Respectful Insolence

ebm-pyramid

One of the most annoying phenomena when it comes to “complementary and alternative medicine” (CAM), which its advocates are more and more insistent on calling “integrative medicine” is how little the average doctor cares that pseudoscience is infiltrating medicine. The reason, of course, is that CAM advocates don’t like the “alternative” part of the term CAM. Come to think of it, they don’t like the “complementary” part, either, because it implies that conventional science-based medicine (what I like to refer to as “real” medicine) is the main treatment and what they do is just “complementary” and therefore not really necessary. The model they prefer and are increasingly getting people to buy is that they are “integrating” their treatments with science-based medicine, the implication being that they are equal and the sales pitch being that they are “integrating” the “best of both worlds.” Of course, to paraphrase my good buddy Mark Crislip, integrating cow pie with apple pie doesn’t make the cow pie better; it makes the apple pie worse. And, yes, the woo of integrative medicine is the cow pie in this analogy.

Worse, however, is how easily physicians buy into the mindset behind “integrative medicine. I found this out yet again when I came across an article by Robert P. Cowan MD, FAAN, a neurologist at Stanford University, entitled CAM in the Real World: You May Practice Evidence-Based Medicine, But Your Patients Don’t. My first thought on reading the title was that he might be discussing how to get one’s patients to accept evidence-based recommendations and how to talk to them about CAM. And it is, sort of. Unfortunately, Dr. Cowan buys into a lot of the tropes about CAM that lead to its acceptance among physicians. Now, I will admit that the abstract, on the surface, doesn’t sound so bad, although I really think Dr. Cowan is exaggerating when he starts out with this background:

Complementary and Alternative Medicine (CAM) approaches are widely used among individuals suffering from headache. The medical literature has focused on the evidence base for such use and has largely ignored the fact that these approaches are in wide use despite that evidence base.

Now, I’m not a neurologist, and I don’t read a lot of the headache literature. However, I do read a lot of the CAM literature, and rarely do I see a paper on CAM that doesn’t mention how such therapies are so popular among patients and that doesn’t mention that the evidence base for such therapies is thin to nonexistent. Even papers by advocates tend to mention these things, although advocates tend to emphasize the popularity and downplay the lack of evidence. So what does Dr. Cowan plan to do? The purpose of this article, apparently, is to suggest strategies for “understanding and addressing this use without referring back to the evidence base,” the rationale pivoting “on the observation that patients are already using these approaches, and for many there are anecdotal and historical bases for use which patients find persuasive in the absence of scientific evidence.” He then concludes that “until such time as the body of scientific literature adequately addresses non-conventional approaches, physicians must acknowledge and understand, as best as possible, CAM approaches which are in common use by patients,” which is about as obvious a conclusion as there is. It’s not the conclusion so much that bothers me. It’s how Dr. Cowan gets there.

He starts off with a a really annoying introduction:

There is a French proverb, dating from the late 13th century that proclaims: “It is the poor craftsman who blames his tools.” But there is a belief in headache medicine (and elsewhere) that, if only we had the proper tools, we could meet all our patients’ expectations.

Similarly, there is another belief, widely held, perhaps not consciously, by many of our patients that the tools to manage their headaches exist, but their doctors, as “Western,” evidence-based practitioners, are unaware, inappropriately skeptical, or simply arrogantly biased when it comes to implementing non-Western approaches. And so they seek these alternatives out, often clandestinely. And why? Because their doctors talk about the “dangers” of using anecdotal “evidence” in making decision treatments or the perils of using treatments that lack scientific foundation? Why do patients turn to folk remedies and other alternative approaches? Should we be trying to dissuade patients from “experimenting” with these nontraditional approaches?

Increasingly, over the last century or so, physicians have been spending more and more time at the altar of evidence-based medicine and implicitly rejecting treatments that lack a “rigorous” and “validated” evidence base. This has occurred despite ongoing discussion of the flaws and deficits in the vetting of and access to the “evidence” in evidence-based medicine.[1] Nonetheless, this approach has become the standard of practice for the doctors. But what about the patients? Do patients accept and practice evidence-based medicine?

Ah, yes. Note the framing. Doctors worship at the “altar of evidence-based medicine” (EBM) and reject treatments that lack a “rigorous” and “validated” evidence base. (Note the scare quotes around “rigorous” and “validated.”) I hate it when doctors who should know better throw around the old trope, beloved of quacks everywhere, that doctors are not practicing based on evidence and science (because, you know, EBM is not perfect) but rather are doing so because EBM has become a religion. And, of course, we’re “arrogantly biased” when it comes to “non-Western” approaches. Does Dr. Cowan know how off-base his use of “Western” medicine as a construct is? As I’ve pointed out before many times, the dichotomy between “Western” and “non-Western” (usually “Eastern”) medicine is a false one—and an implicitly racist one, to boot, although most people who use it don’t realize the racism inherent in the construct. The implication of this dichotomy is that only “Western” medicine is scientific while “Eastern medicine” (or non-Western medicine) is not scientific. Only the West, or so it seems, can claim the mantle of science in medicine, while the West, or so it seems, can’t claim the mantle of “wholism” or understanding that the patient might have other understandings of how to determine what works than EBM. It’s irritating as hell.

It’s also a bit of a straw man to say that proponents of EBM tell patients about the “danger” of relying on anecdotal evidence. What patients are told is that anecdotes are unreliable as a means of determining what does and doesn’t work, which is absolutely true, particularly for subjective symptoms. Placebo effects, regression to the mean, and the form of selective memory known as confirmation bias lead human beings, including doctors, to think they know what works.

After an anecdote about a patient with headaches coming in and telling him of all the various natural treatments that seem to work or the various substances that seem to trigger his headaches, Dr. Cowan does make a reasonable point when he describes what his patients tell him when about reactions of other doctors to their descriptions of what work and don’t work for their headaches:

  • There is no scientific basis for these “so-called” natural cures. Stop them, you’re wasting your money and might even be harming yourself.
  • Have you considered seeing a Pain Psychologist? Generally, when a patient goes to such extremes, there is some underlying psychiatric issue.
  • There is a variety of prescription medications that may be more effective for you, and these other things you are taking might be interfering with the real medicines, making them ineffective.

Dr. Cowan (and I) both think that #1 is the wrong approach. Although I do tell patients when I think that there is no scientific basis for a treatment, I rarely tell them not to use them, at least not bluntly. I’m also very careful to try to remain as nonjudgmental as possible, having learned the hard way from being too blunt in the past. I’d be lying if I said that I don’t occasionally slip up and revert to such bluntness, but such incidents have become so rare that I honestly can’t remember how long ago the last one occurred, although I can remember (and regret) what I said. I can’t comment on #2, but #e certainly sounds about right. Dr. Cowan, though, instead of sticking with that reasonable solution goes a bit off the deep end:

Obviously, we cannot be expected to know about every treatment option in every medical system under the sun. The armamentarium of the homeopathic or Classical Chinese healer or Ayurvedic doctor is every bit as complex as that used in Western medicine. Each practitioner is obligated to provide enough information to allow our patients to make informed decisions about their health care. Moreover, we need to know enough about different therapies to help protect our patients from potentially dangerous practices, and finally, we need to be as non-judgmental as possible without compromising our own critical thinking.

Here, Dr. Cowan seems to be mistaking complexity for profundity or plausibility. Otherwise, he wouldn’t mention homeopathy in this context. After all, given that the very principles that underlie homeopathy are complete and total pseudoscience and most homeopathic remedies are diluted to the point that the odds against there being a single molecule of active remedy left over are incredible, it is not necessary for a physician to know much about all the various remedies prescribed by homeopath. All one has to know are two things. First, what dilutions are low enough that there might be actual substance left (12C—or 10-24—being the dilution that would roughly leave maybe one molecule left. Realistically, any dilution over 6C (10-12) would be highly unlikely to have enough substance left to have a pharmacological effect. Second, one has to know that the very basis of homeopathy is pseudoscience. Knowing that, one can know that the vast majority of homeopathic remedies are water and therefore inert placebos.

As for Ayurveda and traditional Chinese medicine, all one needs to know is that both are based on prescientific concepts that don’t have a basis in science. Unfortunately, that doesn’t stop Dr. Cowan from, in essence, treating them as equals:

Every one of the medicines (for want of a better word) that AG is taking has some basis in the treatment of headache in one or another medical system.[4] Some have an evidence-based rationale, while others have a historical rationale dating back thousands of years. Some are based on a Western diagnosis such as migraine without aura, while others are based on a classical Chinese medicine diagnosis of cool, damp headache, or an Ayurvedic diagnosis headache due to too much pitta dosha (see Dr. Gokani’s accompanying explanation). A couple trace back to traditional American folk treatments. It is not reasonable, practical, or perhaps even appropriate for Western physicians to be skilled in classical Chinese, Ayurvedic and homeopathic medicine. But an awareness of the reality that other medical systems exist, and perhaps more importantly, are practiced by our patients, is critical to our ability to properly care for patients. When these differing approaches conflict or complement each other, shouldn’t we broaden our knowledge base to allow for interaction?

Broadening one’s knowledge base is good, but if, by “interaction” Dr. Cowan means embracing pseudoscience just because our patients embrace it, then that is where we part ways. Unfortunately, that does appear to be what he means. Rather than knowing about these things so that we can explain why they have no basis in science and/or be aware of possible interactions with pharmaceutical agents, Dr. Cowan seems to be arguing that we should know more about these “non-Western” treatments so that we can work with our patients in using them. Of course, the wag in me can’t help but note at this point that homeopathy, for example, is as “Western” a treatment as there is, given that Samuel Hahnemann was German and popularized homeopathy first in Germany.

Dr. Cowan also seems to have a bug up his posterior about the Flexner report. Yes, the Flexner report, the report that spurred American medical Schools over 100 years ago to abandon a lot of the non-science-based treatments and modalities being used throughout the land:

The Carnegie Foundation took it upon itself to survey and evaluate the more than 150 medical institutions in the United States and determine which among them were using an educational model that was suitable by their standards.[6] They selected Abraham Flexner to conduct the survey. Flexner was an educator by training, not a physician. He was a strong proponent of the “German” approach to education and a firm believer in the new “scientific approach.” Thus, when he surveyed schools, he used reliance on the scientific method as a major criterion for recommending accreditation. He dismissed any notion of healing based on historical evidence or anecdote.

While no one could rationally dispute the enormous benefit this has had for the advancement of science and medicine in the ensuing century, it should be noted that Flexner and his report had its detractors, not the least of whom was William Osler, who felt such a heavy reliance on the science of medicine, to the exclusion of the art and history of the practice, was a serious flaw.

In any case, one consequence of the Flexner Report of 1910 was that virtually all “proprietary” schools were closed. Moreover, those that attempted to remain active (despite legislation that all medical schools would require state licensure and vetting by the American Medical Association), no longer had access to major endowment funding by the likes of the Carnegie and Rockefeller foundations, and later from the federal government itself. It is worth noting that these “proprietary” schools were generally not university affiliated and provided “practical” training in “folk” medicine, including naturopathy, homeopathy, etc. From that point forward, these approaches were no longer generally considered conventional medicine. Other consequences of the Flexner Report were the establishment of the “full time system” in medical education, in which professors were no longer obligated or expected to provide patient care, and pre-eminence of advancing science over ethics and patient care came to the forefront of medical education. The adoption of the Flexner Report signaled the end of the apprenticeship system.

To summarize, what is presently accepted as conventional medicine came to be so by caveat. Other medical systems have neither been subject to the rigorous vetting that Western medicine approaches have undergone in order to further develop nor have they been demonstrated to be ineffective or dangerous in any systematic way. In other words, there are no scientifically accepted criteria for inclusion or exclusion of specific modalities as CAM or as conventional. Conventional medicine is exactly that – medicine by convention.

Note the loaded language throughout this entire description. Notice how the Carnegie foundation “took it upon itself” to survey the medical schools in the US and determine which ones were using an educational model “suitable” to their standards. Dr. Cowan describes Flexner as using reliance on the scientific method as a major criterion for recommending accreditation of medical schools as if it were a bad thing. One thing that Dr. Cowan also neglects to mention is that most “proprietary” schools not associated with a major university were run to make a profit, that only two years of study wer required, and that laboratory work and dissection were not even necessarily required. In other words, practical knowledge of human anatomy was not necessarily a requirement in these schools. Most such schools also didn’t require any university training. The Flexner report changed that, and resulted in the lengthening of the medical school curriculum to the current four years. Moreover, a lot of medical schools offered courses in quack modalities such as chiropractic medicine, eclectic medicine, naturopathy, homeopathy, electromagnetic field therapy, phototherapy, eclectic medicine, and physiomedicalism. The Flexner report led to the leaders of these medical schools either to drop this quackery from their curriculum or lose their accreditation and underwriting support.

In other words, Dr. Cowan gets it backwards. The reason that these other medical systems were removed from the curriculum of medical schools and schools teaching them closed was because it was already known in 1910 that these medical systems had no basis in science. Homeopathy doesn’t have to be demonstrated to be ineffective. Its very rationale tells us that it’s only water and can’t be effective; that is, unless huge swaths of physics and chemistry are wrong. Yes, these medical systems were eliminated by caveat, but it was completely the right thing to do. In the over 100 years since then, advocates of these other treatments have failed to produce evidence that these systems should be re-introduced into medicine, but advocates of “integrative medicine” are sure enough trying.

In the end, Dr. Cowan makes points that are fairly unobjectionable in that he says that patient preference needs to be considered (which we usually do as physicians); that physicians should be at least somewhat knowledgeable about CAM; and that we should listen to our patients nonjudgmentally. Unfortunately, he has a lot of assumptions about CAM that don’t jibe with reality, not the least of which is that the only reason it doesn’t have a rigorous scientific basis is because it hasn’t been studied is because its study has been precluded by the Flexner report and the arrogance of “Western” physicians, rather than because there’s no “there” there.

Comments

  1. #1 Denice Walter
    August 11, 2014

    What does a SB physician advise when a patient reveals that he or she is taking massive dosages of supplements in the belief ( based upon the tutelage of an esteemed altie expert or self-generated**) that this action will prevent cancer or serious disease when we KNOW that there have been associations observed between high doses of various supplements ( including beta-carotene, vitamin E, Omega 3s, folates, calcium) and cancer and CVD? ( As well as other problems associated with megadoses of vitamins C and D).

    I know about beta-carotene and increased cancer risk in smokers for a long time but more recently have become aware of the others and a possible mechanism ( that high doses of anti-oxidants suppress anti-tumour factors).

    Does following woo-tropes increase -rather than decrease- your risk of cancer?

    ** yeah, right.

  2. #2 KayMarie
    August 11, 2014

    @ Denice

    As a toxicologist I tend to want to go off on the dose makes the poison rants coupled with redox reactions go both ways depending on conditions and how my embryology professor started using vitamin A because it more consistently caused birth defects in mice than dioxin at doses the mom tolerates well (and besides is less regulated so easier to get and dispose of)

    None of which I have found work out in the real world to change the mind anyone that is deep in the woo. I went round and round with a seller of antioxidants who just dismissed any data that showed there could ever be a possible harm at any dose. If a glass of wine is good, then the amount if 100 casks of wine must be 100,000X better!

    My guess is what may work is a thanks for informing us. We need to know this should you ever need emergency surgery as some vitamins and herbs thin the blood and while that is good most of the time it is bad in the OR and we would need to be ready to deal with that (coupled with a reminder for scheduled surgery they recommend stopping the high doses of vitamins and herbs for about 2 weeks before the date). Also knowing this information may change which treatments we may use for some things in the future to avoid known interactions.

    I might remind them that the amounts of these good things we know are good is generally from diet studies with people not getting more of these nutrients than they can get in food and in the combinations they can get in food. It really isn’t known how much more than that is a good idea, or if throwing off the balance between all the different vitamins you get from foods by picking a few to take a lot of is healthy. In doses similar to diet studies to make sure you didn’t miss anything the risk should be low, but the more you take and the more out of balance the whole nutrient/phytochemical profile gets (both ones we put in pills and ones we do not) the more chances there are for something unwanted to happen.

  3. #3 Eric Lund
    August 11, 2014

    @Denice: You can’t reason somebody out of a position he didn’t reason himself into.

    Some of these supplements will interfere with the action of certain drugs, so the best you can do is thank the patient for letting you know (as KayMarie says), and avoid prescribing the drugs in question.

    I agree that following certain alt-med regimens may well increase cancer risk. Many other forms of excess do: alcohol, red meat, etc. And some of the ingredients found in alt-med supplements (such as certain ayurvedic medicines) are actually toxic.

  4. #4 Denice Walter
    August 11, 2014

    @ KayMarie:

    Thanks for that.

    @ Eric Lund:

    Of course.
    But I would tend to think that SBM advocates making that knowledge more generally known (i.e., the risks of megadoses) might cause those ‘on the fence’ to re-consider their actions. The most woo-besotten are already too far gone and may not be consulting physicians anyway.

    Real Woo ™ doesn’t believe in vitamin overdoses- even when it happens to them personally.

  5. #5 mho
    August 11, 2014

    Sadly, what I’ve seen on a few cancer support boards, is that once someone gets patients wondering about taking excessive supplements and vitamins, they respond by thinking they need to go to someone who is an “expert”, like, [sigh], a naturopath.

  6. #6 Krebiozen
    August 11, 2014

    Denise,

    The active risks from supplements and CAM generally are fairly low. Beta carotene increases risk of lung cancer in heavy smokers by up to 25%, according to this study. When you consider that smoking alone increases the risk of lung cancer by a factor of 15-30 (i.e. 1,500% – 3,000%) it seems clear to me that persuading a patient to quit smoking would be far better than persuading them to quit taking supplements.

    I think the real risk of CAM is in discouraging patients from getting effective evidence-based care. Focusing on the relatively low risk of a punctured lung from acupuncture*, or of turning blue from ingesting colloidal silver**, or on the danger of kidney stones from taking vitamin C*** may result in a patient ignoring further good advice.

    I understand the concept of risk without benefit, but I think this area does need to be handled carefully if we don’t want to scare some patients away from conventional medicine altogether. It reminds me of using scare tactics to stop teenagers using marijuana; when they see for themselves that the vast majority of people using marijuana do not run into problems, they are less likely to trust the person who gave them the inaccurate information, and may perhaps assume that warning about the risks of opiates and other drugs are equally exaggerated. Hyperbole may be counterproductive.

    * Witt et al reported 2 cases of pneumothorax in 2.2 million acupuncture sessions in 229,230 patients.

    ** The only cases I have read about were in people who had taken enormous overdoses of silver, certainly not the 5 mg/l stuff I have seen on sale in health food stores with a suggested daily dose of 5 ml (25 micrograms). People with argyria have almost all either been prescribed silver nitrate or have made DIY ‘colloidal silver’ using tap water or saline instead of distilled water, resulting in a silver salts solution with thousands of times more silver than recommended.

    *** Vitamin C supplementation doubled the risk of renal calculi in man, but not women, in some studies, probably due to increased oxalate excretion, but absolute risk was 147 in 100,000 for first incident cases.

  7. #7 Krebiozen
    August 11, 2014

    Apologies for typos in last comment.

  8. #8 sadmar
    August 12, 2014

    What I draw from this: It is unwise to consider “medicine” as unified system in which all forms ‘play by the same rules’, as this benefits the legitimation of quackery to the harm of patients.

    The circumstances of a patient visiting Dr. Cowan for a headache, and a patient visiting Orac for a lung tumor are so different, that is damages reason to lump them together under one rubric.

    Cowan’s sin (and it is a considerable one) is extrapolating from treatments for HEADACHES(!) to medicine in general. ‘Hey guys, CAM helps some headache sufferers, so you should all be giving CAM a chance!” Er, no.

    Now I have no problem with the first part of the proposition: I am perfectly willing to entertain the hypothesis that certain CAM ‘modalities’ (can somebody ban that word!) may help relieve various sorts of routine aches and pains. The placebo effect is a Thing, after all. The human brain can apparently reduce the perception of pain, and psychologal functions may in some cases address sources of pain. Maybe acupuncture works better than aspirin for some people not only because they believe it will, but taking the time for the treatment relaxes them, relieves stress… I dunno. Anyway, it’s no great leap to imagine that for different people some placebos have more effect than others, and some may even experience more relief for a headache from their placebo of choice than from the mysterious workings of Bayer’s Wonder Drug™.

    Cowan notes that a significant number of patients he sees report positive experiences with CAM treatments for headaches. So he argues, “If it makes them feel better, it’s my responsibility as a care-giver to prescribe it — under the appropriate conditions.” The end. I suspect he is being a tad disingenuous.

    I suspect he is responding to patient demand. If he admitted that, we might better understand the reality of dealing with real patients in the real world. People have minds of their own, and tend to think they know more than they do. If a patient comes to Dr. Cowan KNOWING that choose-your-placebo has not only made her headaches feel better, but the headaches of half-a-dozen close friends, Cowan probably understands that if he tells her that’s all a bunch of woo and only FDA-approved SBM is appropriate for her treatment, he’s might lose a patient. Which would be bad for him.

    (Perhaps it’s worth noting that Dr. Cowan works in a part of the country that has a large Asian immigrant population. Though The Farm itself is pretty pale, I live about a half-hour up the peninsula, closer to the City, and there are a full page of tiny line listings for acupuncturists in the Yellow Pages. Probably don’t get that in Michigan…)

    And bad for the patient, too. What’s missing from Cowan’s article is a clear disclaimer, “I’m only saying this is OK for headaches, not anything else, and then only under the supervision of a real doctor.” Which is exactly what he needs to tell his patients as well.

    In short, he ought to draw clear distinctions between different categories of medicine based on the nature of the ailments. Why give CAM any limited purchase in legitimacy? Because patients drive their own care, and you will not convince all of them that CAM doesn’t work for aches pains no matter how many studies you do, no matter how many times Orac blogs ‘the truth’ on RI. The BEST you can do in the real world is split the difference, “Yes, you can do that for this. No, you can’t do that for that.”

    If you DEMAND the patient go whole hog, ‘SBM for everything, and nothing else’ you’re setting up a too rigid dichotomy on terms you are going to lose too much of the time. The little aches and pains that CAM may appear to assuage for various folks are a hell of a lot more common than life-threatening illnesses, so people have more lived experience with them, which produces a level of trust (because that’s how the brain works, because that’s been a useful survival skill for millennia, and, you know, because Darwin). Deny their experiential knowledge, and people will think you are arrogant and narrow-minded. If they think you’re arrogant and narrow minded about their headache, they’ll think you’re arrogant and narrow-minded about everything. Tell them ‘CAM never works’ and they know you’re wrong so they conclude CAM must be OK in general. And so some poor dumb schmuck dies at 45 leaving three orphaned kids because he didn’t go see a real doctor when he had real treatable life-threatening illness.

    Conversely, if good Dr. Cowan sent his pill-recalcitrant patients off to get. needled with the proper caution (only for things I OK, and you have to keep me in the loop because while most of the time a headache is just a headache, sometimes it’s a sign of something really serious, and Mr. Yang is not equipped for that, OK?) he gains their trust by confirming their experience with the aches and pains, and USES that to keep them connected to real medicine for the important stuff.

  9. #9 Denice Walter
    August 12, 2014

    @ Krebiozen:

    I don’t think that supplements present a great risk HOWEVER those who have answered the siren’s song of woo, may be purchasing and ingesting megadoses as protection, an insurance policy as it were, against cancer- which is how they’re often marketted- hearing that they may indeed CAUSE cancer ( even infrequently) may serve as a wake up call to rallly their common sense.

  10. #10 KayMarie
    August 12, 2014

    I agree that anything that helps counter the more is always better approach is important. Especially given the marketing efforts to get people to always believe more and more can only be better and even miraculous and that more can never be toxic.

    Even just playing up the diminishing returns aspect may be important information. Like the recent meta-analysis shows. We are really pretty darn certain the vitamins and phytochemicals in two servings of fruits and veggies a day lowers the risk of death including cancer compared to one serving, and so on up to 5 servings a day. Anything more than that, and you’ve reached the point of diminishing returns and 6-10 is no better than 5 (and 10-20 is no better than 6-10).

    The body only absorbs so much of anything, only has so many receptors on so many cells to interact with something, and generally tends to quickly eliminate most things (although it stores a few), so there likely is a maximum effective dose for everything and seems like most of those are in the dosing levels our free-range hunter-gatherer ancestors could achieve without industrial processing (either stuffing 3 weeks worth of a vitamin into a pill or juicing three weeks of produce into a glass).

    You gotta wonder what all the excess will do when it doesn’t have a job to do. Kinda like a working dog (like a border collie) left alone at home with only a couch and no work to do. Something bad is going to happen sooner or later as it doesn’t have a shut off tied to if work (or chemical reaction, etc.) is needed or not.

  11. #11 Denice Walter
    August 12, 2014

    @ KayMarie:

    One of the loons I survey holds that you require at least 13 servings a day ( 8 of green vegetables and 5 of red fruits/ vegetables) and that juicing should be done as well. Of course, if you fall short of the mark, you can always supplement with the powdered greens and reds he manufactures ( creatively called “green stuff” and ‘red stuff”) and sells at exorbitant prices.
    -btw- these powders are commonly sold both at websites ( like his and his competitors’- like Mikey) and at vitamin/ health food shops: I recently spent a half an hour looking over the powdered vegetables, fruits, proteins etc.
    Don’t these people eat solid food?

  12. #12 Krebiozen
    August 13, 2014

    Denice,

    hearing that they may indeed CAUSE cancer ( even infrequently) may serve as a wake up call to rallly their common sense.

    Good point, though I would expect them to more easily accept the idea that artificial supplements made by Big Pharma are bad, while continuing to insist that natural plant extracts are good. There is very limited evidence for the effects of drinking juices (or the red and green powders you mentioned), and they often contain a lot of sugar and sodium. There are also antinutrients to consider – humans have been cooking food for tens of thousands of years for good reasons!

  13. #13 Larry Esser
    August 15, 2014

    When dealing with family members who are religious and also into CAM, the phrase, “there’s no ‘there’ there” comes to mind quite often! They mix fantasy and reality together and then act as if the real part makes the fantasy part also real. They call this “critical thinking.” It’s astonishing to hear this drivel from otherwise intelligent people, but it seems to come from an emotional attachment to what they want to be true–wishful thinking. Since it’s emotional, using reason to go after it won’t work. All you can do is keep pointing out how and why pseudoscience and religion are not about reality and hope they will think about it.

  14. #14 Mike
    August 19, 2014

    It looks like Josephine Briggs over at the National Center for Canards and Magic has weighed in. http://nccam.nih.gov/about/offices/od/real-world

  15. #15 Leigh Jackson
    August 19, 2014

    @Mike

    Briggs refers to a recent Java review summarising “the sizeable body of data pointing to benefits of acupuncture for chronic pain”.

    This review, however, merely reproduces the results of a meta-analysis by the acupuncturist authors analysed by Orac a couple of years ago. Results which Orac showed to be clinically meaningless:

    http://scienceblogs.com/insolence/2012/09/12/can-we-finally-just-say-that-acupuncture-is-nothing-more-than-an-elaborate-placebo-can-we-2012-edition/

    Briggs brags about providing robust information for health care providers. She fails to do so, in this instance, quite shamefully.

  16. #16 Leigh Jackson
    August 19, 2014

    Blooper – JAMA review, of course!

  17. #17 Mephistopheles O'Brien
    August 19, 2014

    A Java review is like a JAMA review, but you read it while drinking coffee.

  18. #18 Leigh Jackson
    August 19, 2014

    :)

  19. #19 Mike
    August 20, 2014

    Thanks Leigh- Yes, it’s embarrassing what Dr. Briggs has written. The NCCAM’s promotion of acupuncture has a treatment for pain is a big win for acupuncturists, who can use it as a seemingly authoritative source.

    Similarly, the TACT trial is already being promoted by quacks like Dr. Joel Kahn as showing efficacy for chelation.

  20. #20 usethebrainsgodgiveyou
    Near Atlanta
    September 5, 2014

    “Science based medicine” in and of itself…doesn’t take precedence over common sense, which might be what the CAM give to the patient. We know most patients are the “worried well” and would probably be better off with a sugar pill, although I doubt that is true in your practice.

    I have only an anecdotal incident. I have gone to a chiropractor once in our lives. Ben was going to a masterful pediatric physician, highly respected and renowned in our area. He had repeated ear infections. After having been on antibiotics for a month to no avail, the good doctor told me that the next step was tubes placed in his inner ear.

    “Go to Randy.” I was told.”He’s helped a lot of kids get rid of ear infections.”

    He did some sublimation reflexology…I can’t think of what they call it, and then asked “Do you give him a bottle at night to go to sleep?”
    “Yes, why?”
    “It leaks onto his skin, and then rolls around into his ears and feeds the bacteria there. Give up the night bottle.”
    Within a week, Ben was HEALED, HEALED I tell you, and being relieved of chronic ear infection, he started walking within a week..
    I’m not even going into iantrogenics.
    Even science cannot be trumped by common sense.

  21. #21 Gray Falcon
    September 5, 2014

    I’ve seen similar anecdotes support the use of leeches and Spanish fly. Try harder.

  22. #22 Gray Falcon
    September 5, 2014

    Sorry, misread the story.

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