Terra Sigillata

[Note: I originally posted this last Thursday under another title but it got lost in other events of that day. As I find it ironic that Mr Comarow has been attacked by an alternative medicine practitioner and advocate, I find this story worthy of reposting.]

A few weeks ago the skeptical blogosphere was up in arms about an article in US News & World Report by Avery Comarow on alternative medicine services in US academic medical centers. Mr Comarow is a senior medical writer for USN&WR and best known as editor for the last 18 years of the magazine’s annual feature, America’s Best Hospitals.

To my med blogger colleagues, Mr Comarow’s article came off as unjustifiably sympathetic toward alternative medicine being practiced in major academic medical centers. Mr Comarow has two blog posts of his own on this story, here and here, the latter of which responded to the unanticipated deluge of critical comments on his story.

Truth be told, I was interviewed on background by Mr Comarow and felt that some of my most critical comments did not make it into the piece, due most likely to the complications with citing me as a pseudonymous source. While I am not a physician, I have been involved with integrative or alternative medical centers at four different US academic medical centers. However, my feeling (and my feeling alone) was that his primary intention was to get inside the mind of the patients, understand why they were pursuing alternative therapies, and grasp why major evidence-based medical centers were establishing centers of alternative/integrative medicine whose standards of proof were below that of each respective health system.

Interestingly, the accompanying video commentary on the article (here), was cited by a commenter on Science Based Medicine as follows: “The US News & World Report article has a video segment by the senior health editor. He seems to be more skeptical than the article’s author.”

The irony: the video segment was done by the same Avery Comarow who wrote the article.

So, you’d think that at least the alternative medicine community would be singing the praises of Mr Comarow’s article. You would be wrong. From Bottom Line Secrets:

U.S. News Got it Wrong on Integrative Medicine
Integrated Practice Can and Does Improve Medical Care at Reduced Cost

Mark A. Stengler, ND
La Jolla Whole Health Clinic

. . .A recent major news magazine cover says: “Top hospitals are now embracing such unconventional techniques as acupuncture, homeopathy and energy healing.” Sadly, one journalist wants you to be very afraid of this very important movement that has the potential to significantly reduce medical costs and improve the health and wellness of our nation. . .

. . .It has an upbeat title — “Embracing Alternative Care: Top Hospitals Put Unorthodox Therapies Into Practice” — but really the article is a thinly veiled CAM-slam. Heavy-handed and bordering on journalistic sensationalism, Comarow’s piece is replete with erroneous research conclusions about CAM and sweeping omissions on its documented benefits and efficacy.

Let me begin by stating that “Doctor” Stengler bills himself as America’s Natural PhysicianTM (yes, he has really trademarked the designation). And unlike medical websites offering support for their practices with clinical trials results or references to peer-reviewed literature, Dr Stengler’s La Jolla Whole Health website prominently lists “testimonials”, the first choice under ‘Home” as the primary support for his healing modalities.

With that background, let’s see how he criticizes Mr Comarow, a journalist who has been vilified for being too soft on alternative/integrative medicine:

Right from the get-go, the article’s title contains the word “unorthodox” to mean “unconventional” therapies. Most telling about the U.S. News article’s intentions is the usage of loaded language about CAM and the “thicket of therapies deemed to fall within CAM’s broad reach”… citing “at one extreme” yoga and massage as having “some benefit, if only to lower stress and anxiety” and at the other end, therapies that “even many who applaud CAM’s newfound academic popularity call ‘woo-woo medicine’ because of the sheer implausibility of their rationale,” such as homeopathy. In what he calls “the broad middle,” Comarow puts acupuncture, herbal medicine and “other CAM approaches that seem to benefit some people with certain conditions.” In a dismissive review of CAM’s history, he likens CAM’s presence in academic centers before the mid-1990s to “a pack of scruffy mutts, noisy and unworthy of notice.”

Well first, “unconventional” and “unorthodox” were the exact terms used by Harvard’s Dr David Eisenberg in his two New England Journal of Medicine and JAMA articles that alternative practitioners cite most often as evidence of huge public acceptance of alternative therapies. Yet Stengler goes on later in the article to cite data from the very same JAMA article in support of CAM use trends – we call this practice “cherrypicking”: only cite that parts of papers that support your contention and discard that which you don’t fancy.

The rest of Comarow’s assessment of the spectrum of CAM approaches is pretty accurate and one that would be held by most physicians: homeopathy is nothing more than magical thinking while yoga and massage have well-documented effects in the medical literature for reducing anxiety and improving muscle tone and joint flexibility. In fact, some may argue that yoga and massage are not necessarily alternative but are rather extensions of conventional exercise recommended by physicians that have been adopted by CAM advocates as “alternative.”

So, I really don’t see Dr Stengler’s rationale with his objection to the previous passage.

Stengler does try to take issue with the relative safety of prescription drugs relative to dietary supplements. Stengler is indeed correct regarding the large number of deaths associated with the use of prescription drugs in the US but then cites a much lower amount for dietary supplements. However, dietary supplement adverse event reporting mechanisms are in their infancy and nowhere near the complexity and rigor of reporting drug-related actions, nor are dietary supplement manufacturers required to disclose to the FDA such information (as is required of pharma). Moreover, these data do not take into account the number of AERs relative to number of users; finally, most dietary supplements are of insufficient quality to produce positive biological effects and, therefore, are unlikely to produce adverse effects as well.

Stengler also goes on to take Comarow to task for his alleged misrepresentation of the background of naturopathic doctors. While some naturopathic training does indeed included didactic work similar to four-year US medical schools, Comarow is correct in describing the inconsistencies in naturopathic training and the limitations in calling such individuals “physicians,” particularly since the quality of naturopathic training varies considerably in North America, including one school that offers correspondence degrees. For a more detailed analysis of naturopathy, the reader should refer to Naturowatch, a page of Quackwatch devoted specifically to the benefits and risks of naturopathic medicine.

There is more in the Stengler article that castigates Mr Comarow for representing statements in his article that are based in fact. So, I leave it to the reader to decide whether Mr Comarow drank the integrative medicine Kool-Aid on one hand or whether he was a ruthless tool of a conventional journalistic enterprise that is hostile toward integrative/alternative medicine.

Having communicated with Mr Comarow throughout the course of his development of the original piece, I understand the difficulties in balancing medical facts with actual health care trends., a challenge for even for such a highly-seasoned reporter. My primary criticism of the final product was that there was an inadequate discussion of the ethics of offering alternative (non-proven) therapies under the masthead of our most highly-respected academic medical centers that enforce the implementation of evidence-based medicine in all other facets of their health systems. My guess is that the latter might not be very entrancing content to the average USN&WR audience, but it is certainly the key issue to medical bloggers critical of the non-critical adopting of CAM by major academic medical centers.

I’ve watched these exchanges and reactions for a little over a month since Mr Comarow first pre-released his article via his blog. As a result, I can say this: mainstream journalists should not fear for their jobs with the proliferation of sci/med bloggers. I don’t believe you could pay me to absorb the amount of grief levied against Mr Comarow who tried to take a contentious and inflammatory area and try to explain the public and medical acceptance of practices so poorly based in evidence. I certainly did not envy him for taking on this task but I respect him for doing so, even if I have some issues with the final product.

So, I’d suggest reading Comarow’s original article, the largely scathing comments of CAM skeptics on his blogpost, and this unusual critique of the very same article by America’s Natural PhysicianTM.

For now, this is Abel Pharmboy, PhD, America’s Natural Medicine BloggerTM.

Comments

  1. #1 JR Stewart,MD, FACA
    September 14, 2008

    MARK STENGLER, ND wrote in a Bottem Line article,
    About the ability to conduct a controlled study on individual patients.

    “If a patient has migraines, I select from among several dozen homeopathic remedies, taking into account the type and location of his/her migraines, how the weather affects him, his diet and exercise habits, etc. With so many variables influencing the choice of homeopathic remedy and the patient’s response to it, I’m not surprised that study results sometimes are inconclusive”.

    First, the study has to be “blinded.” Neither he nor the patient can know what they are administering.

    “Doctor” Stengler makes up his treatment solution, which we assume is colorless and tastless, since it essentially has nothing in it, and sends to an independant lab, which transfers it to a new vial and makes up a matching placebo solution. Then a computer generated code numbered label is placed on each identical vial with the “treatment” solution and the placebo, which are returned to “Doctor” Stengler, to administer in any order he wants and record the results. The only perceivable difference is the computer generated number.

    If it usually takes, say, 2 weeks to see results, your record the levels of the patients symptoms for 2 weeks (a baseline), then you administer either vile for 2 weeks and record symptom levels, then go off for 2 weeks and record symptom levels. Then repeat with the other vile.

    Second, the patients become their own control.

    The only variables are the two indistinguishable, except for the code, solutions and a different time, but the same patient.

    Repeat this for a number of patients, for statistical significance, and send your results to the independant lab, who will correlate the scores and “treatment” vile codes.

    Since both the patient and the “Doctor” have no idea which vile is which, this is a truly double blinded study. Since it’s the same patient, it’s a controlled study.

    WOW! A very inexpensive Double Blind, Controlled Study! This is the gold standard of research.

    I’m a retired research physician, and would be happy to provide the outside lab services for FREE!

    It’s always nice to debunk nonsense, and replace it with science, or to prove something works.

    Have “Doctor” Stengler contact me, since he seems to lack the courage to list his email, and I’ll be more than happy to assist in the design of a meaningful study.

    J R Stewart, MD
    JRStewartMD@hotmail.com
    (801) 278-2233
    6400 Canyon Cove Drive
    Salt Lake City, UT 84121-6301

  2. #2 cindy abdalla
    July 23, 2010

    While I do understand the requirements of medical doctors for established controls, etc. etc., homeopathy is an area where it is impossible to duplicate results, simply because no 2 people will have exactly the same problem with all the exact symptoms that homeopathy takes into account. even in the same patient you cannot duplicate results, because once you have a treatment, the symptoms will change, and once improvement is seen with homeopathic medicine the treatment is stopped – or as in chronic conditions, it might be adjusted to a different remedy or dose. I’ve been using it for 10 years now and am continually amazed at the success with it’s treatment. My teenage daughter suffered from migraines, and after going through all the conventional channels of consultation, which offer no hope of a cure – just use of stronger and stronger prophylaxis (like brufen, etc) – she was cured of the migraines that she’d suffered for more than 5 years in just a few months – all with only homeopathic medicine prescribed by a Pakistani homeopath in my area.

    Dr. Stengler is a Naturopathic Doctor and one that I trust unquestionably. Ten years ago my youngest daughter at the age of 3 had continual middle ear infections that lasted for 10+ months. She was in the ENT specialists offices at least 2x per month, and they always gave her antihistamines and antibiotics, nose drops sometimes – all to no avail and in the end just made her more sick. Finally 5 (yes, five doctors, I’m not exaggerating) EarNosethroat specialists(ENT) doctors told me she needed surgery – grommets-tubes for the ears, removal of her tonsils and andenoids. I couldn’t bear the thought of letting them take a knife to my baby. People kept telling me about different alternative therapies so I started researching and thank God for the day I found Dr. Stengler. We did a telephone consultation since we lived far away, and he sent us all the herbal and homeopathic remedies by mail.He also advised diet/nutrition changes and chiropractic care. I followed all his advice to the letter and within 6 weeks took my girl back to the ENT for a check. He was shocked. No more middle ear fluid remained. After 10 months of constant illness. He said 6 weeks ago this child needed surgery…. what did I do? So I briefed him. I also told the pediatrician. They told me not to tell anyone because it would put them out of business! My family is so much healthier – hardly ever need to see a doctor. The MDs are supposed to be dedictated to patients’ health, but the real fact is they have protocols to follow and don’t look for other solutions that may be better. I also respected and liked Dr. Stengler because he would send me to a conventional doctor for diagnosis and testing and treatment when needed, and knew how to combine the best of both. By the way, after those 6 weeks, Dr. Stengler prescribed other herbs to heal the damage done by all the antibiotics, about another 2 months, and thereafter, that was it. She has never had a relapse of Middle Ear infection since.

    I’m from Missouri – the “show me state” – and there’s no doubt in the results. I have all the medical files of my children’s cases to prove it too. So what if homeopathy or naturopathy can’t be proven by conventional methods – I’ve seen it work time and again – and as a mother I want nothing more than my children’s health and freedom from illness. July 2010

    I’d also like to point out that Dr. Stengler is easily found through his clinic in La Jolla, Calif. no way does he lack the courage… just hasn’t the time to waste.

  3. #3 gmcevoy
    July 24, 2010

    “homeopathy is an area where it is impossible to duplicate results, simply because no 2 people will have exactly the same problem with all the exact symptoms that homeopathy takes into account”

    I assume this is referring to the individuality of homeopathic treatment, where you and I see a naturopath for the exact same physical ailment but get a different set of herbs because of a difference in our personal history.

    Why is it then these highly individualized notions, potions and lotions can be freely purchased off the shelf without prescription in many, many pharmacies?

    If you’ve seen it work, anyone else would too – under any conditions including conventional methods. Missouri is no different.

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