cholesterol levels and death due to trauma, treatment of hypertension and stroke, and treatment of hypertension and coronary heart disease. Moreover, Concato et al have been criticized for cherry picking their examples. In contrast, most CAM modalities are designed to treat symptoms with a major subjective component. Also going against Weil's argument that, because RCTs are designed for pharmaceutical treatments, they might not be so good evaluating non-pharmaceutical treatments is a more recent study comparing effects in RCTs versus observational studies in digestive surgery, which found that a quarter of observational studies gave different results than randomized trials and that between-study heterogeneity was more common in observational studies. If this study holds up, it would appear that RCTs work just fine (and better than observational studies) for surgical interventions.
The merits and flaws of Concato et al aside, it is a false dichotomy that we must choose either controlled RCTs or less rigorously controlled observational studies. EBM and SBM can and do encompass them all; they simply disagree on how much relative weight to give each type of evidence. Fortunately, Weil doesn't make the argument that we must favor one or the other. Unfortunately, he's more subtle than that. What he does instead is to argue for decreased influence of RCTs by arguing that they should be only one part of the picture, an argument he makes by bringing up the Bradford-Hill criteria.
RCTs? They're not that important, are they?
The heart of the argument in this paper is that RCTs should be only one (presumably of many) factors that determine whether medicine considers and intervention to be effective or not. As the title suggests, safety and patient preferences play a prominent role in Weil's argument, but first Weil yokes poor Sir Austin Bradford-Hill, FRS, a pioneering early to mid-20th century epidemiologist best known for his work linking smoking to lung cancer and pioneering the RCT, into his service. Bradford-Hill proposed a set of criteria for drawing causality about disease etiology, but his nine criteria are sometimes used in considering the effectiveness of treatments.
Shannon et al set the stage:
As he [Bradford-Hill] pointed out, not all criteria are appropriate for all issues being analyzed, but he listed nine in total from which appropriate ones should be selected for any given situation:
- Strength--referring to the robustness of the association between the causative agent and the outcome
- Consistency--meaning being able to obtain similar results across different research sites and methodologies (i.e., replication)
- Specificity--by which Bradford-Hill meant one disease having one specific outcome, which may not be relevant to complex disorders (e.g., psychiatric problems)
- Temporality--referring to the commonsense notion that the cause always precedes the outcome
- Biologic gradient--which is best described as a dose- response curve: increased treatment would presumably result in a proportionate increase in the effect (again, not relevant in all disorders)
- Plausibility--referring to whether the results are biologically sound
- Coherence--which refers to the agreement of a study's findings with what is already known (hence, not relevant in situations of truly novel interventions)
- Experiment--the situation in which randomly introducing the causative agent results in the outcome
- Analogy--which is the idea that a similar cause results in a similar outcome.
It is particularly interesting to note that the Bradford-Hill criteria, specified by the individual who influenced the methodology we now accept for RCTs massively, lists experiment with randomization methods as only one of nine criteria for establishing causality.
See, you nasty, reductionist, Western scientists? RCTs are only one criteria! They're not the be-all and end-all of clinical evidence! I can't help but point out that there is an implicit straw man here in that embedded in many of the Bradford-Hill criteria are the same sorts of arguments advocates of SBM make, particularly criteria numbers 1, 2, 5, 6, and 7. In particular, SBM aficionados tend to like criteria numbers 6 and 7. Key to the very concept of SBM is that interventions should have biological plausibility. They should also be congruent with what is known about the disease or, if the treatment is not congruent with what is known, then the evidence supporting an intervention must be sufficiently compelling that it justifies overthrowing the existing paradigm (for example, in the case of the discovery that H. pylori causes peptic ulcers). I also can't help but point out that most CAM/IM treatments still fail most of Bradford-Hill's criteria. In particular, CAM/IM treatments almost always run afoul of all of Bradford-Hill's criteria other than #4, and, quite frankly, sometimes the wackier ones even seems as though they could run afoul of #4 as well.
Perhaps realizing this, Weil says nothing more about Bernard-Hill criteria other than to mention them again briefly in his conclusion. Instead, he and his merry trio of woo-apologists move on, Gish gallop-like, to other deficiencies in the "Western, reductionistic" model.
Systems biology? I'll give you systems biology!
Unable to abuse poor Bradford-Hill anymore, Weil moves on to list "unique" features of CAM/IM research that--surprise!--turn out to be not-so-unique and not nearly as difficult to take into account in SBM (or even in EBM) as he implies:
For instance, the healing relationship of a doctor and patient is generally excluded or "controlled for" in conventional RCTs, whereas some researchers would argue that unconditional positive regard forms the underpinnings of the healing relationship between two people.
The enhanced focus on the healing relationship is thus another factor delineating IM from conventional health care models. A second example is the concept of individualized care, which is rarely included in RCTs (perhaps the MTA study in childhood ADHD is a notable exception). The notion that each patient is unique and quite different permeates IM.
I like the admission that most CAM/IM is placebo medicine, though. Oh, you didn't see that admission? The emphasis on the "healing relationship" between practitioner and patient tells you that what Weil is talking about is placebo medicine. After all, that relationship is very important to placebo effects.
Be that as it may, I've discussed the so-called "individualization" of CAM treatments before, as well as the difference between the "personalized medicine" when practitioners of SBM use the term versus when CAM/IM advocates use the term. For the full discussion click on the links; the CliffsNotes version follows. Basically, the notion that each patient is unique is a notion that is recognized in EBM and SBM. It's also utterly facile and obvious, given that it's utterly facile and obvious that no two people are alike. What EBM and SBM try to do is to classify and stratify patients based on science-based characteristics that can be objectively related to disease severity, etiology, and response to therapy. As genomic medicine, systems biology, proteomics, and metabolomics become more sophisticated, it has become possible to make finer and finer distinctions between patients based on biology. The hope is that ultimately knowing these fine distinctions will allow us to "personalize" therapies to individual patients, thus ushering in an era of truly personalized medicine.
In contrast, in CAM/IM the idea of "individualization" and "personalized" medicine most frequently boils down to "making shit up" as the practitioner goes along and doing whatever the practitioner feels like, all without a basis in sound science and evidence. In fact, Weil appeals to just such "personalization" or "individualization" based on magic and fairy dust as being a problem with applying RCTs to CAM/IM:
However, classic RCT research design requires patients to be broken out into groups with a similar diagnosis, which impairs the ability to evaluate an individualized treatment system, such as classical homeopathy, Traditional Chinese Medicine, or Ayurveda. In each of these systems, the patient must be individualized into a quite unique pattern that does not lend itself to a more broad disease generalization such as that found in conventional allopathic medicine. Curiously, the cutting edge of modern medicine anticipates that customized and individualized care looms as a result of advances in single nucleotide polymorphisms (SNPs) and the ability to create a specific genetic fingerprint for each individual.
Imagine that! Using groups that are based on diagnosis and actual disease biology, rather than based on prescientific vitalistic thinking! The nerve of those reductionistic "Western" physicians!
Here's a hint: Genome variations, as demonstrated by SNPs, are not an example of the sorts of classifications one finds in homeopathy, traditional Chinese medicine, or Ayurveda, although I am impressed at the attempt to liken CAM classifications to "cutting edge" genomic variations and science-based classification systems. Sadly, though, leaving aside the utter ridiculousness of the analogy, Weil appears to be behind the times when it comes to personalized medicine and genomics. Ask any systems biologist or geneticist. SNPs aren't even really "cutting edge" anymore. Maybe they were ten years ago (possibly even five years ago), but other methods and markers are rapidly supplanting SNPs, in particular direct sequencing of relevant parts of the genome, a technique made practical by next generation sequencing technologies and the concomitant exponential plummeting of the cost of such analyses. Also, as Harriet Hall has pointed out, the claim to "personalization" is a sham; many CAM/IM therapies ultimately appeal to one of many examples of the "One True Cause of Disease" fallacy.
Speaking of shams, so is Dr. Weil's claim of being "holistic":
A third methodological issue that distinguishes IM from the environment of pharmaceutical RCTs involves systems thinking. With its roots in holistic, natural, and aboriginal medicine, IM has always embraced a more systems-based orientation to patient care than conventional care. It should come as no surprise that a narrow modality for evaluating treatment effectiveness would become increasingly limiting to IM research. The movement toward increasingly narrow scientific evaluations may create an artificial and arbitrary view of human health, medicine, and treatment effectiveness. Fritjof Capra, PhD, the well-known physicist, indicated that the great surprise of twentieth century science was that complex systems cannot be understood by analysis. Ecology and epigenetics are examples of the strong movement toward systems thinking in modern biology.
This is, of course, utter nonsense. "Holistic," "natural," and aboriginal medicine relied upon a prescientific, not a "holistic," understanding of biology and patient care. Appealing to "systems" thinking based on prescientific or outright religious systems, such as homeopathic provings, traditional Chinese medicine, Ayurveda, and "energy healing," is meaningless when the systems being invoked are without a grounding in science--or even reality. The rise of systems theory in biology and elsewhere has nothing to do with the sort of false "holistic" thinking invoked by Weil and his ilk. Rather, it has to do with the increasing ability to analyze more than one aspect of a complex system at once. For example, in my field (cancer), thirty years ago it was only possible to analyze one gene or perhaps handful of genes at a time. Then, beginning in the late 1990s, the development of cDNA microarray chips made it possible to analyze hundreds, then thousands of genes simultaneously--then every gene in the genome. As technology and computing power increased and scientists and mathematicians developed techniques to analyze ever larger datasets, it became possible to take the data from these sorts of experiments and begin to understand the complex networks inherent in the expression of the thousands of genes that are produced in human cells. Today, it is becoming increasingly possible to integrate massive quantities of data from various sources, including genomics, proteomics, and metabolomics and begin to understand the vastly complex networks that they form, how they resist perturbation, and how they can be restored when they are perturbed.
That is real holism. Not homeopathy. Not traditional Chinese medicine. Not Ayurveda. What Weil represents as "holism" is in reality a series of pretenders to "holistic" understanding that substitute non-evidence-based prescientific belief systems for science, gussying them up in "science-y"-sounding language that co-opts new science the way CAM/IM co-opts science-based modalities like diet and exercise as being somehow "alternative."
Miscellaneous nonsense from Weil
Those who have actually read Dr. Weil's article will note that I have not yet mentioned one point that Weil hammered on relentlessly, apparently thinking himself Maxwell bringing his silver hammer down upon the heads of those who think scientifically, the better to knock the propensity towards SBM (or even EBM) out of them. That issue is safety. Weil goes on and on about patient safety, even going so far as to propose a ranking system for patient safety. This part of his article is, quite frankly, an insult to physicians' intelligence. Physicians practicing EBM already weigh efficacy/effectiveness versus safety; all Weil is doing is to rename and rebrand something that EBM does already. To a small extent he has a point that EBM does not yet have a as rigorous "hierarchy" of risk or harm to evaluate treatments as it does levels of evidence for efficacy, but even if we did have such a rigorous hierarchy, risk-benefit estimates still require weighing benefit versus risk. If the expected benefit is zero, or near zero, then even a tiny risk can quickly become unacceptable. To take one example, in the case of acupuncture, where the benefit is not distinguishable from that of placebo, then even a tiny risk of, say, a pneumothorax from a needle stuck too deep becomes very problematic. In other words, Weil's classification system is unlikely to make CAM seem as attractive as he seems to think it will, although no doubt his intent is to make that evil "reductionistic" allopathic medicine seem more dangerous by comparison.
In addition, Weil makes a big show of complaining about commercial influence, in essence using a weaker form of the "pharma shill" gambit to dismiss pharma-funded RCTs whose conclusions he does not like. This serves, more than anything else, as a ploy to imply guilt by association, given that virtually all pharmaceuticals are manufactured for profit. As we have written about here on numerous occasions, commercial influence is a problem that is recognized in EBM (and SBM). It is increasingly appreciated as an issue, and practitioners of EBM do consider funding sources when considering clinical trial results. Indeed, one can't help but wonder why Dr. Weil's concern about pharma influence is so conveniently limited. Does he complain about the influence of supplement manufacturers (which, by the way, are increasingly owned by various pharmaceutical companies and wield a great deal of clout in Congress)? If he does, I haven't seen evidence of it. Steve was right; this part is just window-dressing, as is Weil's proposal for a different five-level hierarchy of evidence that not-so-subtly tilts the playing field so that some observational studies and other studies that can't be considered RCTs could be considered Level One evidence.
What's truly ironic is that Weil would never admit that there are few, if any, CAM modalities that can meet the criteria of level one evidence even under his own proposed system! In fact, most of the very best-supported CAM modalities would fall either into level four ("Weak indicators of uncertain value: poorly designed studies without strong support from the Hill criteria; small observational studies") to level five ("Very weak indicators of efficacy or effectiveness: expert opinion of effectiveness; case series; multiple anecdotal reports"). That's why it's tempting simply to grant Weil his new system and then challenge him to show more than a pitiful handful of CAM modalities that have evidence to support them stronger than level four.
Finally, two of the more pernicious proposals in Weil's paper are related. First, he repeats his explicit argument for favoring placebo medicine:
Given the history and philosophical preferences of allopathic medicine, it should come as no surprise that the factors defining the healing response become minimized or ignored in current practice. This failing must be remedied, as these factors account for a huge component of how humans heal and recover. The healing relationship has taken a much larger role in IM as practitioners in nearly all CAM modalities place a much higher emphasis on it. The importance of these issues can be demonstrated most clearly in psychiatry research, where the placebo response plays a huge role accounting for as much as 40%-90%+ of the total response.26
Significant placebo and expectancy responses inhabit other areas of medical practice, such as dealing with pain and even life expectancy in patients with terminal cancer. Clearly, patient factors must compose a significant part of all treatment selection processes. Ideally, every treatment should be matched to the individual's belief system to reach the highest level of response possible.
Aside from stating, "CAM is placebo medicine, and we should use placebo medicine when it fits in with patient beliefs," a more explicit admission that what is being proposed in this opinion piece is placebo medicine I cannot imagine. Worse, it's based on misinformation, the most egregious of which is Weil's claim that placebo and expectancy effects can increase life expectancy in patients with terminal cancer. Would that it were true, but unfortunately it's not, either in late stage cancer or early stage cancer. Nor is there any evidence that it has an effect on recurrence. This is where Weil's second, related thrust occurs. Using this assumption that placebo medicine "works" better if its tenets match the patient's belief system, he proposes turning the entire concept of informed consent on its head with respect to medical decision-making (MDM):
The ideal process in MDM would remodel the process of informed consent. The actively engaged patient would be offered a quick overview of appropriate treatments (both CAM and conventional) with an unbiased reflection of both safety and effectiveness. The patient would then declare a preference for one over the other(s). Once a practitioner ascertains the basic worldview of a patient (natural versus conventional; safety versus effectiveness) many simple elements of MDM would flow quickly in the future.
This is a process that to which I've referred in the context of two other discussions, vaccines and supplements. In essence, what Dr. Weil is proposing is an ideology-based version of misinformed consent. Although Dr. Weil would not doubt strenuously object to my comparison, when you boil it all down, what he is doing, although more subtle, is not materially different than what anti-vaccine groups do when they grossly exaggerate the risks of vaccination and downplay its benefits or what "health freedom" groups do when they exaggerate the benefits (and the scientific evidence for such benefits) of supplements. What these groups each do is to give patients a skewed view of the risks and benefits of an intervention, intentionally making it more likely that patients will choose the "alternative" option. Weil is doing the same thing by trying to confuse the issue of efficacy/effectiveness by throwing in the issue of "patient belief" and placebo medicine. As is the case with anti-vaccine activists and supplement hawkers, the purpose is, having failed to win on "conventional science," to find a way to tilt the playing field back towards the "alternative" using other means.
Conclusion
The proposals in Shannon et al are nothing original, although I must grudgingly tip my hat to Weil and his acolytes for having repackaged old ideas in a very attractive, slick new package. In essence, they boil down to a massive appeal to other ways of knowing, hence the attack on RCTs in which they point out deficiencies that those of us advocating SBM and EBM have recognized for decades; the emphasis on effectiveness over efficacy that ignores the fact that it's necessary to have good evidence of efficacy before even considering effectiveness in the "real world"; the tarting up of safety considerations as though EBM doesn't take safety into account; and a direct appeal to placebo medicine via the methodology of misinformed consent. All of these strategies are clearly designed to try to give CAM/IM a leg up on science that it can't achieve through science alone. Unfortunately, although such strategies are transparent to SBM bloggers (and, I daresay, many of our readers), to others they are not so obvious, even to proponents of EBM. I also can't help but think: If Dr. Weil detests EBM so much, he's really not going to like SBM at all. Not one bit.
Perhaps the most ironic part of all of this is that many of us at SBM actually agree with the contention that EBM relies on RCTs too much. Many of us would even agree with several of the Bradford-Hill criteria as considerations that are worthy of more emphasis in EBM. Where we differ is in how to do this. Most importantly, we emphasize much more strongly scientific/biological plausibility. Prior probability appears to be anathema to Weil, given that he mentions it as part of the Bradford-Hill criteria and then completely ignores it thereafter. No doubt, he knows how scientifically implausible many CAM/IM modalities are. Instead, Dr. Weil Gish gallops off to emphasize, as he does in the title of his article, patient preferences and safety, in essence using these issues to bolster an explicit plea for placebo medicine. Rather than accepting that rigorous scientific examination of his favorite CAM/IM modalities fails to find any benefit over placebo, Dr. Weil cleverly embraces placebo medicine and argues for lower scientific standards to permit pseudoscientific and unscientific medicine to appear to be co-equal with EBM.
Unfortunately, such are the arguments that have been the wedge used to insert quackademic medicine into medical academia. Even more unfortunately, they are working.
REFERENCE:
Shannon, S., Weil, A., & Kaplan, B. (2011). Medical Decision Making in Integrative Medicine: Safety, Efficacy, and Patient Preference Alternative and Complementary Therapies, 17 (2), 84-91 DOI: 10.1089/act.2011.17210
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Excellent post Orac.
You write "I also can't help but think: If Dr. Weil detests EBM so much, he's really not going to like SBM at all. Not one bit."
Well, Dr. Weil is on the advisory board of PCRM -the rather ironically named Physicians Committee for Responsible Medicine (in reality a vegan/animal rights lobby group) - so it's pretty much a given that he detests science based medicine.
Is the journal Alternative and Complementary Therapies a pseduo peer review thing to sell more alternative products? Seems a story about cupping would fit well with this journal's scope:
The Age of Purification
By GUY TREBAY
New Yorkers are giving their psyches a spring cleaning with treatments that sweep out both body and wallet.
http://www.nytimes.com/pages/fashion/index.html?adxnnl=1&adxnnlx=130615…
What?!? No Timothy Leary angle? I'm disappointed.
clinical questions with objective outcomes
Just as long as the objective outcome can be validated. I've noticed some problems over at endocrinology with changing TSH cutoff values, multiple times lately, and their disconnect from other measures. But I'm big on labs in general, to extend or back the more qualitative data.
making shit up
"Regular" medicine and the medical advertising media, too. That, or getting all the med students with the lowest MCAT Verbal and Basic Science (4, 5, 6 or 7?) to run the RCTs, since they obviously didn't read or follow the directions within an order of magnitude in some cases that I've bothered to track down.
Neil Craig, haven't seen your previous posts/comments about Orac, and I can't rememberreading his comments or posts about AnnCoulter or your good self, but I am 99% sure that Orac is right and that you are wrong.
Do you want to know how I can be so sure?
It's very simple, you wrote:
"if it supported the Earth centred universe he would be denouncing Galileo"
I rest my case:-)
[RANT ABOUT IATROGENIC DEATHS DELETED AT COMMENTER'S REQUEST.]
Incoherent trolls are especially incoherent today.
@Jonathan Burgess
Iatrogenic deaths are plummeting. The figure was 783,936 a year just a couple of weeks ago.
Do you really think that mangling science to make people believe in magic is going to help reduce unnecessary deaths?
Woo-meisters often point lovingly to MD's -like Weil- who were trained by "orthodox" masters but became disgruntled by the "sorry state" of medicine and then, self-illuminated by revelation, "saw the light" of a more natural way. If there is "but a step from the sublime to the ridiculous", there is nary a half-step from Weil, Ornish, and Oz to Adams, Null,and Mercola. And they tell us so.
These doctors provide a gateway for the *poseurs*- they are the proverbial "foot in the door" that door-to-door salesmen rely upon: yes, the "paradigm shift" is underway- we're told in many a set-piece at NaturalNews or the Progressive Radio Network- institutions like med schools and universities, formerly engaged in lock-step rigidity imposed by the rules of SBM and the FDA, are undergoing an invigorating *metamorphosis*, awakening to the new order of freedom from reality. Doctors and nurses are becoming "holistic", patients are *demanding* safe treaments like homeopathy, while all are discovering the mysteries of the "East" ( wasn't that appellation supposed to go out with the Empire?). My files are filled to the max with the "evidence" that they provide about this earth-shattering event newly upon our collective horizon.
So what are the goods? Well, they have studies. Remember that they dismiss much of what we might consider appropriate as "compromised" with COI's, sponsored by Pharma, the government, or universities who were *bought and paid for* by corporate interests. They go to their own cronies, dig up ancient woo, or make up stuff that they self-publish. This is paraded as *independent research* to the marks. Two areas are especially prone to claims of "research": cancer treatment and vaccine "damage". In other words, the areas most enshrouded by fear.
Right now, there is an effort to stop state legislation about mandatory flu vaccination and tracking for *health care workers* ( LKH @ NJ Coalition for Vaccine Choice website; 5/18 & 19/11). Now why would an anti-vax autism advocate be so concerned with *adult* workers? Aren't they past the critical period for pharma-induced autism? If you read your AoA, you know that workers can be future *mothers* who might then inadvertently transmit their own damage to their foetus.( I wouldn't be surprised _at all_ if they now also claimed that the *fathers* might transmit *their* own vax damage to their future daughters who might then pass it on to their future children). Plus, it really *is* all about the vax, isn't it? LHK isn't the only one to oppose flu vaccination.
I said before that there is "but a step"...but after that, there is no stopping the process as it makes its way down, circing the drain.
@Jonathan Burgess
Have you actually looked at the source for your claims? The biggest source of iatrogenic death listed was from bed sores. While this is clearly horrible and something that medicine should be working to address, it isn't quite what you imply. The deaths were due to a failure to intervene appropriately, not due to an inappropriate intervention.
I am not a fan of Weil, or Oz, or many of the populist media advocates of CAM, but we do have to acknowledge that the track records of RCTs and SBM have a lot of problems as well.
RCTs suffer from requiring large "n" values, which means they either take years to collect the data, or they get done at multiple centers. Either way the data gets clouded by unanticipated and uncontrolled variables such as changes in diagnostic tools or surgical technique.
Authors and publishers place far to much faith in statistical p values and don't differentiate between clinical and statistical significance.
And evidence is only useful when we get a chance to see not only the studies we like (positive) but also the ones we don't (negative), but our publishers have big-time bias against negative study.
So far too often we are left with the "art of medicine" wrapped in beliefs and hunches and personal experiences. Not particularly scientific.
I have a quibble with their definitions of "efficacy", i.e.:
"Efficacy" is more properly "demonstration of benefit under controlled conditions", not "ideal conditions". There is no reason to believe that a RCT will be, a priori, designed to provide ideal conditions, as those may not be known yet.
Certainly, a drug manufacturer will try to test the drug under ideal conditions (optimal patient type, etc.), but they may be constrained by practical, financial or ethical restrictions to testing their drug under less-than-ideal conditions. A good example of this would be many cancer therapies, which are often tested (at least at first) on people who have failed "standard" treatment regimens. This is hardly the "ideal" condition and may result in drugs that would work well on less advanced cancers being erroneously rejected.
However, it is reasonable to assume (in the absence of data to the contrary) that the efficacy of a drug in an RCT will be greater than its efficacy in "real life" - as long as it is used in "real life" only on the type of patients it was tested on in the RCT.
I suspect that the purpose of Shannon et al's definition of "efficacy" was to subtly imply that RCT's grossly overestimate the efficacy of drugs and other treatments, thereby laying part of the groundwork to claim that RCT's aren't "valid" for "alternative medicine".
This goes hand-in-glove with the persistent claims by various "alternative medicine" proponents that RCT's are "biased" against "alternative medicine" and shouldn't be granted any precedence over "other ways of knowing" - thus opening the door for the "alternative medicine" proponents to claim whatever they want based on nothing but their own wishes and fantasies.
This is the classic clash between evidence-based medicine and fantasy-based medicine. They hope that by tearing down the RCT, they will be able to create a sort of "knowledge anarchy" so that they can make big claims (and big profits) without having to actually do any research.
Prometheus
[RANT AGAINST CONVENTIONAL MEDICINE DELETED AT COMMENTER'S REQUEST]
RCTs can only test for ONE thing at a time. This creates inherent problems since most complementary and alternatives are holistic in nature, not singular. Given that many pharmaceutical options are now being found to be more dangerous than previously thought and have side effects that are listed as a full page of fine print, is it any wonder people are questioning the "science" used by cronies in the FDA for their corporate buddies?
Whatever the science says (to you), I see the revolving door that is the FDA to Big Pharma and the obvious problems with the science being conducted (and paid for) by Big Pharma for their own ends and wonder why people like yourself feel justified in attacking alternatives when your own house is such a rickety structure.
Face it, there is no objective science in medicine.
Jonathan Burgess, you are so full of shit. Medical practitioners (MD's, DO's, NP's, Pa's) go over family, social, environmental, and medical aspects of patient health BEFORE prescribing medications. Diet, lifestyle, and symptomatic treatments are discussed, THEN, when those things fail,or if we already have a good suspicion that those things aren't going to be enough, pharmacology is brought in.
I could only dream of a day when my patients were more willing to incorporate healthy diets and exercise into their lives than a pill, or preferred Physical Therapy to Percocet!
To make things even worse, when I clicked on this article guess what banner greeted me?
Yep, Andrew Weil: "Need an Energy Boost? Dr. Weil's Energy Formula provides traditional herbs to help boost your energy levels".
Appalling, as are the conspiracy trolls that have apparently infested this thread - such as "Future physician" Jonathan Burgess failing completely to understand papers (or deliberately lying, which is more likely), for instance. JAMA. 2010;303(20):2058-2064 does not say that "40% of pharmaceutical clinical trials are published with falsified information," but I guess Mike Adams fans and shrill loons may interpret it as such (it has been discussed on this blog earlier as well, as far as I can remember). On the other hand, Dean Ornish's studies are reliable ... Words fail.
@Aaron - If you are so concerned about Big Pharma, how do you feel about Dr Weil's website? Pretty much every link you click leads you to nice little form where you are expected to provide your credit card information so that you can receive one of his products or services? Seems a little hypocritical to complain about Big Pharma making money, but to let Dr. Weil slide for such blatant attempts at making money.
@Jonathan Burgess - You do realize that Orac is a cancer surgeon and researcher right? He's not treating people with heart disease. Also, this post was about Dr. Weil, not Dean Ornish, so I'm not sure why you keep bringing him up.
Jonathan Burgess - Please provide a link to Orac's post where he said that diet and lifestyle were of no benefit in treating obesity related illnesses. Alternatively, please provide the curriculum of any medical school program that only trains in differential diagnosis and the treatment of disease with pharmacological agents so we can verify that such training you describe actually occurs.I don't know about your doctor, but mine regularly tells me to exercise, eat mostly vegetables and grain with less meat, and that I need to maintain a healthy weight. He also recommends vitamin D (2000 IU per day for me). So I'm missing where all of this "doctors don't know anything about diet" stuff is coming from.
Wordfail: I did not mean to say that Ornish's studies are unreliable in general (he has published real and interesting science); the problem is what he, and especially his fans, take those studies to show.
Aaron: what's your point (apart from trying to hide your glaring tu quoque fallacy behind a false equivalence)? No one is saying that the pharma-connection is unproblematic. But that is not an argument to reject methodologically sound science in favor of loose intuitions and anecdotal evidence.
"RCTs can only test for ONE thing at a time. This creates inherent problems since most complementary and alternatives are holistic in nature, not singular."
Since you, by your own admission, doesn't have any evidence that these holistic treatments work since, as you claim, they are not testable by methodologically sound, unbiased methods, how come you think they actually work?
"... and have side effects that are listed as a full page of fine print"
It is true that most CAM doesn't have list anything like that. Indeed, many alternative methods claim to be entirely without side-effects. But when did accountability become a bad thing? Doesn't the fact that that "pharmaceutical options" actually list the potential side effects a good thing? After all, many "pharmaceutical options" are powerful stuff. Things that actually do something to your body are likely to have side effects as well.
@ Jonathan Burgess
Not that tired old "conventional doctors don't deal with diet and lifestyle" again. How mind-numbingly stupid can you get? You claim to be a "future physician" but you know nothing.
I have a number of chronic health issues -- depression, elevated blood sugar and high blood pressure for starters. For every one of these conditions, my doctors went through a long period of working on diet and exercise/lifestyle before we decided, together that the conditions weren't going to be well controlled without drugs. My GP teaches at UCLA and I know that he teaches this same approach to all of his students.
@Jonathan Burgess
Have you even looked at the study you link to? It was not a study of pharmaceutical trials alone, it included many different treatments (including urinary catheterization for example), and it was not about falsified information. It was about spin, or presenting the results in a better light than they deserved. I'm not claiming this is a good thing, but it hardly proves that "nearly half of your evidence is total BS" as you claim, and there is nothing in the study that suggests that profit was the motive.
Take a look at the e-supplement to see the RCTs and the kind of spin the study looked at.
Orac discussed this study here by the way.
Jonathan Burgess said:
So what year in your undergrad are you? Or are you not even there yet?
And in the unlikely case that you are currently in med school: which school are you attending? I want to make sure not to apply to a school with such a poor teaching curriculum.
Future physician Jonathan Burgess had better massively improve his reading comprehension if he wants to be able to interpret and report the scientific literature. His citation of JAMA. 2010;303(20):2058-2064 as supporting the claim that 40% of pharmaceutical clinical trials are published with falsified information is demonstrably and egregiously inaccurate.
The actual publication (doi: 10.1001/jama.2010.651) evaluated the use of "spin" in published RCTs with exclusively nonsignificant results (P > .05) for all primary outcomes. "Spin" was defined as
The study evaluated 72 RCTs and determined that over half of the publications had one or more elements of "spin" included. The study is very interesting and the breakdown in Table 3 demonstrates the variety of spin 'flavors', some of which are more devious or benign than others (e.g., focusing on stat sig secondary outcomes can be problematic if not done with great care and statistical rigor; recommending a treatment even though the RCT outcome is negative may be very inappropriate). Check out the supplemental materials for detailed examples of the types of spin evaluated: http://jama.ama-assn.org/content/303/20/2058/suppl/DC1
Also, for those with a disclosed funding sources, for-profit funding accounted for 1/3rd of the 72. No further breakdown of spin was provided, so it is unclear whether industry was more heavily represented in the papers with identified problems. (Previous studies have demonstrated that industry-funded studies are more likely to spin conclusions positively, according the the study authors.*)
There are certainly important lessons to learn in this kind of analysis and the associated discussions of publication ethics and clinical treatments are very important. However, what this publication decidedly does not support is the explicit claim that "40% of pharmaceutical clinical trials are published with falsified information". That is grossly inaccurate and misleading (and possibly libelous and falsification of data is a serious charge not supported by this source). One might be able to argue a more defensible
I recognize that this more accurate report completely lacks the pizazz of Jonathan Burgess's claim...then again, I'm not trying to spin anything.
*Yank V, Rennie D, Bero LA. Financial ties and concordance between results and conclusions in metaanalyses: retrospective cohort study. BMJ. 2007; 335(7631):1202-1205
Prn, quoted because it's a common argument:
I seee your tu quoque and raise you an ad hominem. You're saying CAM tells the same sort of lies and uses outright fraudulent studies like the worst behaviour Big Pharma sometimes engages in. Yes. Exactly. That's very much why we don't like CAM. It's fraud. Fraud just like Pharma companies sometimes commit. Thanks for mentioning it.
Regarding the JAMA study cited by Mr. Burgess, as is usually the case with CAM apologists like him I'm way ahead of him, having blogged about the study not long after it was released:
http://scienceblogs.com/insolence/2010/10/mark_hyman_deceives_about_sci…
It looks to me as though Mr. Burgess has taken a page out of the Mark Hyman playbook.
RCTs can only test for ONE thing at a time. This creates inherent problems since most complementary and alternatives are holistic in nature, not singular. Given that many pharmaceutical options are now being found to be more dangerous than previously thought and have side effects that are listed as a full page of fine print, is it any wonder people are questioning the "science" used by cronies in the FDA for their corporate buddies?
yeÅilçam turkseks
Fine. In this case, test for the outcome: symptom reliefs.
Enroll one group of CAM practitioners doing whatever you want, even if it is a dozen different modalities on each patient, and one group of actors who are going to mimic the first group, using only biologically neutral chemicals (plain water or sugar pills instead of CAMs substances*) or sham procedures (e.g. toothpicks instead of needles).
Enroll a large group of patients, and randomly send them see either a real CAM or an actor. Without telling the patients in which group they are.
One way to do it is to have a few CAMs and actors sharing office space in the same clinic.
Wait a while, to let the treatment works, and then collect patients' outcome, unblind and compare.
* in the case of homeopathy, distinguishing between the control and the tested substance is gonna be tricky.
Jonathan Burgess:
See my point with prn. Some studies are intentionally falsified. CAM studies are routinely falsified or designed to produce false positive outcomes. Pharma companies lying does not make CAM promoters saints for lying too. It makes them both liars. That is not a plus for CAM.
What? Surely Big Macs, sedentary jobs, and patients who don't want to exercise and don't follow doctor's advice bear some responsibility here. That "doctors dismiss diet/exercise" thing is such a strawman, it's singing and dancing with Dorothy and the cowardly lion.
The irony! The irony!
Orac regularly dismantles the claims of CAM, which is nothing if not a profit driven mishmash of treatments that don't work, for illnesses that not only "shouldn't exist" as you wishfully say of heart disease, but frequently don't exist, such as Morgellon's disease and imaginary "toxins." Take for example homeopathy, which is nothing but water, accupuncture, which is pure placebo effect, colonic cleanses for imaginary toxins and impacted fecal matter that isn't there, or echinacea, which does nothing.
I don't doubt it. I see a lot of magic thinking and disregard for fact or evidence creeping into the university I attend and it's undergraduate preperatory classes for the local medical school.
Do your future patients a favour. Take a logic elective. Take more statistics courses, and learn how to identify badly designed studies prone to false positives. You'll be surprised. CAM cries the loudest outrage, but they are the Emperor wearing no clothes.
Turk
RCTs only test one hypothesis. This creates an inherent opportunity for CAM promoters, since most CAM promoters remain intentionally vague so they can shift the goalposts all the way South of the Mexican border in the dead of night.
There's a reason they play that holistic card, sir. It is so that they can weasel out of contrary evidence and engage in special pleading.
I especially enjoy your articles on CAM/IM because it is flying under the radar. Keep up the good work!
Prn, quoted because it's a common argument:
making shit up
"Regular" medicine and the medical advertising media, too.
I seee your tu quoque and raise you an ad hominem. You're saying CAM tells the same sort of lies and uses outright fraudulent studies like the worst behaviour Big Pharma sometimes engages in.
Scott, I am not justifying any "CAM errors", much less fraud, tu quoque. Sure there's a lot of bs out there - everywhere. One gets the impression that many "mainstream" won't acknowledge frequency and specific areas where mainstream breaks down. Or acknowedge how much "mainstream" varies geographically.
Can't fix what you won't see.
If the author is so concerned about weeding out bias in medical decision-making, why does he not acknowledge that Cochrane Systematic Reviews, among the most prestigious and conservative of meta-analyzers, have found "In the four trials in which acupuncture was compared to a proven prophylactic drug treatment, patients receiving acupuncture tended to report more improvement and fewer side effects. Collectively, the studies suggest that migraine patients benefit from acupuncture..." and that "the available evidence suggests that acupuncture could be a valuable option for patients suffering from frequent tension-type headache." (You can verify this for free at
http://www2.cochrane.org/reviews/
It is a shame that the very voices that clamor loudest for evidence-based medicine exhibit cultural bias when they talk about what is evidence-based vs. not evidence-based. The list of conventional medical treatments which have been put on the market without an adequate evidence basis, or a basis which has later been overturned, is very long, but one might start with the travesties of COX-2 inhibitors and thalidomide.
To assert that CAM is inherently profit-driven and unsupported by evidence vs. conventional medicine as EBM and not-for-profit is absurd...but if we were to take RCTs and profit motive as the determining criteria, as suggested above, some CAM therapies should be re-named as conventional, and many drugs and surgical procedures re-classified as CAM. Believe it or not, some of us CAM providers do believe in and practice EBM because of the sometimes (though not always) superior risk/benefit/cost ratios of CAM for certain patients and diseases vs. conventional medicine. But what the data say for sure is that hardly anyone gets rich practicing acupuncture. Has anyone looked at the DOL statistics on the average earnings of surgeons? And who is it that is profit-motivated again? Read more at my blog at wwww.santacruzacupunctureclinic.com
@Anthony Von der Muhll: What? Don't you have a book to sell?
If you didn't notice, many commenters and Orac himself have noted that what CAM people practice only mimics the movements of EBM and SBM. What was that quotation again, something about you being the easiest person to fool?
Oh, and learn how to cite appropriately. No one is going to go do your homework for you.
Andrew Weil and the SBM movement might agree that RCTs can be misleading and should not be regarded as the final say of the evidence, but they're doing so for completely opposite reasons. Â The SBM movement expects RCTs to sometimes give us false positives, indicating a treatment should be effective in a real-world setting when unforeseen factors of the real world may prevent this from being so. Â Andrew Weil and his crowd, however, thinks RCTs must be giving false negatives when they indicate that the woo he pitches isn't helpful to anyone, in the real world or even under lab conditions. Â Too bad for him his reasoning pretty much amounts to special pleading.
Scott Cunningham #28 wrote:
Indeed. And in addition to its vagueness, the term "holistic" carries with it the implication that it's adding the "spiritual component" to the nature-based mix. That's supposed to make it more complete than consciousness-denying science-based medicine. Supernatural realms forbid the concept of contrary evidence, and faith is the special pleading of confirmation bias spun into being a positive virtue.
Fantastic post, Orac. I just don't see how you find the time to do such great work as well as your day job.
Patient OUTcomes are one thing. Practioner INcome is another. CAM strikes me as a license to print money. They can tu quoque all they want about greedy "allopathic" doctors, but at least real medicine sometimes cures things for real.
Question for the audience: If someone uses the word "allopathic" in earnest, are they always a quack? I'm not an expert -- I'm looking for useful heuristics.
@ Anthony Von der Muhll:
Can you explain how it is that it does not matter where you place the needles (no meridians needed) or if for that matter if you even use needles (toothpicks appear to work equally well) or whether it is a trained accupuncturist or an untrained stand in placing the needles? Oh, that's right ... its a placebo.
Oh, deer. Mr. Burgess is being a silly Necromancer. You really do need to work on your reading comprehension if you want to become a physician.
[RANT ABOUT DEAN ORNISH AND CONVENTIONAL MEDICINE DELETED AT COMMENTER'S REQUEST.]
Orac's name is so incredibly well known, it could be considered equivilant to list unproven and unsubstantiated vague accusations against him under either name.
If you can't play nice, don't run your mouth off at other people. You just end up looking stupid, hypocritical and slightly unhinged.
Ah, sigh. This article, with slightly less insolence, was posted under his own name elsewhere a week ago. It is noteworthy that you have failed to figure out the worst secret on the internet.
Jonathan Burgess - Did you read any of Orac's posts that were actually about Dean Ornish, MD? What do you find so objectionable about them?
Jonathon Burgess
Note the use of misogynistic language by our putative future physician. Yet another another reason to hope he never actually becomes a doctor.
"Show that stents actually work to reduce long term risk of heart attacks (they don't). Why won't you do this?"
Because he's a cancer researcher.
Why do you claim to be a future physician when you don't appear to have ever met a physician in real life? Practically every physician who's ever treated me has lectured me about diet and exercise. That is a *common* experience of which you appear to be unaware.
Oh joy! I'm a future Timelord. I don't mention it here coz these sciency types most likely don't believe in time travel.
I am a future physician
For the purposes of claiming any authority, "Planning to enter medical school in 2012" is a slightly nebulous qualification.
herr doktor bimler:
I suspect this is someone who expects to enter medical school closer to 2014. Little does he know that they want actual reading comprehension, passing several required classes, passing a qualifying exam, and the most difficult feat: doing well in certain interviews.
I know this because there was a certain very annoying person that my friends who still lived in the dorms had to endure. He was a bible thumper who tried to convert anyone he encountered. He cornered me once as I visited friends, and I blew him off by telling him I was okay with my life and to go away. He swarmed in to prevent a friend from taking Tylenol when he was sick with a fever because it causes Reye's Syndrome (which was really caused by aspirin). He scolded fellow dormies on the movies they viewed because they were pornographic (which they weren't, I think one was the original 1977 Star Wars). And all the time gathering a bevy of female groupies.
Apparently he did not get into medical school. The rumor is that he actually explained he wanted to make his patients live well by controlling their lives. Bzzzt... can you say "rejection"? This was told to me with a great deal of glee by a few college friends who lived in that dorm (I lived two blocks away in an apartment).
But he had his groupies, who had taken to wearing long skirts. Apparently he told them that a certain deity wanted them to have sex with him. Yikes! Last I heard he left with his own little cult. I really don't know what happened to him. After over thirty years I cannot even remember his name, plus the details may have morphed. Though medical school interviews do exist (google checked), and I was told by several happy people that this is what he failed.
Here a little bee for your war bonnet, Allopathic Medicine has only been around for a relatively short time in the history of human kind. Many of the CAM therapies have been around for thousands of years. If I'm looking at what causes the least amount of harm and has sufficient history behind it to be worthy of my attention, I'm going to choose CAM. Not to the exclusion of Allopathic Medicine but in concert with it as appropriate. You've obviously an axe to grind. Instead of criticizing Dr. Weil why don't you put your passion into supporting research directed to CURING disease so that wellness prevails throughout humanity. Andrew Weil has done more to promote wellness and wholeness than most physicians in this country.
Rev. Magdalena, that is an argument from antiquity. It is essentially meaningless.
Orac is an surgeon oncologist and is working to very hard to cure breast cancer. How do you propose to rid women of the BRCA1 and BRCA2 genes that make them more vulnerable to breast cancer? What are the ways you plan to prevent the one out of a thousand chance of a person getting my son's genetic heart disorder, hypertrophic cardiomyopathy with obstruction?
Surely you have all the answers. Why don't you share them with us? Except with one caveat: provide actual evidence that they work. They must be cites that can be accessed through our local medical school library. No websites, books or news reports are allowed, but PubMed identification numbers are okay.
I love how you attack other physician scientists by name and are too much of a pussy to put your real name behind your attacks.
Well, that took 90 seconds.
@Rev. Magdalena:
Nope. "Allopathy" is a derogatory term made up by an 18th century quack called Samuel Hahnemann for the "orthodox" medicine of his day. Much of this had been around for centuries, if not millennia, dating back to the ancient Greeks. Most, if not all, of it has since been abandoned because it has been discovered that it didn't work. Modern medicine is nothing like "allopathy" - in fact, use of the term to describe modern medicine is a pretty good marker for quackery.
Until they were abandoned as useless and harmful, "allopathic" treatments like bloodletting had been around for thousands of years. It doesn't mean that they worked, although the doctors of the time thought they did for exactly the same reasons that practitioners of your well-established CAM think it works - they had been around for thousands of years, and the doctors had seen patients recover after the treatments were used.
I see some new trolls have come out to play; they are especially nasty trolls as well.
The potential medical doctor/"I am a future physician" is a case in point. If he makes it past the MCAT, he will be in competition with highly educated students who took a boatload of science courses...which obviously he hasn't. Unfortunately, judging his postings here, he is totally unqualified to gain entry into any medical school in 2012, 2013, 2014 or in the foreseeable future.
It is the same old b.s. with these medical doctor wannabes who are totally clueless about medicine and science and the grueling experiences of medical school, residencies and post-doc fellowships.
The acupuncturist tries to impress us with his ability to research the value of his trade by citing Cochrane!!!
Gee, I almost wish doctors had a way of identifying (a small tatoo on their butts?) the CAM practitioners and their fans, when they get hauled in to the ER on a gurney. Ideally medical doctors could offer them CAM treatments and alternative medicines, in lieu of those nasty invasive treatments and all those chemical-laden drugs...just a silly dream I had recently.
I'm getting the impression that there's a great deal of exasperation on lilady's part. And a teensy bit of hostility.
Superb posting by Orac though; I love a solid dismantling and burning of rubbish articles and claims, especially when it imparts valuable information at the same time while being entertaining.
From others (there are three in particular; the acupuncturist, the med student, and the pseudo-historian) who are making me feel very warm from the stupid.
@Rev. Magdalena:
A little hint - you won't achieve this by supporting therapies that "have been around for thousands of years".
No Paul Browne #3 I feel little need to know the cause of your certainty since you boast that it is based on a complete ignorance of the subject.
I am sure you will be grateful to Orac for, having proven himeself unable to dispute the facts in any way whastsoever, censoring my post thereby saving you from ever seeing anything that might teach you anything that disagrees with the revealed truths of government.
Censorship is so much more convenient than adopting the principles of science.
@Neil Craig:
No one could have predicted post #55.
@Neil Craig
You have been warned twice. Three strikes and you're out. From here on out, any off-topic posts by about LNT on threads that have nothing to do with LNT will be summarily deleted as soon as I see them.
@ technically impartial: A lot of exasperation on my part and no hostility. But, you have to know my past experiences in the health department and the early exposure I had to some anti-vaccine loons. Years ago, when State laws were enacted to require testing of pregnant women for hepatitis B carrier status and to require the birth dose of the vaccine and HB immune globulin for exposed newborns, anti-vax loons were stating that the vaccine dramatically increased the chances of acquired multiple sclerosis. I met some opposition when we offered testing and vaccine to partners/husbands and other household members due to this. It was a few years later when the vaccines-causing-autism gang cranked up their campaign. We were very fortunate that our department's catchment area was composed of intelligent young parents who trusted their pediatrician's advice about vaccines our immunization rates for timely and complete immunizations coverage always exceeded 90 % for all the recommended childhood immunizations.
If you live long enough and if you have a very disabled, medically fragile kid like I did, you have had experiences with a slew of doctors and specialists. I appreciate every one of them for their competence and for their superb care.
While I am not a Registered Dietician, I have a science background (BSc-Nursing) and I know that supplements, extra vitamins are at best a waste of money...at worst may interfere with prescribed medication metabolism and cause electrolyte imbalances. I myself have prescribed potassium and take an over-the-counter Calcium-D pill each morning because I am prescribed a strong diuretic for hypertension.
Also I am more than perturbed about the vicious slurs directed at esteemed blogger Orac, who takes the time to write the blogs for our enlightenment and for our discussions.
@ lilady: re "vicious slurs"- it comes with the territory. BTW, those who hurl the invective aren't exactly pleased with us either (generically)! My mother used to say that if someone who isn't too bright calls you stupid, take it as a compliment: they have poor taste and worse judgment!
The *worse* (or is it best?) insult I've ever heard - about myself- was when I commented on a snarky guy's blog contra pseudo-science I was called an *invention* of the blogger! Seems I was created by a sarcastic gay man! It was the source of much merriment! So smart women aren't real? Sounds like Carol Gilligan c. 1975? Hah!
"This is paraded as *independent research* to the marks. Two areas are especially prone to claims of "research": cancer treatment and vaccine "damage". In other words, the areas most enshrouded by fear."
For the record, I am attending a CAM masters program and have NOT been taught that the standard cancer treatment is bogus or that vaccines should be avoided. Why? Because we look at the research! Yes, that research included things other than RCT, as long as they were done well.
There are people and institutions on BOTH sides that are doing much more than blindly promoting and hubrisly defending their side at all costs. If we spent half as much time and energy trying to work together to help patients and further develop medical research and understanding as we did attacking each other, we all could be a lot better off.
lilady:
I don't think that "future physician" is going to be taking the MCAT - I suspect that he/she is headed down the naturopath/chiropractor track. It's just a hunch, but someone showing that degree of antipathy to real medicine (not to mention science) probably isn't planning to become an MD or DO.
Frankly, I think that the potential for profit is much higher as a ND or DC, since there is no downward pressure on fees applied by insurance companies, Medicare or Medicaid. The only limitation to their earning potential is their imagination (and their conscience, if present). When you eliminate the restrictions of reality, there is no end to the things you can do (and charge for).
Prometheus
What's CAM that works - MEDICINE!
If any of that stuff actually worked, it'd be considered actual medicine. It is very much like "I don't like the truth, so I'll go with the alternative" - which is a lie.
LOL.
@ Celia: My reference was to the *poseurs* who ape SBM- BTW, aren't RCT's one way to insure that your help to patients is based on *real* effects rather than placebo?
Orac (and friends): I could not take this article seriously once I saw the word "Quackademic" in the third sentence. I think the evangelists of "alternative" medicine often make some misleading or subjective claims, but to consider this article objective or fair shows your tremendous bias.
I don't think that "future physician" is going to be taking the MCAT
I am willing to believe that there is a Dunning-Kroger College of Medicine, ready to sign Jonathan Burgess up as a student.
I just came back to check comments, and who was smiling at me from the sidebar but the Santa Claus of the Desert himself! I suppose he's marginally less creepy than the 72 year old guy with all the muscles.
@timnewweb -- Orac can more than defend himself, but he basically insists on high scientific standards, and is dismayed to see ill-tested modalities which have, in many cases, no possible way of actually working, infiltrating the great medical schools. "Quackademic medicine" is a perfect moniker for this trend. One-sided? You bet. But to anyone who thinks logically and insists on scientific integrity, there is only one side.
@timnewweb:
You are very, very confused. Either that, or you skipped some critical logical steps in your argument.
Orac used a word that made you think he is biased. Great. That doesn't mean he *is* biased. That doesn't mean he isn't fair.
I am willing to agree that this article may not sound fair to people who are unfamiliar with Orac or with the subject he is talking about. However, you claim that Orac is himself unfair. Please show me what he has said that is inaccurate.
@Gopiballava
the purpose of my post was to point out that using bias-revealing puns like "quackademic" DO reveal biases which cloud (except in the eyes of believers) what may otherwise be a flawless article. however, you are correct in pointing out that such words don't, in and of themselves, mean that the research contained in an article is biased, or, in this case, that orac himself is biased -- just that he sounds biased and language can be very telling.
@69 timnewweb
I respectfully suggest that you might want to pull the hammer all the way back to the fully cocked position before touching the trigger.
As an elderly lay person it is good to see this dialog because my wife and I find that communication is the area most in need of improvement in medicine which seems to be what is going on here. Thankfully there is no ruling class that suppresses alternative views or questions. And thanks to everyone who contributes both the information and the internet infrastructure that allows us to watch and learn. It's fascinating to observe evolution in action.
@timnewweb:
Do you think that Orac, or any of us, consider the term quackademic to be neutral or friendly?
At least in my view, there is no question that Orac does not endeavor for each post to start with a tone of polite neutrality.
Each post is not an individual column in a newspaper or chapter in a book, devoid of context and intended for an audience primarily of people who don't know the author. This is a blog. Each post builds upon previous material.
If you look back, you will find *ample* evidence to back up Orac's tone and his positions on the issues that he covers.
Also, the title of this blog is "Respectful Insolence." Writing with an insolent tone seems on-topic.
So: Yes, he's insolent. Yes, some people might be put off by that. Personally, I like reading articles by people who are up-front and direct. If you're on the fence and unsure whether evidence is important in medicine, you may be offended.
people who are so sure the evidence is all in their corner and blind themselves to the evidence elsewhere make poor listeners. even if someone presented evidence to support a contrary position, you would not really hear them.
gopiballava, i don't mind upfront and direct, just not crazy about silly puns whose purpose is to belittle the views of others. and, i am quite positive evidence is important is medicine, but less than positive that you all have fairly considered the evidence which might lead to different conclusions.
@timnewweb
Do you have something substantial to contribute to the discussion or are you just a low-level tone troll?
This blog is what it is. If you want nice, there are other places to go.
Or, you could continue to read here and begin to understand where the frustration comes from. We've been nice, and kind and understanding to a lot of people. What we get back is lies, accusations of being "pharma shills," and "poisoners." The frustration comes from people pitching nostrums and folk remedies as if they had value, leading sick people to avoid therapies that can actually help.
If you want to complain about tone, try the folks over at Age of Autism. They're the ones who produce photoshopped pictures making it look like doctors and reporters who aren't anti-vax are eating babies.
@timnewweb
"less than positive that you all have fairly considered the evidence which might lead to different conclusions."
Give it your best shot. Tell me what modality you think I may not have fully or properly considered the evidence for. I will tell you what I think about it, and why, without recourse to any sources - I'll answer entirely from memory.
In my experience, people in the skeptical community are far more likely to know the *official* claims made by CAM practitioners than most consumers of CAM. ie: most skeptics I know can give an accurate description of what homeopathy claims to be. Most people I've spoken to who use homeopathic remedies can't begin to do the same.
ArtK: Thanks for setting me straight with your "substantial contribution" of name-calling. I have not even picked a side in this discussion you guys are having, yet I seem to have riled some feathers just by suggesting that you guys would make your point more effectively if you did not resort to biased semantics.
Having said that, I came to this site because I was interested in an article; I have perused some interesting articles and been introduced to some interesting insights; then, I was just struck wrong by Orac's choice of words that made the article seemed bias and prompted me to post a comment; now, I bid you all adieu and wish you all the best as you search for the truth.
timnewweb, you take offense to "quackademic." I take offense at your failure to condemn quackery in our medical schools.
[blockquote]There are people and institutions on BOTH sides that are doing much more than blindly promoting and hubrisly defending their side at all costs.[/blockquote]
You've been conned.
You can have your alt med and your real med provided you keep them separated. Combined, you lose the real med.
Order + chaos = chaos
Real med + alt med = alt med
#75
I'll second the request.
Nope...now it's gone.
They, well apart from the same old serial trolls who unfailingly evade any requests for evidence via some unintelligible and/or irrelevant response, always disappear when asked for specifics and evidence!
The Truth (TM)? Do you mean your pet version of The Truth (TM)?
I think I'll stick to searching for facts and tangible evidence. Thanks anyway.
re timnewweb: yep, concern troll is concerned.
@timnewweb:
You haven't picked a side, or you haven't divulged which side you're on?
You think that we must be too quick to dismiss *something*, yet you can't, or won't, identify anything we might be wrong about?
Why did you even bother complaining if you can't even think of a single thing we might be wrong about?
You've had enough of the discussion, right when you're asked for something precise?
I dunno, somebody could get the impression that you're being a little bit misleading here.
I like the term "quackademic medicine", it reflects real problems. Including those in bed with (should be) black boxed, or withdrawn, products, or those academics that skip basic medical instruction to promote their own sponsors' specialty interests.
I suspect we don't quite agree as to who or what "quackademic" constitutes in some areas, we might agree on others.
Bad science is bad science - and there should be an accounting regardless of the source, but while there are mechanisms in place to deal with issues in modern medicine (regulations, watchdogs, etc), as far as I can tell, there is nothing on the CAM side to prevent abuse & fraud - and these same people actively rail against any attempts to hold themselves accountable (i.e. the recent North Carolina bill).
You're entitled to your own opinions, but not to your own set of facts.
Dear Orac,
Thank you for posting your provocative blog on integrative medicine.
We have a professional disagreement. You position is defensible. In terms of volume, there is limited evidence for some complementary medicinal approaches, and many of the promotional approaches that CAM practitioners use are very questionable.
My position is that there is a stacked deck against diet and lifestyle medicine. The pharmaceutical industry invests over 300 billion dollars per year on researching and promoting their products. Alternatively, those who research for diet and lifestyle-based medicine must divvy up a few billion dollars per year and spend that sparse money on variegated projects, such that no project gains a quantity of research that would be necessary to profoundly prove its methods.
As such, in terms of shear volume, I personally believe that the pharmaceutical approach to medicine has control of the airways. I assume that you believe that they have control of the airways because they produce products that work. This is where are disagreement is located. They do produce products that work (who can argue with Gleevac?) But the system as a whole fosters pharmaceutical-based solutions to many problems that could justifiably have better solutions with simple diet and lifestyle approachs. I hold that this stacked deck approach can be improved upon, and I hope that generations from now more independent research and less pharmaceutical monopoly will become the new standard for evidence-based medicine.
However, we are in full agreement on the importance of good science and use of evidence-based medicine.
I am sure that we have other disagreements as well. But I would prefer to keep them in professional and testable settings. I will eventually work to further research diet and lifestyle modifications as an approach to health and illness, and you will continue to perform research in your own fashion. Science by definition is an approach to sorting out differing opinions by using unbiased methods that each side can agree upon. And in the spirit of science, we will both continue on our current paths.
As such, I apologize for any personal comments that I have made. I also request that you extend some compassion and will delete the comments that I have posted. I prefer to have my comments be a private mistake of late night and not very well thought out emotion, and I humbly request your grace on this matter.
I wish you the best as you work to advance science in its approach to medicine. I will be doing the same.
Yours,
Jonathan Burgess
Nice apology, Jonathan. You proved that you have not read many of the comments, too. You must go to a lousy physician, if you see one at all, if your physician does not talk about exercise, diet, self care BEFORE medications (unless the problem requires medication - cancer, pneumonia, etc)
When I was diagnosed with hypertension, my physician discussed diet, exercise, weight loss, relaxation exercises with me. He encouraged me to utilize all of these for several months, then re-evaluated me. At that time, my pressure was still high, so he put me on the cheapest effective medication for hypertension. Once I lost a lot of weight and my BP stabilized, we stopped the medication. THIS is an appropriate "approach to health and illness".
And, as has been pointed out to you before, ORAC is a BREAST CANCER SURGEON. He is not in general practice, he is not seeing healthy people. He is seeing women who have been diagnosed with a LIFE-THREATENING DISEASE. I am sure he does discuss diet and exercise with them in context of the care he will be offering - which generally involves surgery. He is NOT an oncologist. He is NOT an internist. General health care is NOT his focus. OK? By the time he sees a woman, it's too late to discuss possible ways to prevent breast cancer. And he is not going to recommend quackery to "cure" it, either.
MI Dawn
@Jonathan Burgess: Looks like someone is afraid of the googles.
Let us all know how well diet and exercise work on multiple infarctions, gunshot wounds or smallpox! We'll all eagerly await your scientific basis for treating these with carrots and a nice jog around the block.
@ JayK
No one, and especially not me, has said that diet and lifestyle approaches will work to treat "multiple infarctions, gunshot wounds or smallpox."
However, in terms of incidence and death, these, and most other treatments that respond well exclusively to pharmaceutical medicine, are pale in comparison to illnesses that are preventable and treatable with diet and lifestyle.
Specifically, most heart disease, most type 2 diabetes, most metabolic syndrome, possibly some early stage non aggressive cancers, are preventable and treatable with diet and lifestyle.
To invest, trillions of dollars treating the few rather than preventing the many is simply not a good model in terms of creating human health.
If you believe that our country and medical field places adequate resources and research into prevention, then we are in a disagreement.
Regardless, we are entrenched in our current system and it will take many years, if not generations, to change it towards a system that prevents more illnesses than it cures.
We have a system that knows next to nothing about diet. Why? Because diet is treated as a third rate science and a third rate source of medicine. This can change.
I hope to remind you that currently surgeons are considered the top of the food chain in medicine. 100 years ago, they were considered the bottom. It was considered the most crude source of medicine. However, after extensive research and development, surgery has become an advanced field. It was research that created that shift. And research will create a shift in diet and lifestyle medicine as well.
Telling a patient to "improve your diet" is a very general statement and very primitive approach compared to what it could be after 100s of billions of dollars worth of research.
In years to come, we will not just say, "eat a better diet," but will be able to look at someone's genetic profile and determine foods that cause a genetic expression program that specifically remedies thier problems before the problems begin.
We are barely seeing this research now. But it is slowly trickling in. For instance, curcumin derived from turmeric is currently in over twenty PHASE III clinical trials for oncology. Its level pleiotropic effect against cancer cells is something that is barely seen in other pharmacologic agents. It is a product that is about to come to market as adjuvant therapy. And it was scoffed at for decades by "top down" physician researchers as "voodoo" medicine.
When the research comes, the information will come. How good would pharmaceuticals be if we only spent a couple of billions of dollars every year researching them? They would be about as advanced as diet and lifestyle medicine is today.
The tables on this issue will turn. It is in the best interest of human health to rigorously investigate all sources of potential health and happiness. Currently, we have enough impetus to begin that more extensive research on diet and lifestyle medicine today. The top-down scoff-at-anything-natural is a disservice to medicine and to health. You cannot kill a science in its infancy, and then blame it for not growing up.
I would certainly like to meet these General Practitioners that don't stress diet & exercise as part of a regular health regimen, because I have't yet to this point.
Each and every doctor that I've gone to for general check-ups stress living healthy, watching my weight and getting plenty of exercise - and if there is an issue, it is always done in the context of my overall health plan, not just shoving pills down my throat.
People seem not to have the ability separate the "Pharma" industry from doctors on the front lines of medicine - they are not one and the same.
@ Lawrence
If you believe that our country and medical field places adequate resources and research into prevention, then we are in a disagreement.
In years to come, we will not just say, "eat a better diet," but will be able to look at someone's genetic profile and determine foods that cause a genetic expression program that specifically remedies thier problems before the problems begin.
We are barely seeing this research now. But it is slowly trickling in. For instance, curcumin derived from turmeric is currently in over twenty PHASE III clinical trials for oncology. Its level pleiotropic effect against cancer cells is something that is barely seen in other pharmacologic agents. It is a product that is about to come to market as adjuvant therapy. And it was scoffed at for decades by "top down" physician researchers as "voodoo" medicine.
When the research comes, the information will come. How good would pharmaceuticals be if we only spent a couple of billions of dollars every year researching them? They would be about as advanced as diet and lifestyle medicine is today.
The tables on this issue will turn. It is in the best interest of human health to rigorously investigate all sources of potential health and happiness. Currently, we have enough impetus to begin that more extensive research on diet and lifestyle medicine today. The top-down scoff-at-anything-natural is a disservice to medicine and to health. You cannot kill a science in its infancy, and then blame it for not growing up.
@ JayK
No one, and especially not me, has said that diet and lifestyle approaches will work to treat "multiple infarctions, gunshot wounds or smallpox."
However, in terms of incidence and death, these, and most other treatments that respond well exclusively to pharmaceutical medicine, are pale in comparison to illnesses that are preventable and treatable with diet and lifestyle.
Specifically, most heart disease, most type 2 diabetes, most metabolic syndrome, possibly some early stage non aggressive cancers, are preventable and treatable with diet and lifestyle.
To invest, trillions of dollars treating the few rather than preventing the many is simply not a good model in terms of creating human health.
Regardless, we are entrenched in our current system and it will take many years, if not generations, to change it towards a system that prevents more illnesses than it cures.
We have a system that knows next to nothing about diet. Why? Because diet is treated as a third rate science and a third rate source of medicine. This can change.
I hope to remind you that currently surgeons are considered the top of the food chain in medicine. 100 years ago, they were considered the bottom. It was considered the most crude source of medicine. However, after extensive research and development, surgery has become an advanced field. It was research that created that shift. And research will create a shift in diet and lifestyle medicine as well.
Will this be before or after I get my time machine and my flying car?
@Bruce
Dean Ornish has already demonstrated in human clinical trials that diet and lifestyle can effectively change the genetic expression program of low risk cancer patients. Over 500 cancer related genes shifted their expression to be antiproliferation and proapoptotic.
We also see extensive research being produced on the anti-angiogenic properties of compounds that are found in specific plant foods. Research on this front is often highlighted by cancer researcher William Li, MD at Harvard.
Understanding dietary effects through genetic expression is the current forefront of dietary medicine and nutritional studies. Nutrigenomic research will is currently bringing our understanding of food beyond compounds that are co-factors in metabolic pathways to compounds that comprehensively cause the changes in the genetic expression profile of an individual. Since we know that genetic expression is the cause of many illnesses, using the power of food to influence better expression profiles is a natural extension of our current and ongoing research and treatment of disease.
I cannot comment on when flying cars to time machines will come into play, but I suspect that nutrigenomic research will be well established by that time.
@ Jonathan Burgess
So what's the problem? When this research yields data and useable therapies it will become part of medicine. In the meantime we use what we have evidence actually works.
So if you already know this, why do we need research? Actually you appear to have put Descartes before des horse -you have a hypothesis, but you're already assuming your beliefs to be fact.
Since (virtually) everyone in this discussion agrees diet and lifestyle are important contributors to good health what more do you want?
Ornish's microarray experiments are far less impressive he makes them sound:
http://scienceblogs.com/insolence/2008/07/teaching_cam_advocates_a_litt…
http://scienceblogs.com/insolence/2009/03/dr_dean_ornish_turn_away_from…
@Yojimbo
You wrote, "Since (virtually) everyone in this discussion agrees diet and lifestyle are important contributors to good health what more do you want?"
Let's substitute some nouns in this sentence and see how it reads.... "Since (virtually) everyone in this discussion agrees pharmaceutical compounds are important contributors to good health what more do you want?"
Let's also try.... "Since (virtually) everyone in this discussion agrees surgery is an important contributor to medical treatments what more do you want?"
I hope that you can see the absurdity of all three of these statements.
Stated plainly, I want 100s of billions of dollars of research spent to developing diet and lifestyle medicine so that we have a refined source of information on its power, and a refined source of information on how to implement its recommendations to patients and to the public at large.
What we have now is a very crude insight. It is actionable information in that we know that eating more unprocessed plant foods would benefit most people. But the information is in its infancy.
We must currently use research dollars to learn how to implement what we already do know. Then immediately shift research dollars to discovering far more than what we know now.
Jonathan Burgess appears to be a bit confused. In comment #84, he complains:
Yet, when he gives an example of a promising "dietary" intervention, he states (#88):
When I searched for published research on curcumin, I found fifty-seven (57) clinical trials had been published. In addition, Mr. Burgess' own statement contradicts his claim, since "twenty PHASE III clincal trials" doesn't fit well with "barely seeing this research".
Mr. Burgess further contradicts his thesis in comment #91, where he states:
Which is it, Mr. Burgess? Are "natural" and "dietary" interventions being shut out of research or are they being "extensively" researched? You can't actually have it both ways.
I note also that Mr. Burgess makes the all too common error (giving him the benefit of the doubt) of conflating the "300 billion dollars" of its own money that the pharmaceutical industry spends developing and researching products with grant support for "diet and lifestyle medicine".
The pharmaceutical industry spends a lot of money researching drugs in large part because it is required to by the USFDA in order to put them on the market. "Diet and lifestyle" interventions, on the other hand, are held to a much lower standard and don't require the amount of safety and efficacy data required of pharmaceuticals.
If the supplement industry ("Big Vitamin") were required to present the same amount and quality of data in order to market their wares, I think you'd see a dramatic uptick in research spending on "dietary" and "natural" therapies. But, since they are not required to show safety of efficacy (or track adverse events), the supplement industry has little incentive to sponsor research into their products.
Prometheus
JB@89 We have a system that knows next to nothing about diet. Why? Because diet is treated as a third rate science and a third rate source of medicine.
As the US stagnates into an overpriced, drug and cartel driven police state, Asia seems poised to move on therapeutic nutrition and cheap, mass oriented labs. Not that the West is not trying to organize its vision of hellth over Asia.
titmouse@78 You've been conned. ... You can have your alt med and your real med provided you keep them separated. Combined, you lose the real med.
Sounds dogmatic. I was in a hospital earlier this month, and the top two surgeons would really like to know how we accomplished some (altmed) things that went beyond "real med", because the "real med" results generally aren't too nice, and are instantly recognizeable when they occur, as expected.
Order + chaos = chaos shows it was a weak, fragile, unstable or misapplied solution, where someone needs to be fired. "Order + chaos = order" may suggest a competently applied, robust solution. More like engineering rather than mangle, or bungled, medicine.
Real med + alt med = alt med says little about whether something altmed works or not, with one possiblity being " = advanced med", as the case may be.
lawrence@83 You're entitled to your own opinions, but not to your own set of facts.
Huh? Sounds like someone hasn't been much around, or inside, corporations. Common examples of "own set of facts" include proprietary information, dirty laundry , and trade secrets.
Mr. Burgess,
So if I understand you, you are not satisfied with the current system of the food pyramid for a healthy life-style, nor are you satisfied with the current recommendations for an active lifestyle (at least an hour/day, 3 days/week).
What you want is a genetic profile that will tell a person to which diseases they are prone, as well as an understanding of which foods to consume that will best prevent (some of) those diseases. It's a fine idea, in my opinion; especially if you are aware and note that it would only be some of the diseases (this is one spot where naturopaths fail).
The problem we have now would be research. You are correct that there is little research in this area, but you are incorrect as to the cause. It is not a lack of want, it is that science is slow. We *just* discovered the human genome, and we still do not understand all of it. Research continues in this area, and as it continues, it will have to be reviewed and concurred by other scientists to ensure accuracy. Meanwhile, we would also have to know the effects of specific foods on the expressions of genes; this will be a challenging effort, especially in the area of combined foods. We already have issues with the unknown effects of multiple drugs (and it can be a valid criticism of our health care system); how would we account for the millions of different molecules in one piece of food, much less multiple types of food. Are the effects additive, subtractive, potentiative, etc..? With some drugs, we know the effects, and that's usually with only two or three drugs combined. With food, it may be an impossible task. It's not the pharmaceutical companies that are hindering research, it's reality that is doing so. But even if it can be done (and it would be nice to have that information), it will take a *very* long time. I mean, heck, look how long we've been studying the cell, and we still don't know everything about it (I just saw an article the other day talking about a protein that was just discovered).
All in all, I think you mean well. But science isn't the enemy; science is what allows us to understand the mechanisms in place, and to properly research new techniques, all the while minimizing our powerful ability to fool ourselves. Yes, pharmaceutical companies do bad things, but denouncing the powerful effects that specific molecules (ie, drugs) can have on our health is a step in the wrong direction. You just have to remember where drugs are on the chain of medicine; and they are not step 1. Proper nutrition and an active lifestyle are step 1; only when these are not enough should drugs come in.
Prometheus said:
In light of the information Prometheus provided, I can modify my previous comment about a lack of research in this area. In the third paragraph, I said, "You are correct that there is little research in this area..." I have been shown to be wrong. Thanks, Prometheus!
Prometheus, I am not confused at all.
Comprehensively, the have been trillions of dollars worth of research that has been performed by big pharma with the sole purpose of discovering patentable compounds that aid illness.
Conversely, there have been only a few billion dollars of research spent researching diet and lifestyle medicine. Some of what has been discovered shows exceptional promise and deserves much more research.
Mind you there are some duds. But given how many duds the big pharma has (all the compounds that they tried that never made it to market), we are dealing with an emphasis in research that is that differs by orders of magnitude.
Given that people pay for this research one way or another (either through taxes spent on independent research or through profit margins that are spent on biased research), it is time for our nation to re-evaluate where we are spending our money.
That evaluation must begin with educating physicians, researchers, and the general public about all the research that they haven't heard about because big pharma is flooding the airways with their own agenda. Do you see Dean Ornish or William Li producing TV comercials on every TV show? No.
The airways are flooded with pharma research. As such, people are missing out on important information.
We are all familiar with competitive inhibition of receptor sites here. Big pharma is producing their alterior-motive research at a level that is orders of magnitude higher than the levels produced by independent research. As such, only a few physicians and scientists are recieving sufficient information and sufficient examination of legitimate independent research in diet and lifestyle medicine. And our medicinal system is suffering for it.
Jarrad C:
The next problem with that is maintaining confidentiality of that information. There could be issues with insurance companies and employers for those who have BRCA1, BRCA2, the risk of Huntington's Chorea, and a bunch of other genes.
@Jonathan Burgess: Jarred C says it pretty well, but I think we can go further. I'd like to point out how you seem to believe that your particular brand of medical research is the magic silver bullet, that when people start following the directives of people like Ornish or Hyman that all of this "crude" allopathic medicine that is being practiced will be thrown to the wayside in favor of a good Salmon Quiche and increasing the distance of the morning jog. It not only ignores the vast reality of patient care but it also places far too much importance on a low amount of evidence. You even admit that little research exists, but you seem convinced that more will just prove out your theories.
Do yourself a favor, stop ignoring that patients don't follow dietary and exercise recommendations and educate yourself on the biases that exist in research and publication. Weil, Ornish, Hyman and all the rest of the CAM/DAN/IM people are only a few steps away from the "That Mitchell and Webb Look: Homeopathic A&E" satire, where someone in a car accident would be diagnosed with aluminum or iron overdose and given a diet of raw potatoes and a shot of essence of pine.
Chris said:
Yeah, I can definitely see that - and it's now added as another reason why I believe we should have universal health care. As a side note, I didn't believe in universal health care until I worked in an emergency department (I was a clerk, working my way through college). It was the ER philosophy of: "treat everyone who comes through our doors, regardless of their ability to pay" that eventually made me realize that it would be good to have that same philosophy everywhere in the healthcare system. The ER system is set up like that because of what ER people call "the dark days of the 90s." Back in the 90s, an ER was legally allowed to turn you away if you were unable to pay upfront, or if you had the wrong insurance. For example, if you had Blue Cross insurance, Kaiser Permanente could (and would) turn you away to go to another hospital. Didn't matter if you were having a heart attack, or had a gunshot wound, or if you were having a stroke (so much for the golden hour). People without insurance would be turned away from hospital after hospital until they found the county hospital who would turn no one away; and the waiting time would be hours upon hours. Fortunately, everyone realized that this was bad, and a law was enacted that stated that no emergency room could every turn away a patient because of an inability to pay, or because of insurance.
As a clerk, collecting the copay was one of my responsibilities; we usually collected after they were given a bed, or as they were leaving the hospital. But sometimes, people would leave without paying, or they were unable to pay at that moment. That's always ok, we can bill later. Billing later, though, meant that there was a chance the person would never pay - and that happened all the time. It was a serious cause of loss of funds that the hospital was concerned about. As a clerk, I would usually attend monthly meetings to discuss better ways to collect copays without having to bill, to prevent those losses. And the best part? Of all the people who had to be billed later, it was the people who had insurance (specifically those who had *our* insurance) that were the least likely to pay their copay.
Jonathan's position seems a wee bit inconsistent to me. He bemoans the prevalence of lifestyle-related diseases, and calls for research on diet and nutrition to address them. The inconsistency comes from the fact that we ALREADY KNOW what the really important lifestyle and dietary factors are:
- Get plenty of exercise
- Drink only in moderation
- Don't smoke
- Consume a reasonable number of calories
- Eat plenty of different fruits and vegetables
- Moderate consumption of fats and sugars
The real issue is that lifestyle changes are hard. Research on "[u]nderstanding dietary effects through genetic expression" won't contribute to that. Dean Ornish won't contribute to that. The observation that:
is correct. Too bad it's not what Jonathan actually seems to care about.
Shall I now accuse him of ignoring lifestyle factors? He certainly seems to dismiss REAL lifestyle factors far more thoroughly than SBM.
JayK and Jarrad C,
This is the point that I always enjoy in these discussions. Truly, we are dealing with different cultures and translations of intent.
I do not believe that diet and lifestyle is a magic bullet. And I do not hold some romantic ideal traditional medicinal systems are superior to our modern approach to science. I think the opposite. And I believe that we can use science to bring diet and lifestyle medicine to a level of accuracy that could not have ever been imagined by traditional people.
I agree with much of what Jarrad C has to say about the complexity of research that natural foods entails, but maintain that our current system does not sufficiently equip us to deal with that complexity as sufficiently as it should. Research dollars is a zero sum game. In order to produce information at a level that big pharm currently produces information, we need to shuttle money away from big pharm and put it into independent research. Unfortunately, that policy decision will come with a huge fight. But it is an important fight to be had.
It may not be big pharma's direct or malicious intention to stymie research into diet and lifestyle, but it is the de facto outcome of our current financial-medicinal interaction with them.
It is also true that diet and lifestyle medicine is stymied by stakeholders. If an approach to illness works, but is not reimbersable, researching that approach or implementing that approach is often inhibited by research hospital administration. Sorry, to place blame. But the situation exists.
Research has shown (I wish I had a specific study to cite here, but if pressed I am sure I can dig them up) that one of the main reasons that physicians do not spend more time discussing diet and lifestyle, is that the service is not reimbersable. And it is not reimbersable because we need more research.
Hence, we have a cycle that needs breaking.
Mr. Burgess,
I see that I was wrong on my judgement of your opinion towards science. I apologize.
Yeah, that's true in almost every aspect of medicine, and nearly every aspect in science. But, it's why we research; and progress progresses slowly. I mean, heck, I would love to see more understanding of Alzheimer's Disease (my grandfather is in the later stages right now; he doesn't even remember that he has kids), but research is slow - despite the fact that there's a ton of money pouring into right now.
That happens with a profit based motive. It's the nature of the beast. But those same companies are providing a ton of research for us. As one of my professors once told me (paraphrased): "we know that happens, that's why us university researchers are here. We balance them by doing the ethical research that needs to be done, and ensuring that any damage done by a profit based system is minimized. Remember, it was a university professor that showed and campaigned the dangers of Vioxx, when Merck was claiming it was safe."
I would love to see that article. If you can find it, please do.
All in all, I really don't think that you're too far off from many of us here in opinions of the medical system; you just place emphasis in other areas. Truthfully; that's a *good* thing. Different people *need* to place emphasis in different areas, otherwise we wouldn't get such a diverse basket of knowledge. I implore you to continue this path; write the grants and do the research in this area that you are so passionate about. And above all, remember, the system of science is there to prevent us from fooling ourselves, and we are the easiest persons to fool.
Beamup,
I disagree.
If a student isn't learning do we blame the student or the teacher? If the teacher cannot teach do we blame the teacher or how they were educated? If how they were educated has been demonstrated to be insufficient to affect the student do we blame the education or the paradigm?
Whereever you wish to address this progression is up to you. I use the student-teacher example in place of patient-physician because at first it is less offensive. But patient-physician and the education of diet and lifestyle is the analogy.
There are many factors that contribute to diet and lifestyle choices of patients. Yes, currently we have an implementation problem first and foremost. Secondarily, we have a research problem. We need orders of magnitude more research to discover better implementation. Some of that implementation is patient centered. Other aspects will be physician centered. Physicians have an insufficient education into diet and lifestyle. Perhaps you were told that you have all that you needed. But the results of our culture speak otherwise. Physicians are one of many aspects that need addressing. And addressing this issue with regards to medicine is not profited by saying "we know enough already." We don't.
We also need orders of magnitude more research into dietary effects on human health.
Can you truly recommend how to make balanced meals everyday. What if the patient's diet is not balanced? Are you capable of diagnosing what is out of balance? I will tell you, if a diet is not balanced, it is unsustainable. More research must be done. Far more.
By shear numbers, we know that we are investing the lion's share of money into producing patentable compounds. We also know that we have an obesity epidemic that is outpacing our medical advancement in other areas. A 10 year old could tell you it is time to shift the balance of where we put our efforts.
Jonathan,
If your hypothesis about why physicians don't spent more time discussing diet and lifestyle is valid, then it should apply only to countries with that system of paying doctors. Do doctors in other countries spend more time on those subjects?
If there's a marked discrepancy between US and non-US practices here, that suggests a problem with our health care system. That doesn't need research: it needs political action, which is even harder. If there is no such discrepancy, it seems unlikely that the ways doctors are paid are leading to this situation.
Also, you're assuming what you need to prove: that if doctors spent more time discussing diet and lifestyle, patients would be healthier. If that isn't true, it doesn't much matter why doctors aren't spending more time on those topics. (It could be false either if the changes doctors are advocating, or the ones you want them to advocate, wouldn't actually help, or if discussing these things with patients doesn't change patient behavior. Or both.)
If you ask people why they don't get more exercise, some will say "why bother?" But even a lot of those have been told about the benefits of exercise. Will hearing it for the 37th time make a difference?
And that's a minority: more often it's "I don't have time" or "exercise is boring" or "I don't want people to laugh at me." Your doctor reminding you that walking more now reduces your risk of a heart attack in ten years isn't going to change those responses.
@ Jonathan Burgess
This is the essence of the point I was trying to make. You believe this. You may well be right, but you cannot expect vast sums of money to be diverted to such research until there is some solid evidence to justify it. You may believe the evidence exists, but it does not appear most science agrees with you.
Moreover, the money spent on pharma research and marketing is not being taken away from nutritional and lifestyle research. It is not a zero sum game.
As I said, we all agree that nutrition and lifestyle are important to good health. To jump from that to the assumption that you can create "diet and lifestyle medicine" needs more than belief. There are plenty of researchers and there are available resources should it be clear that train is going somewhere. But it will take more than belief
Mr. Burgess' argument seems focused on demanding parity in research spending between "big pharma" and "diet and lifestyle medicine" without showing why there should be parity. He also can't resist putting in a little "dig" about pharmaceutical research being "biased". I'd also ask Mr. Burgess to show that pharmaceutical research (which is largely conducted outside the company) is "biased" to a larger degree than "diet and lifestyle medicine" research.
As I mentioned above, one of the drivers of the money spent on pharmaceutical research is the cost of getting approval from the USFDA (or its equivalent in other countries). Dietary and lifestyle changes require no such approval, so it should be expected that less money would be spent on researching those modalities. Apart from the dollar (or euro) amount spent on research, is there any other indication that these interventions (I hesitate to call them "medicine") have the "deck stacked" against them, which seems to imply a deliberate, conscious and coordinated effort to "suppress" research in these areas?
There is an alternative explanation (one not requiring a massive conspiracy) for why dietary and lifestyle interventions get relatively less money and attention than pharmaceutical (or surgical) interventions - time scale. With a pill or a surgery, the results are evident in a matter of days, weeks or months. Occasionally, a couple of years might be needed (as in the case of cancer therapies) to see the effects. Dietary and lifestyle changes need to be applied early in life to have the maximum effect and the effects may not be seen for decades.
Few researchers have the perseverance and stamina (or the funding sources) to carry out a program of research that may not show results in their lifetime. Moreover, controlling confounding variables over the time necessary to see the results of dietary and lifestyle interventions is a nightmare - the best that can be done is to try and document as much as possible, in order to later stratify the subjects into comparable groups.
Again, we run into a point of confusion with Mr. Burgess - perhaps, as he suggests, on my part rather than his. His example - curcumin - is not, strictly speaking, "dietary medicine". While it is derived from a spice (tumeric), it is more properly called a "natural product" or a "bioactive phytochemical", unless Mr. Burgess is claiming that people can obtain the same results by eating more curry (I don't think the same dose levels can be attained).
In fact, much of the research I was able to find on curcumin involved making chemical modifications to the parent (natural) compound in order to make it more effective and less toxic. This begins to look a lot more like "big pharma" than "dietary medicine".
So, here is the dichotomy as I see it: there is research into the effects of dietary and lifestyle modifications and then there is research into the pharmacological effects of natural products. The first has been done since the Framingham Study of 1948 (and is being done today) and is actually rather inexpensive although it requires a lot of organisation and patience. The latter is an ongoing process in many pharmaceutical companies, with some "big bucks" ("extravagent euros"?) behind it.
I think what Mr. Burgess is complaining about - based on his comments - is that "Big Pharma" has a lot of money and spends a lot of money on research (much of the latter driven by government regulations) and advertising (to which I also object) and that his favorite niche area of research (which appears to be the questionable gene expression studies of Dean Ornish) isn't getting the funding that he - Mr. Burgess - feels it warrants.
But to generalise this to "Dietary and lifestyle medicine is being ignored" is not only over-reaching, it is just plain wrong. The simplistic comparison of research funding is misleading because - as I hope I've shown above - pharmaceutical research is fast-paced and expensive (a lot of money spent in a short period of time) while dietary and lifestyle research is slow and (relatively) inexpensive.
As an aside, gene expression studies like those done by Dean Ornish (and cited by Mr. Burgess) are very popular in my field - and they have been a tremendous headache. Even after you get beyond the question of whether the changes in gene expression are real or an artifact, you are left with - most often - a lot of data that points in no particular direction.
This sort of "random noise" is a tempting blank canvas on which researchers with an agenda can paint their own beliefs. By picking a few genes that seem to be going in the "right" direction and are at least tangentially relevant to the desired condition, a belief-struck researcher can write their very own "Just So Story" about whatever they want.
Prometheus
@ Jonathan:
Sounds like we may have more agreement than I initially thought. To be clear, I'm not saying that everyone should just do what is known to be the healthy thing - like I said, it's hard. I'm saying that there are no known good ways to make it easy to follow these principles, and we need more research into finding them. I gather that you agree.
Where we part company is that I'm far more skeptical about how much benefit will be found from learning more about details of nutrition. Certainly there will be some. But will any new insights on nutrition have anything approaching the impact of understanding the importance of calorie control? I doubt it. Will new information about the most effective forms of exercise contribute as much as the simple observation that getting plenty of exercise - any exercise - is very important? Again, probably not.
I also suspect that details will be even harder to implement than the general principles.
You also seem to be under the misapprehension that I'm in the medical profession myself; this is not the case.
Let's look at this. Insurance companies would LOVE to be able to deal with lower cost issues...like discussing diet, exercise, general health care.
Unfortunately, they have to pay for the high cost issues. Costs are passed on to the companies who buy the insurance, who want premiums as low as possible. But, the bigger issue is people.
People don't want to change. My company has a health initiative going on. Even as a health insurance company, they can't get their employees to participate 100%. People don't want to change their diet, exercise more, learn about health and wellness if it doesn't fit their current world view. They are working to help employees lose weight, stop smoking, improve health. But they can't get employees to do so. They have partnered with a group to help employees to lose weight. One of my friends refuses because "(she) doesn't want to have to exercise".
Knowing someone's genome and what diet is best for them is of no use if the person does not want to change. NO recommendation will help if the person doesn't want to change. Unless you can figure out some way to get 100% compliance from all your patients, this is something you need to learn and recognize.
As a physician, I can't help but point out a few things. First, we do, at almost every visit, discuss diet and lifestyle. If doctors today can't spend as much time as they'd like, that's more related to decreasing reimbursement for each office visit. It has nothing to do with not being able to bill for the advice. I mean, if a patient modifies their lifestyle to the point where they no longer need a prescription for DM or HTN, I'm ecstatic. I know it's primarily the patient's victory, but I consider it a professional victory as well. If all my patients could do that, nothing would make me happier, and I can't imagine a doctor feeling any other way. I get a little frustrated with the alt med crowd implying anything else, as you have.
Next a word on compliance. Suppose we did find the perfect diet, how well would it work in the real world? I mean, the simplest dietary advice I give is lose some weight. And all that entails is eating less and exercising more, and that's hard to get people to do. Not their fault, losing weight is tough, but so is following any diet. Point being, I'm not so sure more research into these issues is going to result in most of heart disease and type 2 DM disappearing, I guess I'm not as optimistic as you.
Great questions being asked. I have enjoyed the challenges and the exchange of these comments. This will (hopefully) be my last post for now.
Food is possibly the most complicated issue with regards to medicine and humanity. It is the most primal need of every organism. And for people, the influence of food touches every aspect of our lives. Education, politics, economies, medicine, personal health, etc... Food serves an integrated and founding position in every aspect of human endeavors. The complexity of food's workings in the body is daunting and the complexity of food's influence on our society is just as daunting.
There are many unanswered questions. Perhaps it would be comfortable to ignore them. I disagree.
With regards to compliance issues, we must ask, is this really a compliance issue or is this a support network systems issue? Are we addressing food thoroughly enough and early enough in people's lives, or are we waiting till it is too late? Is health a value that our culture has neglected in order to address more immediate and answerable questions, or is the science that we have now just becoming complex enough to tackle these questions again with new eyes and new scientific tools?
By all means, scientists will focus on whatever drives their passion. My passion is reigniting the food issue because today we have an obesity epidemic that is outpacing the advances of pharmaceutical medicine. Many scientists, believe that focusing on food can erradicate, or at least significantly diminish, many of the chronic illnesses that we see today. Others relegate nutrition as something along the lines of "just eat a healthy diet." I contend, that it is not that simple. I would not tell a neurosurgeon to "just cut a person's head open and remove the tumor." Likewise, given that food is one of the most complicated interactions with human health and human culture, I would not assume that such a negligent approach to food will get you the results that anyone is looking for.
I think that as a culture we have gotten too comfortable and too complacent with food, and our current negligence is costing our nation dearly. With the complicated structures that food influences, doctors and scientists must do our part and use scientific tools to guide our nation towards one of healthy structures with healthy food systems by engaging our agriculture, politics, education, and patient with the preeminent value of health. The complexity of food and its far reaching influence deserves our best scientists working on it full time with all their energy.
Once our knowledge and our implementation of food increases to the level where neurosurgery is today, then we can swing the balance the other way again, and investigate whatever is lacking at that time. Currently, however, using the power of food in our culture is an elephant in the room. Diminishing its presence will not move it.
I wish you all the best in health and happiness.
@Jonathan:
"There are many unanswered questions. Perhaps it would be comfortable to ignore them. I disagree."
I don't think anybody is proposing that these questions should be ignored.
What I *think* your hypothesis is:
For many people, specific and focused changes in diet/nutrients/lifestyle/etc. would significantly reduce their likelihood of getting certain diseases.
For example, somebody may have a genetic disposition for a certain kind of tumor, and increasing nutrient X, decreasing nutrient Y would reduce their odds of getting cancer?
The hypothesis is that variations on this are very common for different conditions and diseases.
Is this roughly what you have in mind?
If so, my primary objection is: How confident are you about how many diseases share these characteristics, and how easy the interventions needed would be?
If you tell somebody, "The average person has a 1 in 5m chance of getting a tumor on their pinky. You have a 1 in 10,000 chance. If you completely cut cinnamon and cloves from your diet, you will have a 1 in 100,000 chance", how many people will assiduously read every ingredient label?
@ carykoh: It seems like it us (doctors, nurses) against them (CAM practitioners, "nutritionists", etc.). Just because we practice science-based medicine and nursing we are accused of being knowledge deficient in the basics of dietetics.
Anyone who has gone through the rigors of medical school or nursing school knows the basics of science-based dietetics and we use that knowledge in our own lives, in our social lives and in our professional lives. We actually know that balanced diets, moderate exercise and obesity have an impact on the burgeoning rates of type II diabetes, hypertension and heart disease. It is so difficult for people to lose weight, balance their diets by changing eating habits and to increase their time doing some physical exercise...when it is "easier" to get in the car, visit a fast-food franchise or "order in".
Based on our education in the sciences, we know that supplements and other nostrums hawked by snake oil purveyors...who are at best uneducated in science-based dietetics...and at worst scam artists...are totally bogus.
lilady said:
I know it's a personal anedcdote, but I seem to run into a lot of nurses who ignore science and believe in pseudoscience. Both in the general world, and when I worked at a hospital. In the ER, we actually put an extra person on staff during night shift on full moons, because the nurse in charge of staffing believed that the full moon makes people crazy.
@Jonathan Burgess:
This is rather nit-picky, but oxygen and water rank higher in the "primal need" category than food.
Based on our education in the sciences, we know that supplements and other nostrums hawked by snake oil purveyors...who are at best uneducated in science-based dietetics...and at worst scam artists...are totally bogus.
Yes, there are those with nostrums, as well as true believers here that haven't any sense of actual physiological results obtained with individual variations of concentrated nutrients.
I've been seeing a lot of the latter lately.
@ prn: I do indeed know a lot about nutrition as do many of the posters here...we also know how to research and read current articles on the internet that are based on real science, chemistry and human physiology. Why not visit the American Dietetic Association website for advice from Registered Dieticians about proper diet, essential vitamins and minerals?
I suspect that you harbor suspicions about any licensed health care professional and would rather spend your time on the internet locating a few old papers to justify your pre-conceived biases against the science of nutrition.
Someone asked for this earlier. Stents don't work:
http://www.ncbi.nlm.nih.gov/pubmed/17387127
Part of the problem is that the average diet has a long-term success rate of about 6%: that is, if people undertake this diet in order to lose weight, about 6% of them will be thinner a year or two later. A piece of that is that the human body seems to be better at losing weight than at staying at the lower weight. Another piece is that a plan that someone can handle for eight weeks may be intolerable for a year, let alone twenty.
As long as people keep trying those 6%-successful diets, you have a large population that is going to be thinking "my doctor keeps telling me to lose weight, and I keep dieting, and my blood pressure/cholesterol/stamina is still bad. I need something else."
Note: it's not just your doctor who is offering those not-very-effective interventions: they're all over television and magazines and random conversations about "Oh, I'm on South Beach/the cabbage diet/etc." It seems to me that it's time to focus less on body weight and more on other things. Let the goal be "eat more vegetables, they're good for you" or exercise for its own sake, rather than "eat salad and go to the gym and you'll be thin." I eat salad and go to the gym. I'm not thin because of it, but that's not the point: the exercise and the greens are good for me. (Conversely, if I somehow lost 40 pounds, I would still need to exercise.)
I'm going to guess that Jonathan Burgess is a politician, because his penultimate post (#114) was a masterpiece of vague platitudes, fuzzy generalisations, inept analogies, false dichotomies and unsupported assertions. To wit:
Vague platitudes:
[trans: food is important; everybody eats]
[trans: metabolism is a complicated subject; food is important]
Fuzzy generalisations:
Inept analogies:
[note: this is also a "straw man" argument]
False dichotomies:
Unsupported assertions:
["many" is a vague word and, in this case, "scientists" may be vague as well]
In all, it reads like a Freshman Composition assignment in "persuasive writing" - long on rhetoric and extremely short on specifics and data. This has been Mr. Burgess' pattern during his sojourn on this 'blog - much passion and little data. When pressed, his examples - as noted above - usually have little or nothing to do with "diet and lifestyle medicine".
Mr. Burgess' complaints that "mainstream medicine" doesn't understand or appreciate nutrition seems to be best translated as "Doctors don't share my eccentric views on nutrition, so they must be ignorant."
It's a passable speech and would probably do well to an audience of the scientifically naive. I, however, keep waiting to hear the "meat" of Mr. Burgess' argument. It has, alas, been an entirely vegan experience.
Prometheus
@Jonathan Burgess: Your citation doesn't say what you think it says, again. The article you finally cited does indicate that PCI does not have the positive effect over current methods. Practices are shifting and there is quite a bit of discussion about changing current practices.
Did you have a point, then, or are you just working on your GoogleU credits?
@Jonathan Burgess #121
I'm no cardiologist, but I think the statement "stents don't work" is a little over-general. The link you gave is to a study that looked at angioplasty in general, not just stents, and concluded it didn't work well in "patients with stable coronary artery disease". As I understand it, in patients with acute MI angioplasty works just fine to prevent immediate death.
@ Burgess: Krebiozen beat me to it. Where in the citation you provided does it mention stents? Furthermore, if you located "stents" in the citation, where did you locate the phrase "stents don't work?"
(hint) If you don't understand common medical terminology such as PCI, you might want to "google" it. I'll help you out here...just this one time...PCI=Percutaneous Coronary Intervention or in common parlance angioplasty.
I suggest you read up on some (very) basic cardiac medicine before you comment here. BTW, stenting is not done for stable coronary disease. Stenting is done on an emergency basis for coronary artery ischemia and may also be done after non-invasive medical interventions (diet, cardio-healthy exercise and medication) don't work and the patient is diagnosed with progressive artery blockages. It is minimally invasive and done in lieu of a CABG (Coronary Artery Bypass Graft) surgery.
these sciency types most likely don't believe in time travel.
As long as it's forward, no problem.
lilady,
I believe he did use Google to find that link. I wasn't sure what PCI was, so I Googled it and went to the wiki page. I was assuming it was another language for "stent" so I did a ctrl-F search for the word stent on the wiki page. I found:
Guess what that [5] linked to. Yup! The same article that Mr. Burgess linked for us!
How he got from "drug-coated stents did not reduce death in non-acute cases" to "stents don't work" is beyond me.
And, of course, if he had read the abstract of the article, he would know that the authors were looking at the use of PCI in combination with "intensive pharmacologic therapy and lifestyle intervention" and comparing it with just drugs and lifestyle changes alone. Their conclusion that the use of PCI in these cases did not do better than drugs and lifestyle changes also does not equal "stents don't work," so I am confused by Mr. Burgess' statement again.
@ Jarred C. I am not a cardiologist and not a nurse who works in cardiac care; my specialty is public health nursing and epidemiology of infectious diseases. But I do have knowledge about cardiac stents...hubby underwent PCI with the placement of three drug eluting stents in two cardiac arteries 3 months ago. After careful frequent monitoring for the past 12 years of partially occluded arteries, there were increasing episodes of bigeminal and trigeminal sinus rhythm irregularities. He has a history of minimally invasive right and left cardiac ablations for atrial flutter and atrial fibulation.
Now my husband has always had great dietary habits, doesn't smoke and gets plenty of exercise and has fitness training provided by a physical therapist. Basically he has a healthy heart, but needed the drug-eluting stents to regulate cardiac sinus rhythms. The stents will not decrease the chance of a myocardial infarction, but in his case have dramatically reduced episodes of bigeminal and trigeminal PVCs and also provide him with more energy, which for me who lives with him...is a two-edged sword....he wears me out!
To make a statement that "Stents don't work" is sheer lunacy. They work for patients who have basic good heart functions, in lieu of more invasive coronary bypass surgery, which oftentimes require additional surgery due to blockages occurring in the grafted arteries.
We also opted for drug eluting stents over "plain" stents to decrease the chances of blood clot blockages.
You better believe that we carefully checked out the credentials of the interventional cardiologist on our States website and chose the physician who performs the most stenting procedures in the State, with the absolute lowest percentage of reported bad outcomes in the immediate post-precedure period as well as one year post-procedure. He's an extraordinarily competent physician.
@ Jarred C. I am not a cardiologist and not a nurse who works in cardiac care; my specialty is public health nursing and epidemiology of infectious diseases. But I do have knowledge about cardiac stents...hubby underwent PCI with the placement of three drug eluting stents in two cardiac arteries 3 months ago. After careful frequent monitoring for the past 12 years of partially occluded arteries, there were increasing episodes of bigeminal and trigeminal sinus rhythm irregularities. He has a history of minimally invasive right and left cardiac ablations for atrial flutter and atrial fibrilation.
Now my husband has always had great dietary habits, doesn't smoke and gets plenty of exercise and has fitness training provided by a physical therapist. Basically he has a healthy heart, but needed the drug-eluting stents to regulate cardiac sinus rhythms. The stents will not decrease the chance of a myocardial infarction, but in his case have dramatically reduced episodes of bigeminal and trigeminal PVCs and also provide him with more energy, which for me who lives with him...is a two-edged sword....he wears me out!
To make a statement that "Stents don't work" is sheer lunacy. They work for patients who have basic good heart functions, in lieu of more invasive coronary bypass surgery, which oftentimes require additional surgery due to blockages occurring in the grafted arteries.
We also opted for drug eluting stents over "plain" stents to decrease the chances of blood clot blockages.
You better believe that we carefully checked out the credentials of the interventional cardiologist on our States website and chose the physician who performs the most stenting procedures in the State, with the absolute lowest percentage of reported bad outcomes in the immediate post-precedure period as well as one year post-procedure. He's an extraordinarily competent physician.
This is what it comes down to (in my humble opinion).
If a patient breaks their arm and is put in a cast, after the cast is taken off, a doctor will recommend physical therapy. What is great is that a patient can then go to evidence-based physical therapy sessions and rehabilitate their arm. There is a complete start to finish medical system in place.
If a patient has a heart attack (or any obesity-related issue, including some cancers), the doctor will recommend that the patient improve their diet. Then what? Not much happens. Sure there are such things as nutritionists (which have debatable information as to the accuracy of the USDA recommendations), but are their cooking class clinics? Are there sufficient support groups to aid the patient in weight loss? Is a reasonable system in place to help this patient reprogram a lifetime of bad food choices and bad food preparation? No, there isn't. And because of this, recommending losing weight is advice that is not followed.
Returning to the previous analogy of physical therapy. What if a physician said to a patient, "You're going to have to rehabilitate that broken arm;" but there was not system in place for them to do so. Are we going to expect them to figure it out themselves? If they don't figure it out, are we going to say, "The patient simply won't listen to my advice." If patient after patient arrived into your office with non-rehabilitated limbs, you would say, "Something is wrong with the system."
This connection must be made more thoroughly with regards to food, obesity related illnesses and the systems in place to treat obesity related illnesses.
From the last post, "This connection must be made more thoroughly with regards to food, obesity related illnesses and the systems in place to treat obesity related illnesses."
Unfortunately, until these connections are better made and solutions are put into place, Food vs Current medical practices will remain a political issue.
People and physicians who are food-centric will look at the recent studies that found that 1 in 5 pacemakers were installed in patients that did not meet evidence-based medicine requirements for them, and they will say, "Wow, at $100,000 a pop that is a profitable business at the expense of patients"
The other side of the aisle will say, "we tell our patients to lose weight and they don't listen."
Both are correct. And it becomes a political issue that needs a scientific solution. That solution is more integration of food-based medicine into standard of care.
I have a friend is alive because a stent was used to drain fluid from his skull after a head-on auto collision. I don't think his diet had anything to do with the other driver being drunk. So I believe that kind of stent worked, which is what I was thinking about with the notion that "Stents don't work" bit.
@ Chris
I miswrote. I tend to become political sometimes due to my background. It is a side that I must learn to control.
The study found that PCI (it was reported by news agencies as "stents") did not add benefit to patients who had otherwise stablized their heart disease with diet and lifestyle and/or medication.
But post 131 stands as my opinion.
You know, political thinking is the opposite of scientific thinking, and writing. The latter requires more preciseness, even in showing how imprecise the results can be.
I am about to spend some of this cloudy Sunday working my way through a book you should read: Nonsense on Stilts.
@Chris
Ideally, science is apolitical. But in reality medicine is very political.
In a conversation that I had with the Surgeon General (current), I asked why reimbursements could not be changed to favor early prevention instead of late-treatment. Science can clearly demonstrate that one is better than the other. But reimbursements aren't going to change anytime soon. The Surgeon General's response was "If we start to pay more for prevention, we have to take away money from surgeons and specialists. It is not an easy thing to do."
So? That does not give you an excuse for sloppy writing.
...Continued...
Mind you this is a Surgeon General who wants to put prevention first. She wants to be remembered as "the Prevention Surgeon General" (in her own words).
But the medical system is severely constrained to favor payments to late-stage treatments rather than early-stage prevention.
@Chris
I should definitely become a more precise writer. This is not a revolution that can be won with sloppiness.
But precision does not exclude someone from political bias.
You can have a lot of advanced specialists writing in very precise terms with very political bias. Their precision does not exclude them from their money making agenda.
@Jonathan
I agree with you in some ways, but I don't much like your analogy. There is no mechanism in place to force a person who has a broken arm to attend their physical therapy sessions. Equally you can't force people to follow the advice about diet and exercise after a heart attack. You don't need special equipment to stop putting too much crappy food in your mouth and take the stairs instead of the lift.
I'm not familiar with how things work in the US, but in the UK anyone who has heart problems gets professional advice about how to improve their lifestyle. I worked for several years with a doctor who held a lipid clinic, and she despaired of persuading her patients to lose weight and get more exercise, they mostly preferred to take a pill.
By the way, the term you are looking for is "dietitian", not "nutritionist". A dietitian is a qualified health care professional, whereas a nutritionist is someone who may not have any training at all - anyone can call themselves a nutritionist. If your doctor is sending you to a nutritionist, I suggest you find yourself a new doctor!
Mr. Burgess wrote:
I live in California. Out here, there's a hospital system (HMO) called Kaiser Permanente. I used to work there. My parents go there for their medical care. In Kaiser's hospital system, there is as much support for weight loss as there is for physical therapy - which is to say, there's a lot. When my grandfather developed Type II diabetes, the physicians at Kaiser put him with a clinical dietician (which is the science-based food expert, compared to the nutritionist). When my mother decided that she wanted to loose weight (no medical necessity in her case), she was also given a clinical dietician. Both their progress was monitored over time, and they were given advice on cooking techniques and information on which types of foods to avoid. Since diet and exercise go together, they both were also given a physical therapist.
My mother also had to have surgery last summer on her shoulder. Like the monitoring progress for her diet, she was given a physical therapist for her shoulder recovery, and her progress was monitored.
You complaints about a lack of science-based nutrition might be a local complaint; I don't know how they do it out in Penn. Or, my experience might be localized, and only Kaiser does this sort of thing. Or it may be somewhere in between. I'm just letting you know that at least at one hospital system, what you desire is happening.
As a side note, never trust a person who uses their nutritionist certificate as a qualifier for being an expert. If you want science-based food advice, seek a clinical dietician. The title of nutritionist is not controlled or monitored in any way. Anyone can get a nutritionist license, and you don't have to go to any sort of school to get the knowledge. I have a nutritionist certificate, and all I had to do was take an online test (oh my god, it was so easy) and pay the website some money. There wasn't even any sort of verification that I was who I said I was. I even thought about getting a nutritionist certificate for my dog.
I was prescribed physical therapy for six weeks. I did three weeks and quit. Real life intervened. There is no mechanism a doctor could use to make me continue the therapy.
There are loads of cookbooks in book stores or on Amazon, for all different types of dietary problems. There are loads of websites with dietary advice. There are community colleges with cooking classes. If a patient wanted to improve their diet, there are *lots* of resources. People don't do it because it's easier not to.
Need to lose weight? There are groups like Weight Watchers. There are books and websites to help you. People don't do it because it's easier not to.
It is ludicrous to condemn medicine for failing to get people to change their diets, lose weight, get more exercise, watch less television, read more, clean up their rooms...
Ahem. Doctors are not the patient's parents.
Jarrad,
Excellent demonstration that with the proper supporting systems in place, diet and lifestyle recommendations are more than just words.
If only we could duplicate Kaiser into every state and every city... we could have a concerted effort against industrialized food companies the same way medicine stands in unison against tabacco.
Thanks for reminding me of Kaiser, home of one of my favorite researchers Haruo Kushi.
@ Jonathan Burgess: Before you comment here about cardiac medicine you should get your facts straight. I realize that you probably lifted your statement, "1 in 5 pacemakers were installed in patients that did not meet evidence-based medicine requirement for them....", because you read a poorly written article in the Huffington Post.
The JAMA study referred to in the H-P article, is not about cardiac pacemakers, it is about ICDs (Implantable Cardioverter Defibrillators) On another post you misinterpreted PCI procedures and drew the conclusion that "stents don't work"
The abstract for the JAMA ICD study is at:
Pubmed 21205965
I'm wondering, (your) "favorite researcher Haruo Kushi"...would that be the researcher who is involved in macrobiotic diet research?
Perhaps Mr. Burgess should go and tell this group of people how diet and exercise can prevent the one out of a thousand who have this particular condition:
http://www.4hcm.org/
@ lilady
Actually, it looks like Kaushi is not a woo-meister. The macrobiotic stuff is from the mid-80s. His recent stuff looks interesting. http://www.dor.kaiser.org/external/Lawrence_Kushi/
I like Dr. Weil and his work. He promotes an organic diet and exercise as the basis for optimal health. Although simplistic, he has nailed it on the head. Common sense is not common anymore. http://allherbalremedies.org
Common sense says that witches weigh less than a duck.
The current scenario is that the medical field only accepts evidence from Randomized Clinical Trials (RCTs) and dismisses other types of potential evidence including statistical studies. RCTs are important, however, it costs a lot of do randomized trials and to have those treatments approved by the FDA. I think the current scenario is that it costs at least 500 million dollars to get enough evidence from a bunch of RCTs. Of course, that doesn't include money wasted on things that may not work. With that type of financial calculus in place, no industry is going to plow any significant amount of money researching something that doesn't have revenue-generating potential. Without true industry focused investments, most "alternative medicine" studies are going to be fairly shallow. So with that being said, most studies are going to be done on pharmaceuticals and technologies that can generate revenue.
So sure, pharmaceutical companies study various plants all the time, but it is so they can isolate a certain singular compound and make a derivative version of that compound so that it can be patented. They can't simply sell you something that has no revenue generating potential. Research is costly, and frankly as large as the return from the alternative treatment markets can be, the return from patented technologies is greater.
Unless we recognize that in the medical community, we're deluding ourselves into believing that our current medical technologies do not have flaws that need to be questioned.
We can argue until our face is blue that Dr. Weill's recommendations are ridiculous, and they may well be, but how much of any of it is thoroughly investigated with the type of true investment that we devote to patent-potential approaches.
The issue at hand is that the public has become cynical towards the medical industry as it has not yet found any cures, and by that I mean complete eliminations, for cancer, HIV, mental illness and a whole host of conditions. This is not to say that the medical industry has not made leaps and bounds in improving the lives of many, but there is some public disappointment that the amount research dollars invested has not produced any cures. Once there isn't an absolute cure, patients will naturally go towards things that might give them hope.
"The current scenario is that the medical field only accepts evidence from Randomized Clinical Trials (RCTs) and dismisses other types of potential evidence including statistical studies."
I'm going to have to ask what your clinical background and level of experience is.
puffpuff01
Hmmm, they wouldn't want to isolate a single compound because then they can determine accurate dosages to determine what's safe and effective, would they? No, no, it must be purely the be patent-for-profit motive.
It seems to me that the "delusions" in your comment are all your own.
Well said puffpuff01.
Someone needed to say it :)
I wouldn't tell Dedj your background if I were you, just let them do the honourable thing with the information and opinions you've been kind enough to share. Let them try to understand what you have said first.
The status quo isn't nearly shaken enough yet!
MK x
Sorry Jacob, but I need to know puffpuff's clinical background in order to know if they are trolling or just stupid.
It's likely that they actually do have some real-world experience, but as they imply that the medical world dismisses the hierarchy of evidence, I doubt they have any.
@puffpuff01 GW Pharma UK have gone the distance already. They have a whole plant extract medicine on the market, just coming to the end of the Phase III trials in the USA for cancer pain. It's cost them nearly a Billion but it's paid off :)
You shouldn't get so hung up on who is behind the words, it shows you're not concentrating on facts.
Cheers,
Not Michael Jackson
@TBruce
When will we prescribe diets based on someone's genome? "When you get your flying car?" you say.
Maybe you should take it up with Dr. Kevin Niswender, Professor at Vanderbilt Medical School:
http://yourlife.usatoday.com/fitness-food/diet-nutrition/story/2011/06/…
Nutrigenomics is the future of diet and lifestyle medicine.
@TBruce
When will we prescribe a diet based on someone's genetic make up? "When you get your flying car" you say?
Maybe you should take that conversation up with Dr. Kevin Niswender of Vanderbilt Medical School
http://yourlife.usatoday.com/fitness-food/diet-nutrition/story/2011/06/…
Nutrigenomics is the future of diet and lifestyle medicine.