Terra Sigillata

PalMD has a nice post up at denialism blog reviewing a recent NYT article on a foundation run by DKNY’s Donna Karan donating $850,000 USD to Beth Israel Medical Center to study the combination of Eastern and Western healing methods. PalMD has the details but he then gets into an area about which I am rather passionate: the incredibly low scientific-based bar that is allowed by journalists and hospital administrators for individuals to be considered “experts” in complementary and alternative medicine (CAM).

As the good doctor notes of one such expert:

Other than his standard medical qualifications, I’m not sure why this guy has anything special to offer a cancer center. If it’s pushing strange supplements, homeopathy, or cranial-sacral therapy, well, perhaps the cancer center isn’t interested in being modern any longer.

When I started teaching about herbal medicines vs. Rx drugs from natural products I was blown away by how quickly CAM people and the MSM began to consider me an expert. The CAM people deserted me when I gave a fact-laden critical analysis at one of their annual tradeshows about ten years ago (I haven’t been invited back since), but some people in the MSM still turn to me because they can count on valuable commentary.

I don’t believe I’ve ever written about this at Terra Sig in the past but University of Exeter’s Dr Edzard Ernst wrote a terrific 2006 editorial entitled, “CAM Pseudoexperts,” in his review journal, FACT: Focus on Alternative and Complementary Medicine.

Ernst appropriately skewers these CAM pseudoexperts although he did not go quite far enough, IMHO, to communicate that journalists should have a more critical eye when seeking out and interviewing such individuals (although the audience was not intended to be journalists):

I have to admit, I occasionally get irritated by some of the so-called CAM ‘experts’ that so vociferously dominate our field, but more often these people amuse me. Virtually all fields of medicine are driven by healthcare professionals and scientists, but CAM is different – it is an area that is driven by consumers. It also is an area where, relative to mainstream medicine, scientific knowledge is still in its early infancy. These important differences have many far-reaching implications, and one of them is that almost everyone seems to be an ‘expert’ in CAM. . .

. . .The personality of the pseudoexpert merits detailed psychological analysis. It helps, I think, not to be too intelligent. This makes it easier for the pseudoexpert to fall victim to his or her own powers of persuasion. The result is often an almost religious belief of the pseudoexpert in the correctness of his or her assertions. One cannot readily disprove a religion and those pseudoexperts who mistake CAM for a religion cannot even conceive the possibility of being wrong. Not all pseudoexperts, however, are true believers nor are all of them stupid. Some are highly motivated by strong self-interest. These are the ones who tend to be addicted to the limelight of public interest. If you read the Sunday papers and follow how some health writers promote certain treatments, you probably understand what I mean. One does not need to do an awful lot of research to find that some of these pseudoexperts are motivated by financial rewards. For others the attraction lies in the prospect of fame or power. Attractive positions and distinctions wait for those who loudly and unscientifically promote what the government of the day or other VIPs want to hear.

I apologize in advance to Dr Ernst for such extensive quotation but his Focus on Alternative and Complementary Medicine doesn’t get the distribution it truly deserves (free text TOC here). This article is now a standard component of my handouts whenever speaking with journalists about natural products and the distinction of this science-based field from herbal medicine.

In fact, Dr Ernst: you should really start a blog.

Comments

  1. #1 James Pannozzi
    October 31, 2008

    Well well well, an article about CAM PSEUD-EXPERTS which quotes a PSEUDO-EXPERT HIMSELF, Dr. Edzard Ernst MD who is unable, in his CV, to provide ANY details on the “alternative” medical training that he claims to have had. Go ahead, search for it and let us know if you find ANYTHING that details his “training” in alternative medicine.

    A two week seminar ? READ a BOOK,
    maybe “Homeopathy for Dogs”?

    WHAT EXACTLY is Dr. Ernst’s training in Alternative medicine?
    Nobody seems to know.

    So we seem to have a PSEUDO EXPERT railing against pseudo experts.

  2. #2 e ernst
    October 31, 2008

    thanks for the compliments on our journal FACT.i only wished more people would know about it!

    and thanks for the insults too, james pannozzi.i have made it clear so many times but for you i do it again:i learned acupuncture during my medical studies in germany in courses run by my uni,homeopathy while working in germany’s only homeopathic hospital as a junior doctor,massage while employed at the uni munich where i then became in charge of running a massage course for med students,spinal manipulation in the same way etc,etc…..

    do i have diplomas or degrees? no,20 years ago,we did not get such things for rather marginal postgrad development;and if they would have given me any ,i would probably have lost them.i can show you my medical degrees though if that makes you happy.i managed to hang on to those during my many moves through many countries.

    the thing is that i don’t attach much importance to such trivia.the crucial issue for me is to understand the subject matter rather than to prove it to nitpickers like you

  3. #3 James Pannozzi
    October 31, 2008

    Wow a reply from Ernst himself!! Viele Danke!

    And now, Herr Dr. ERNST, could you tell us the duration of these courses on Acupuncture and Homeopathy which you took.

    A Seminar? Two weeks? Three months?
    A whole Year? Did you learn any Chinese? Read some of the classics?

    Details Dr. Ernst, details, YOU are considered an EXPERT on alterntive medicine and yet STILL you are vague about the exact training that you have had in this field. What Acupuncture or Homeopathy books did you like?

    You will, I hope, pardon me for NOT thinking that it is “nitpicking” to ASK FOR A DETAILED RESUME’ OF YOUR CREDENTIALS IN ALTERNATIVE MEDICINE or for giving us some idea of the extent of your “expertise”.

  4. #4 Badger3k
    October 31, 2008

    James, James, James – you’re doing it wrong. You need more CAPS. Everyone knows that the more CAPS you have, the TRUER YOUR ARGUMENTS ARE!!!!!!!! (a lot of exclamation points also does the trick, like that).

    I do think it amusing that people want to argue for “expertise” in a field that lacks any evidence for there to be real expertise. They make up what they want (look at the lakc of uniformity in acupuncture, for starters), so everyone is an expert – excuse me, “expert”. It would be great for journalists to realize this and put these whackaloons in their place, but since I just saw a commercial for convicted fraud Enzyte, I guess people don’t learn.

  5. #5 James Pannozzi
    October 31, 2008

    Badger3k:

    I AGREE partly (oops, sorry you don’t like capitals).
    There are people out there calling themselves Homeopaths that I would not entrust the care of my cat to – and there are properly trained Homeopathic physicians of enormous skill. In part that is because a systematic attack on a political level was made against it in an era when standard medicine included poisonous and ill advised treatments that were later completely discredited and in that era, the penalty for any AMA member for hobnobbing with Homeopaths or practicing Homeopathy was expulsion.

    That is why it is important to establish if people like Dr. Ernst, who is indeed an MD and a Doctor of considerable experience, actually has the “alternative” medicine background that would be needed to justify his position as some sort of critic of that field. In his response to me, Ernst addmitted that he has no degrees in alternative medicine but has served in a Homeopathic hospital and that he has had some course in acupuncture and both of these 20 years ago. Well that is good but I question if that qualifies him to have sufficient knowledge and/or experience to justify his position as a critic of alternative medicine.

    Your additional statements demeaning alternative medicine,
    denying that there is evidence for there to be real expertise
    and that they”make up what they want” I disregard without comment as uninformed and ignorant opinion unworthy of response.

  6. #6 PalMD
    October 31, 2008

    James, answer me this—HOW COME THERE IS STILL MONKEYS??!?!!!11eLEvEN!2@

  7. #7 qetzal
    October 31, 2008

    So, if I have a PhD in biology but no formal training in homeopathy, I’m unable to judge whether vigorously shaken water can be pharmacologically active?

    Poppycock!

  8. #8 Abel Pharmboy
    October 31, 2008

    I was only just able to log back in this afternoon so I am grateful to Dr Ernst for coming by to comment and not minding that I quoted him from the journal so extensively.

    Let me say this for those not familiar with Dr Ernst: he gave up an incredibly secure, high-stature position in Vienna to start the Complementary Medicine program at Exeter’s Peninsula Medical School because of an intense intellectual curiosity about what science might indeed be behind some of CAM modalities (read this 2003 UK Guardian interview for more background.).

    Beyond the journal, Dr Ernst’s unit sponsors an international conference on complementary health that will be celebrating its 15th year. I have not yet had the pleasure of attending but a quick scan of last year’s program will illustrate precisely how open-minded Dr Ernst and his team are in at least considering the potential for even nonscience-based modalities to have clinical benefit. In fact, I have spoken with a scientist or two who instead feel that Dr Ernst is even a little too generous at times in giving the benefit of the doubt in supporting investigation of even the most seemingly outrageous approaches. I credit him with giving CAM practitioners every opportunity to prove the benefit of their favorite modalities as well as the setting in which to promote and communicate their data.

    Demanding that any clinical modality have a basis in science and prove better than placebo in a randomized and well-controlled trial is the only “offense” of which Dr Ernst is guilty.

  9. #9 thalarctos
    October 31, 2008

    hey, Dr. Ernst–

    Nice to see you commenting here! I’ve mentioned more than once here that I had the privilege of seeing the address you gave at the massage research conference in Albuquerque in 2005. Now I can tell you as well how much I enjoyed not only the warm, funny talk you gave there, but also getting to discuss it with you afterwards.

    it was a pleasure to get to meet you, Doctor.

  10. #10 Michael Ellner
    November 1, 2008

    If only Dr. Ernst held conventional medicine practice to the same standards that he demands of CAM – the world would be a healthier and happier place. The fact is that most drugs are not working for most of the people consuming them most of the time! How scientific is that? I am confident that as soon as “outcome studies” become the gold standard of medical research – conventional medical practice will be seen for what it is – expensive, infective and dangerous!

    In terms of non-science – the placebo operates within the realm of non-science and yet the placebo effect often out performs the most promising drugs — Think about it.

    Physicians Heal Thyselves

  11. #11 qetzal
    November 1, 2008

    The fact is that most drugs are not working for most of the people consuming them most of the time!

    I think you’re going a bit far with all those “mosts” but I agree that drugs don’t work as well for as many people as often as we’d like. And even if you’re right about how often drugs don’t work, your argument is still specious. Out of all medical practices, drugs are by far the most evidence-based.

    In terms of non-science – the placebo operates within the realm of non-science…

    No it doesn’t

    …and yet the placebo effect often out performs the most promising drugs.

    This definitely goes too far. Yes, in some indications (esp. pain), the placebo effect can be quite substantial. But in most indications, placebos have little or no effect compared to drugs. Placebos can’t lower cholesterol like statins, or control blood glucose like insulin and oral antidiabetics, or kill bacteria like antibiotics, or reduce tumor size and prolong life like chemotherapeutics, or etc. or etc.

  12. #12 Joe
    November 1, 2008

    Michael Ellner | November 1, 2008 8:32 AM wrote “If only Dr. Ernst held conventional medicine practice to the same standards …”

    That is the standard, foolish, diversion. The topic is irrational (often dis-proven but certainly unproven) CAM notions and methods. Problems in medicine (whether real or, in your case imagined) do not support CAM.

    On the other hand, the reason we know about problems in medicine is because medical researchers study them in order to identify them and work to minimize them. Alties never do that. The most egregious cases of harm from alties (e.g., chiro strokes) are met with “no we don’t;” but no reliable studies.

    If you want to try to defend sCAM, insulting health professionals (especially since they are constantly trying to improve their work) misses the target.

  13. #13 Michael Ellner
    November 1, 2008

    “Our drugs don’t work on most patients.” “The vast majority of drugs more than 90% – only work in 30 to 50 per cent of the people.”
    - Allen Roses, worldwide vice president of genetics at Glaxo SmithKline Independent, UK (8 December, p 1)
    http://www.independent.co.uk/news/science/glaxo-chief-our-drugs-do-not-work-on-most-patients-575942.html

    Sooner or later the public will realize that all the major scandals in the most trusted journals are just the tip of the iceberg. They will see treating cholesterol for what it is- “disease mongering”, they will appreciate that the reckless abuse of antibiotics is a serious threat to public health, and realize that at best chemotherapies are weapons of mass destruction and when they do…

  14. #14 Joe
    November 2, 2008

    Mr. Ellner,

    Look into my eyes, deeper, deeeperr, you are getting very sleepy. You will awaken from this trance when I SNAP my fingers. Then, you will realize that nothing you say about real medicine mitigates the faults of quackery.

  15. #15 Joe
    November 2, 2008

    Mr. Ellner,

    Dr Roses said. “I wouldn’t say that most drugs don’t work. I would say that most drugs work in 30 to 50 per cent of people. Drugs out there on the market work, but they don’t work in everybody.”

    Wow, you quoted Dr. Roses out of context; who would have expected that?!

    Let me explain this to you, it is really simple, Dr. Roses wants to find a way to match the right drug to the patient faster than the “try this, okay let’s try that” method that we have today.

    I can add a simple example of what we are talking about. My friend recently had major surgery. She was given a narcotic post-op in the ICU. It was better than nothing; but she did not like it. So, they gave her another narcotic which was acceptable to her. Dr. Roses wants ways to determine the more acceptable drug, in advance.

  16. #16 Joe
    November 2, 2008

    Geez.

    Mr. Ellner I forgot to snap my fingers. So, here it is: SNAP.

    Now, look at the post I wrote while you were transfixed by your computer screen.

  17. #17 Simon
    November 3, 2008

    Living near Exeter I’ve had the pleasure of attending a couple of lectures by Dr Ernst, and had the opportunity to ask him specifically about how much of established medical practice he believes meets the evidence based criteria he applies to other treatments.

    He was of the opinion that a lot (most!) of conventional medicine does meet those criteria, but that a significant fraction still does not. He certainly applies the same standards to all treatments – indeed this is what his opening remarks addressed in one of the lectures. However his group is funded to research treatments currently classed as CAM, not the failings of conventional treatments.

    He also pointed out that the very definition of “CAM” varies between countries.

    The question of experience is rather silly, whatever his experience before appointment (and I have no reason to doubt his public statements), after 15 years researching CAM full time a man of his obvious abilities is bound to have picked up a thing or two.

  18. #18 Joe
    November 4, 2008

    Simon, I appreciate your comments. When considering the basis for medical vs. sCAM procedures, there is also an issue of rationality. Woo is based magical ideas- such as meridians, subluxations and life-force. Medical treatments that have not been thoroughly examined (yet) are usually at least plausible.

    In the late 18th century, a pathologist at Harvard noticed, at autopsy, that people who died after exhibiting certain symptoms had burst appendices. He recommended appendectomy, which remains the standard of care despite that basis not being the highest level of proof.

  19. #19 James Pannozzi
    November 4, 2008

    to Michael Ellner: Well said. And no it is not a diversion – when the exact same “standards” that are being used in an attempt to discredit CAM are turned on “standard” medicine, it crumbles.

    to Simon who stated,
    “The question of experience is rather silly, whatever his experience before appointment (and I have no reason to doubt his public statements), after 15 years researching CAM full time a man of his obvious abilities is bound to have picked up a thing or two.”

    Oh I’m certain Dr. Ernst has lots of medical experience. What I questioned and continue to question was his expertise in any CAM field.
    And THAT is not silly.

    To Joe who said:
    “Woo is based magical ideas- such as meridians, subluxations and life-force. Medical treatments that have not been thoroughly examined (yet) are usually at least plausible.” Come on Joe, try telling that to the chemo”therapy” survivors who, on the next “relapse” chose death rather than undergo the “therapy” again.”

    I don’t know what Woo is but Acupuncture’s meridians have been researched with modern scientific theory and neural theories to explain their existence have been proposed, by scientists for over 30 years.
    Go to http://www.medicalacupuncture.og in their past archives (you don’t have to be a member to search the ones more than a few months old) and see for yourself.

    Likewise, is not a subluxation an actual physical derangement of the spine? Did not chiropractors defeat the AMA in a lausuit in which they proved, in court, that their therapy did exactly what they said?

    And you STILL call it woo? Maybe we should call Vioxx woo for killing people. How about I dismiss all of modern pharmacology because of Vioxx and Thalidomide – after all it’s all woo!? Doesn’t work.
    It’s just chemicals.

  20. #20 Joe
    November 4, 2008

    @James Pannozzi

    No, meridians have not been demonstrated scientifically. I have previously looked at the ridiculous studies that are said to demonstrate them. You need to cite a good, medical journal if you want to support your arguments.

    As for (chiropractic) subluxations- NO they have never been demonstrated. Once again, if you beg to differ, you need to find the proof in a good, medical journal.

    The legal case you refer to is Wilk v. AMA, 1987 or ’88. The judge acknowledged that the AMA had plenty of reason to oppose chiropractic because it is not valid in health-care. (Now, people who make your argument are quick to say that a judge isn’t competent to draw such a conclusion.)

    The ruling favored the chiros under business law which does not allow the AMA to engage in “restraint of trade” against chiros.

    Three strikes, you’re out. See http://www.chirobase.org But, before you reply that chirobase is too mean; just pick an article and tell us where it is meaningfully wrong.

    As for recalled drugs, that happens because health professionals continue to study and improve their practices. On the other hand, even though they know their neck-snaps cripple and kill people, chiros won’t stop doing them. In a 2007 case a healthy woman (Sandra Nette) had a stroke minutes after the snap, she was completely incapacitated. The doctor emerging from the ER asked her husband (Chiropractor, right?” Bilateral vertebral artery dissection is the chiro’s hallmark.

  21. #21 James Pannozzi
    November 5, 2008

    to Joe:
    My understanding of “subluxation” is that it is an actual physical misalignment of the vertebrae, irrespective of what other meanings are attached to it. I have never used it and the first thing I would worry about is exactly the kind of accident such as you describe.
    But in that legal case you cite it was the AMA that struck out bigtime, just as “quackwatch”(sic) did recently in another case against a chiropractor.

    Now with regards to Acupuncture, which is my main interest (as is Chinese Herbology and lately, Homeopathy), try this one – it is one my favorite research article (of course not definitive) and I believe you will find it of interest.
    http://www.medicalacupuncture.org/aama_marf/journal/vol11_2/conduct.html

    In addition, there is THIS:
    “Infrared Thermographic Visualization Of The
    Traditional Chinese Acupuncture Meridian Points”
    http://www.medicalacupuncture.org/aama_marf/journal/vol16_2/article_5.html

    written by a collection of experts – physiologists, MD’s, physicists –
    I believe you will also find it interesting.

    Lastly, though I have lost the cite, there is MRI research showing, for example, that when an acupuncture point located in the foot and said to be related to the eye is needled, there is clear evidence of visual cortex activity showing up in the scan, but when nearby points are needled there is not. Yes I know there are other explanations for this but I hope I have at least convinced you that it is not all woo being done by charlatans.

    Likewise in Homeopathy, the most speculative and controversial of all, if the anti-intellectual and unscientific hysteria against it were dropped and we simply let LOGIC be our guide we would much sooner zero in on the exact mechanism of a currently unknown phenomena – and it is most certainly NOT the placebo effect as the latest research, rendering the Lancet 2005 “review” (of homeopathy) as so much rubbish, shows; see THIS for instance:
    “Review Rubbishing Homeopathy Discredited”
    http://www.news-medical.net/?id=42412

    There is more than enough problems with the theories of Homeopathy mechanism without the necessity of resorting to charges of “woo”, “magic”, insulting the researchers or any of the other usual innuendo.
    I myself find Milgrom’s quantum mechanical explanation rather curious, to say the least. Instead, we must acknowledge the genuniness of the Homeopathic effect and see if we can latch onto the mechanism or uncover what is happening – it would be a GREAT benefit to know the explanation.

    Reaearchers such as Ennis and St. Laudy have made headway into uncharted territory.

    And, as far as I know, nobody knows exactly what
    “just water” is – so the premature dismissal of Homeopathy without the allowance of proper research is, in my opinion, just nonsense.

  22. #22 Joe
    November 5, 2008

    James Pannozzi | November 5, 2008 12:41 AM wrote “My understanding of “subluxation” is that it is an actual physical misalignment …”

    That is the medical description, it does not apply to chiropracty. Chiros don’t treat that, they were forced to concede a different (entirely imaginary) definition: “A subluxation is a complex of functional and/or structural and/or pathological articular changes that compromise neural integrity and may influence organ system function and general health.” http://www.chirocolleges.org/paradigm_scopet.html That is, it’s anything they pretend to fix and then charge the customer.

    James Pannozzi | November 5, 2008 12:41 AM wrote “… as far as I know, nobody knows exactly what “just water” is …”

    And that is your problem, you do not know; but scientists have a pretty good idea. At least chiros offer a nice massage (except for the 30-60% who experience transient discomfort http://jrsm.rsmjournals.com/cgi/reprint/100/7/330?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&author1=ernst%252C+edzard&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT ) acupuncts and homeopathetics don’t even provide that. The AAMA is a particularly pathetic group. I await your citations of medical literature.

  23. #23 James Pannozzi
    November 5, 2008

    to Joe, thanks for trying to explain chiropractic concept of subluxation to me.

    Regarding water, there remain several anomalies in its behaviour whose explanation remain completely unknown. Likewise, several models of molecular behaviour of water, left over from the 1930′s are now under review – we must await research from real scientists – there is no woo.

    Regarding Acupuncture and Homeopathy – you seem to lump them together and they are really two very different things. BOTH show strong evidence of efficacy, PLEASE don’t tell me its placebo or “woo” and let the scientist researchers do their stuff. For example in Homeopathy, M. Ennis’ research has clearly shown evidence of biological activity from ultra high dilutions Her experiments WERE repeated with even better controls and confirmed.

    I thought I did give you some research links – did you not find them of interest? What others did you need?

    Thanks
    JP

  24. #24 Joe
    November 5, 2008

    James Pannozzi | November 5, 2008 8:41 AM wrote “Regarding Acupuncture and Homeopathy – you seem to lump them together and they are really two very different things. BOTH show strong evidence of efficacy …”

    No, they do not.

    As far as the placebo effect, acu may seem better because it is a more elaborate procedure. You need to show high-quality evidence in medical literature. You did not link to medical lit.

    Here is a good place to read about acu and homeo http://www.sciencebasedmedicine.org/

  25. #25 James Pannozzi
    November 5, 2008

    Joe, thanks for the link, we shall agree to disagree.

    JP

  26. #26 Michael Ellner
    January 5, 2009

    Just to set the record straight–

    “Experts say that most drugs, whatever the disease, work for only about half
    the people who take them. Not only is much of the nation’s approximately
    $300 billion annual drug spending wasted, but countless patients are being
    exposed unnecessarily to side effects.”

    Hmmmmmm…. Think about it. These are drugs that have “proven” their effectiveness in validated studies and are FDA licensed for use — How scientific is that?

    Here’s the article:
    http://www.nytimes.com/2008/12/30/business/30gene.html

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