White Coat Underground

In a piece written for health reporters, journalist Jane Allen gives some useful advice about covering alternative medicine, but there are some gaps that are are hard for a non-medical professional to recognize (and frankly, for many medical professionals as well). She quite rightly urges skepticism, but when looking into ideologic and muddled topic of alternative medicine, skepticism needs to be turned up to “11”. A major complaint that doctors have about health coverage is not the objectivity, earnestness, or research abilities of the reporter but the lack of some of the fundamental knowledge of the subject.

“Alternative medicine” can mean many things and the National Centers for Complementary and Alternative Medicine (NCCAM) provides a good starting point.  Whan many skeptics have pointed out over the years however is that there really is no “alternative” to medicine; only that which is proven to work, and that which is not.  This is one of the bases for ethical medical practice.  Medicine is full of compelling stories—we physicians hear them every day. But, knowledge of what does and does not work cannot be based on a good story.  The histories we record each day help guide us in treating individuals using interventions tested on larger groups.  The randomized-controlled trial (RCT) is often seen as the “gold standard” for testing medical interventions, but there are a two primary limitations to this view.  First, not all interventions can be examined using an RCT due to ethical and technical concerns.  Second, an RCT is often blind to the idea of “plausibility”.  This leaves us open to what Dr. Harriet Hall has termed “Tooth Fairy Science”:  we can generate statistically significant data about the average price of an incisor, the average time between tooth loss and monetary gain, and other such factors, but none of these numbers tells us whether the Tooth Fairy in fact exists.

 

If in reporting on health the goal is to inform as well as tell a good story, an informed skepticism is necessary.  Supporters of alternative medicine are often gripped by a religious-like zeal and may be somewhat deficient in skepticism.  Doctors and scientists are trained to be skeptics (a training that ometimes wears off) and usually start from the premise of “I don’t believe it, show me the data”.  Ms. Allen’s excellent article lays out some of the problems:

 

The task of sorting it all out becomes all the harder because evidence for health claims in non-traditional medicine often does not rise to the gold-standard — randomized, controlled clinical trials (those in which participants are randomly assigned either to an experimental group or to a comparison group) published in major peer-reviewed journals.

 

“There isn’t the same depth of research, and there never will be,” says Hardy, medical director of the Simms/Mann-UCLA Center for Integrative Oncology, who has long studied herbs and dietary supplements and often recommends them to appropriate patients. She says safety margins for herbal remedies, especially those used for thousands of years, are better than for prescription drugs. “It’s very uncommon that any herb with traditional knowledge behind it will be as toxic as a new drug.”

 

Claims about alternative, complementary and integrative medicine often are built on anecdotal evidence. But that’s not the same as demonstrating their effectiveness through rigorous science….

 

When she’s trying to evaluate such claims of an alternative remedy’s effectiveness, Hardy wants study authors or those making the claims to provide multiple cases of good responses. She also wants to see a rationale for the treatment that is either consistent with the principles of alternative medicine practices, such as traditional Chinese medicine, or explainable through principles of Western medicine.

 

This credulous claim by a supporter of alternative medicine deserves careful parsing.  There is no reason that any claim made by alternative medicine cannot be subjected to the same scrutiny as any other intervention.  In fact, it’s done regularly.  An NCCAM-funded study of Saw Palmetto, for example, found insufficient evidence to recommend its use.  This wasn’t a set of anecdotes but a randomized-controlled trial, just the sort of “gold standard” that Hardy claims “there never will be” in researching herbs.

 

Her next claim that “any herb with traditional knowledge behind it” is unlikely to be as toxic as a new drug” is a non sequitur. Safety is only one factor to consider in evaluating an intervention—the other, of course, is efficacy.  Something with no physiologic effects at all will not be toxic, by definition.  Something with significant physiologic effects can always have potential toxicities.  Another way of framing it is that there is no such thing as “side effects”—only effects, some desired, some not.

 

The final disturbing point made by Hardy is that claims should be evaluated via anecdotes that are seen through the lense of alternative medicine principles.  This is a terrible idea.  The evaluation of a medical intervention must rest on its safety and efficacy and its scientific plausibility. Calling something “alternative” does not render it immune from scientific investigation.


Ms Allen goes on to discuss areas in which alternative medicine may be most useful, but unfortunately appears to have fallen for the seductive propaganda of alternative medicine’s boosters. 

 

Integrative medicine is particularly useful in treating chronic diseases like diabetes, coronary artery disease and pain, which are all can be influenced by such lifestyle factors, such as diet and exercise. With the aging of the Baby Boomers, integrative approaches are likely to generate rafts of stories in coming years. It’s already happening: just think about how often you hear that regular exercise and a diet rich in antioxidant- packed fruits and vegetables and plant-based proteins (rather than proteins high in saturated fats) may prevent cancer and heart disease.

 

Lifestyle factors such as diet and exercise are not the exlusive domain of alternative medicine—they are an important tool in the medicine internists like me practice every day.  Attempts to co-opt these tools are usually done out of ignorance or deception.  (Also, claims about anti-oxidant rich diets have been largely unsupported by the literature).

 

As a medical professional, I can only imagine the difficulties inherent in covering such a complicated field.  Some important rules though should be kept in mind: don’t trust your own knowledge or instincts as they are an inconstant guide; don’t trust sources with significant investment in an alternative therapy unless the greater part of the data supports their claims (PubMed is your friend, as are competeing sources); and subject all claims to the Tooth Fairy test—would accepting a claim mean having to overturn the entirety of our understanding of biology, physics, and chemistry.

 

Journalists take their duties seriously, but doctors perhaps more so, at least on a moment-to-moment basis, but we have similar abilities to help or harm large numbers of people. Protecting the public requires a deep but compassionate skepticism.

Comments

  1. #1 Dianne
    November 18, 2009

    She says safety margins for herbal remedies, especially those used for thousands of years, are better than for prescription drugs

    What the? Just to give a few examples: willow bark (salicylic acid) versus aspirin (acetyl salicylic acid)-the acetylation makes the molecule less likely to rip up your gut. And then there are drugs derived from traditional or non-traditional herbal remedies. Does Hardy really think that it’s safer to give uncontrolled and uncontrollable doses of taxol or digoxin by giving the patient yew bark or foxglove than to give them the precise amount needed via isolation and purification of the active ingredient?

  2. #2 Philip Tan-Gatue, MD
    November 18, 2009

    While I may not agree with your statement that acupuncture is “clearly” unproven, I agree with you here in that “alternative” medicine is like a door holding back floodwaters. Give in too much and get drowned. There are indeed a lot of quacks out there (who give real Chinese medicine and acupuncture a bad name).

    Some agencies like the Asian Development Bank’s inhouse insurance will cover acupuncture treatments for their employees but only for certain conditions, usually pain control. I think this is one model that can be used. Otherwise, we’ll be opening up coverage for every plant or animal part or grain of sand out there that may have either real or imagined benefit.

    Actually, for someone interested in acupuncture I am known in Philippine alternative medicine circles as a “skeptic” (funny, huh) because I really do demand evidence. Maybe I am biased with acupuncture because it really helped me with my migraines and rhinitis, but you can see that for me that is the best evidence, albeit for you it is anecdotal. But yes in general I understand what you mean about being “raised” a skeptic. Where’s the proof? Where’s the evidence?

    So cover only the “unconventional” treatments for indications where they have proof supporting it, like acupuncture for pain. Deny coverage for treatments for indications with little proof supporting it, like acupuncture for… (guess what) color blindness… (I know, duh).

  3. #3 Philip Tan-Gatue, MD
    November 18, 2009

    @ Dianne

    I agree that opening up all kinds of herbal medicine to coverage can lead to abuse and potential disaster, but I have to comment that at least, in chinese medicine, dosages are controlled and that potentially toxic substances are always combined with other substances to mediate the toxicity. For example, aconite is never given raw but comes already prepared by soaking with (if memory serves me right) ginger and licorice root.

  4. #4 Denice Walter
    November 18, 2009

    In explaining alt med, I find it useful to differentiate A.”things that can make you *feel* better”(e.g.1.”Grandma med”-drink chicken soup or tea for a cold;and 2.”Spa med”-massage,skin care,soothing music, etc.)from B.”things that actually make you *better*”(EBM/SBM therapies).Alt med woo masquerades as B,when it’s probably A(or something worse).The use of self-reports in alt med(what is laughably called)”research” points to its true nature.

  5. #5 Philip Tan-Gatue, MD
    November 18, 2009

    @ Denice
    we should also differentiate A. “alternative” therapies for which research is only beginning to unravel how it works or for which research is finding useful (and thus may someday no longer be alternative) and B. therapies that have no basis whatsoever.

  6. #6 Stephanie Z
    November 18, 2009

    [T]here is no such thing as “side effects”—only effects, some desired, some not.

    I’m going to have to steal this. I’ve been saying, “If it’s potent enough to have an effect, it’s potent enough to have some kind of side effect,” but this is much better.

  7. #7 Dianne
    November 18, 2009

    in chinese medicine, dosages are controlled and that potentially toxic substances are always combined with other substances to mediate the toxicity.

    How do you control the dosage you’re giving with a plant? The plant may make more or less of the active ingredient depending on genetics, conditions under which it was grown, and maybe randomly. Also if you simply say that condition X should be treated with so much of herb Y per day, how do you even know what the active ingredient is and how to monitor for it? It’s not like you can get a blood level of St John’s wort.

    Using medications to counter toxicity is a common theme in allopathic* medicine as well. But it frequently has to be done carefully to avoid destroying the desired effect of the original medication. Leukovorin can rescue normal cells from the effects of methotrexate when given in low doses-but it also rescues cancer cells if given at higher doses. How do you know that you’ve soaked the aconite in just the right amount of ginger root?

    *I originally said “western” medicine, but changed it because the term is inaccurate. A fair number of innovations in “western” medicine come from Japan, India, China, and other places in the “east” (Australia and New Zealand when it comes down to it as well).

  8. #8 Philip Tan-Gatue, MD
    November 18, 2009

    “How do you control the dosage you’re giving with a plant? The plant may make more or less of the active ingredient depending on genetics, conditions under which it was grown, and maybe randomly.”

    Firstly, they’re not all plants. Chinese materia medica includes animal parts and minerals too. Second, a cursory examination of Chinese materia medica textbooks shows that not just any specimen of a species will do, but that best specimens grow under certain conditions. For example herb so-and-so is usually gathered from this province or even this town in this province. While it’s not an exact science, it at least provides for some consistency. also, Chinese herbal medicine gives herb values in weight in grams and usually have a range, let’s say between 3-9 grams, to be adjusted according to the practitioner’s judgment of the clinical picture… This is not unlike me trying to judge if a sore throat in a child deserves 40 or 60 mg/kg…

    “Also if you simply say that condition X should be treated with so much of herb Y per day, how do you even know what the active ingredient is and how to monitor for it? It’s not like you can get a blood level of St John’s wort.””

    In Chinese medicine, there is a saying which will no doubt earn me PalMD’s ire. It is “many diseases one treatment, one disease, many treatments” it means there is no absolute condition X should be treated with this much herb y per day. Rather it is “if conditions X, Y and Z have these common signs, they may be treated with formula A. if condition X presents another way, however, it may be treated with formula A with modifications or formula B” Now to explain this will take a LONG time so feel free to correspond with me directly if you like =)

    I know, it took me a while to get, too, being first trained in “conventional” medicine.

    “Using medications to counter toxicity is a common theme in allopathic* medicine as well. But it frequently has to be done carefully to avoid destroying the desired effect of the original medication. Leukovorin can rescue normal cells from the effects of methotrexate when given in low doses-but it also rescues cancer cells if given at higher doses. How do you know that you’ve soaked the aconite in just the right amount of ginger root?”

    Again, that’s where we rely on 2000 years of experience. Much like you rely on the experience and expertise of the mushroom harvesters in the wild who know which mushrooms to eat and which not to eat.

    Yes, Chinese medicine recognizes these effects too. There are some formulas where if you reverse the ratios of certain ingredients, the therapeutic effects are different. The ratio of herbs to each other is important. A study presented in a conference I attended in Hong Kong (got to find the title) validated the clinical use of a formula called Dang Gui Bu Xue Tang. I forget the details but I remember that the ingredients (astragalus root and angelica sinesis) MUST be decocted at a ratio of 5 astragalus to 1 angelica to get the maximum amount of active ingredient (in this case, an estrogen analogue if memory serves me right). Any other ratio would reduce the amount of active ingredient dramatically. (this formula was chosen precisely because it only had two ingredients).

    Obviously, Li Gao in the 13th century had no access to modern equipment when he recorded this formula. However, he had years of experience. I guess this is one aspect of chinese medicine that makes some MDs cringe – that the experiences of past practioners matters a lot even if they have yet to or are only now being validated by modern science. Of course, not everything the “gods” say must be trusted. Zhang Zhongjing once prescribed a formula containing the (get this) burnt crotch area of the pants of a person of the opposite gender… Li Shizhen listed a prescription calling for the rope used by a suicide victim to hang himself…

  9. #9 Jeff
    November 18, 2009

    Scientific research is beginning to show that antioxidants may have a role treating heart disease. Oxidation of LDL molecules is involved in the development of an atherosclerotic lesion.

    In a March 12 NEJM article called Reversing Atherosclerosis?, Immunologist Linda K. Curtiss, Ph.D. writes of the work being done at the Cleveland Clinic by cell biologist Young Mi Park:
    “Atherosclerosis is reversible and involves the removal of trapped cholesterol-loaded foam-cell macrophages from the arterial intima. A recent study by Park and colleagues showed that these foam cells are trapped by interaction with oxidized low-density lipoprotein (LDL) and can be remobilized by dynamic exposure to key antioxidants such as resveratrol, a polyphenolic compound found in grapes and red wine and having potential antiatherogenic properties.”

    Imagine! Resveratrol, a dietary supplement, might reverse atherosclerosis!

    Then there’s this recent study which found the use of the B vitamin niacin to raise HDL cholesterol levels was more effective than using the drug ezetimibe to lower LDL cholesterol levels for patients at high cardiovascular risk who also took statins. The study found Niacin was more effective than Zetia (a statin-lowering drug from Merck & Co. Inc.) at reducing the artery plaque buildup after 14 months.

    Of course some doctors, like this cardiologist, have been using niacin as a first line treatment for years to improve cholesterol levels.

  10. #10 red rabbit
    November 18, 2009

    I suppose the issue with journalists is, if they had the understanding (read, training) to parse what was wrong with the alt-med claims, they’d be scientists and not journalists. Small wonder people get so confused: how is one to pick out the real from the woo?

    Not everyone understands that magic isn’t real.

  11. #11 daedalus2u
    November 18, 2009

    Saying that TCM is less likely to have toxic effects because it has been used a long time and the people giving and taking it didn’t notice much is nonsense. The appropriate course of action is to actually test them for both toxicity and efficacy. Then there is no doubt.

    Every drug used in TSBM (traditional science based medicine) requires testing for safety and efficacy before it is used. It needs to have plausible pharmacological effects and have undergone testing. There is a paper trail of that testing that can be looked at, errors can be found and the results updated as scientific understanding of the relevant physiology increases.

    What does TCM have? We think a bunch of TCM practitioners used this herb (because their description kind of sounds like it) and no one reported lots of deaths from it, so it must be ok. In other words because there are not very many anecdotes of it being harmful, it must be safe.

  12. #12 Tsu Dho Nimh
    November 18, 2009

    Ms. Allen says, It’s already happening: just think about how often you hear that regular exercise and a diet rich in antioxidant- packed fruits and vegetables and plant-based proteins (rather than proteins high in saturated fats) may prevent cancer and heart disease.

    And where are you hearing it from most often? It’s coming from the AMA and mainstream medicine … the “alternative medicine” sites all want you to buy their potions, pills, extracts and supplements.

  13. #13 Philip Tan-Gatue, MD
    November 18, 2009

    @daedalus

    I understand your train of thought. Now please try to understand the train of thought of a person who uses TCM:

    “let’s see, a drug tested on less than ten thousand people in less than five years compared to a formula used by billions for the past two thousand… I’ll take my chances with the latter.” Now I don’t agree with this statement, but I’m telling you this is how they think. As I myself wrote, not everything written in the “classics” is to be swallowed without question – this is what 50+ years of tcm “modernization” is trying to do – weed out the chaff from the grain.

    I am tempted to call into question the testing for safety and efficacy of “science” based medicine. All I need to do is say a few words. AZT. Vioxx. Bextra. Of course these are exceptions, but they do prove that the system is not infallible.

    Of course, one common criticism against Chinese medicine is (well okay two) a) oh but this herb isn’t safe and b) we don’t understand how it works. One word answer: lithium (for bipolar disorder).

    As for the research being done as to the safety and efficacy of chinese herbal meds, I recommend this book:

    http://www.amazon.com/Chinese-Medical-Herbology-Pharmacology-John/dp/0974063509/ref=sr_1_16?ie=UTF8&s=books&qid=1258585735&sr=8-16

    @ Tsu Dho Nimh

    Yes, unfortunately that is true. “alternative” medicine is a lucrative business, but that is why more mainstream physicians should try to be less closed minded about alternative medicine in general and should try to be more aware about which modalities can actually work for which conditions – I get a lot of questions in my rounds and lectures about alternative medicine (being a known proponent of Chinese medicine) and I must separate the wheat from the chaff. Some people assume that since someone like myself likes chinese medicine and acupuncture then I am one of those tree hugging, weed smoking snake oil salesmen as well. I bluntly tell patients that this is shown to work but this other thing isn’t. Unfortunately, I know not all are like me. But is condemning alternative medicine IN GENERAL the answer? I believe not, because then the quacks will put out their crocodile tears and go “Big Pharma hates us, Big Pharma doesn’t want you to be healthy’ and do the martyr act. (yes, some TCM docs do this too – those that aren’t skilled enough to get enough patients by actually being good at what they’re supposed to do)

  14. #14 Dan
    November 18, 2009

    Funnily enough, when I loaded the page, the topmost advertisement in the right sidebar read “Blood Pressure Cure: Drop blood pressure naturally. Drug companies hate this!”

  15. #15 Ian Musgrave
    November 18, 2009

    Hardy said

    “It’s very uncommon that any herb with traditional knowledge behind it will be as toxic as a new drug.”

    This is pure unadulterated rubbish. Dianne at #1 nailed it with some nice examples, but the list is huge, traditional herbals such as aconite, foxglove, belladonna and Nux Vomica are all highly toxic.

    Less spectacularly toxic, but still problematical, the traditional Chinese medicine Ma-Huang contains ephedra alkaloids, and can cause stroke and hepatotoxicity. Preparations such as Ma-Huang containing ephedra and related compounds are now banned in Australia and Europe. Kava (now banned), Sho-saiko-to, germander and black cohosh all cause hepatotoxicity, but despite “thousands’ of years of use, no one noticed the serious hepatotoxic risks. The notion of adverse reaction reporting apparently isn’t a part of herbal medicine.

    This is just the tip of the iceberg in terms of toxicity of herbals because they have not been as rigorously investigated as modern drugs. In contrast, modern medicines undergo rigorous toxicity testing. To take an example, the incidence of *hepatotoxicity* from all Chinese herbal remedies has been estimated at between 0.2% and 1% (these are the the “tested for thousands of years” herbals, okay*). The incidence of the less serious myopathy from the cholesterol lowering drug simvistation is 0.03% at 20mg and 0.08% at 40mg. Doesn’t even approach the lowest bound of toxicity of Chinese herbal remedies. Hepatotoxicity for simvistatin appears to be in the range of 0.005%, nearly 40 times lower than the lowest bound for Chinese herbals.

    Herbals less toxic than new drugs**? Unadulterated rubbish.

    *This is the average over all herbals, some will be much higher risk than others.
    **Excluding of course, those herbal preparations that have no physiologicaly active ingredients in them.

  16. #16 Ian Musgrave
    November 18, 2009

    Philip Tan-Gatue, MD at #3 wrote:

    in chinese medicine, dosages are controlled and that potentially toxic substances are always combined with other substances to mediate the toxicity. For example, aconite is never given raw but comes already prepared by soaking with (if memory serves me right) ginger and licorice root.

    It’s just the soaking that helps break down the neurotoxic aconitine, the ginger and licorice play no role in the breakdown of the toxin. Even so something like 4-6 people per year enter hospital with significant aconite poisoning from aconite conating herbal medicines in Hong Kong, and this represents an underestimate of the true incidence of poisoning. (Internal Medicine Journal, 1993, Volume 23, Issue 3 (p 268-271)).

    Tell me again why it is preferable to take plants with an uncontrolled level of neurotoxin, process them in an uncontrolled manner to break down the amounts of neurotoxin to a level that hopefully won’t cause severe toxicity, rather than take paracetamol?

    (In this case, the neuortoxin aconitine is being used for it’s antifever and anti pain effects, well, it stops nerev conduction after all, but aconitine has a very, very narrow therapeutic index between analgesia and toxicity)

  17. #17 Ian Musgrave
    November 18, 2009

    Jeff at #9 wrote:

    Imagine! Resveratrol, a dietary supplement, might reverse atherosclerosis!

    First, resveratrol is not a dietary supplement, it’s a drug. Secondly, as an antioxidant, it’s pretty rubbish in real physiological situations. It’s also broken down pretty rapidly, so for example to get therapeutic concentrations of reveratrol by drinking, for example, red wine, you need to drink about 57 bottles of red wine in one go. So resveratrol will have to be taken in concentrated doses in tablet form. And based on the track record of other antioxidants that are given as pills, where they either do not affect cardiovascular disease (or cancer or Alzheimer’s) or even make it worse, I am not sanguine about resveratrol as drug.

    And I say this as someone who is researching resveratrol as an anti-Alzheimer therapy.

    Epidemiologically, we know that a diet that is rich in fresh fruit and vegetables is good for you, scientists have been showing this for years (I worked with a group who, amongst other things, looked at diet and high blood pressure in the early 80’s). Note that it was the standard medical researchers that showed this, not herbalists or naturopaths. But we also know that just adding antioxidant vitamins to your diet doesn’t work.

    Jeff at #9 wrote:

    Then there’s this recent study which found the use of the B vitamin niacin to raise HDL cholesterol levels was more effective than using the drug ezetimibe to lower LDL cholesterol levels for patients at high cardiovascular risk who also took statins.

    No, that study was looking at whether adding Niacin or ezetimibe to a regime of statin drugs was better than statin alone. Niacin does seem to be additive with statins, while ezetimibe, while reducing some risk factors, didn’t affect plaque thickness. But both Niacin and ezetimibe were adjuncts to see if they could make a good existing drug (statins) work better. Niacin by itself is pretty much rubbish for cholesterol.

  18. #18 Philip Tan-Gatue, MD
    November 18, 2009

    @ Hardy: again I refer you to the question: what about lithium for bipolar disorder – we’re not sure how it works, it has a low therapeutic index…
    @ Ian yes, aconite poisoning by people going to drugstores by themselves and buying herbs without a prescription can cause that. I am not unaware of these events. I have managed patients in our hospital with kidney failure due to overdose of Korean red ginseng.

    About ephedra, and I’ve lectured on this: ephedra has a very specific set of indications and there are clear instructions on when to stop using it – when the patient perspires. I do not blame the herb itself but for true alternative medicine quacks who utilize it without knowing these facts. Oh and it is always given with gancao (licorice root) to mediate it’s effect.

    About aconite, there are very specific instructions on how to boil it at home. In my opinion, a practitioner who prescribes aconite without telling patients to boil at least an hour at low doses and another 20 minutes beyond a particular dose (forgot exactly which – am not a chinese herbalist) is liable for negligence. This is why we also need regulation of herbal medicine – so the store that sells the aconite without a prescription can be held legally liable.

    Why is it preferable to take one toxic substance over another? The fact that one works for them and another doesn’t. I’ve tried every anti-migraine med available. Didn’t work. Three doses of a herbal decoction and no headache for five years and counting…

    Now that amount of evidence won’t be sufficient for some, but it will be for others. All I ask is an acknowledgement of that fact and not a flat out – “all alternative is bullcrap” judgment.

    Again I point to an example in scientific medicine about medicines utilized with no definite knowledge of pharmacodynamics, and with low therapeutic evidence – lithium.

  19. #19 Dave Ruddell
    November 19, 2009

    All I need to do is say a few words. AZT. Vioxx. Bextra.

    Okay, I’ll bite. What’s wrong with AZT?

  20. #20 Ian Musgrave
    November 19, 2009

    Philip Tan-Gatue, MD at #18 wrote:

    @ Ian yes, aconite poisoning by people going to drugstores by themselves and buying herbs without a prescription can cause that. I am not unaware of these events.

    No these are people who had been prescribed traditional remedies by traditional Chinese medicine practitioners.

    Philip Tan-Gatue, MD at #18 wrote:

    About aconite, there are very specific instructions on how to boil it at home. In my opinion, a practitioner who prescribes aconite without telling patients to boil at least an hour at low doses and another 20 minutes beyond a particular dose (forgot exactly which – am not a chinese herbalist) is liable for negligence.

    You still have an uncontrolled dose of a neurotoxin being moderated in an uncontrolled way (Boil at least an hour is not a controlled way of obtaining a dose reduction). Remember, aconite is a straight out neurotoxin with a very narrow dose range between poisoning you a little (and producing analgesia) and killing you (or making you very, very sick).

    Paracetamol? It has a wide margin of safety. You have to work really hard to get paracetamol toxicity (unless you are an alcoholic), you need somewhere between 6-10 times the maximum recommended dose to begin to see any toxicity.

    Philip Tan-Gatue, MD at #18 wrote:

    Again I point to an example in scientific medicine about medicines utilized with no definite knowledge of pharmacodynamics, and with low therapeutic evidence – lithium.

    You’re kidding, right? Several high quality reviews strongly show that Lithium is efficacious in mood disorders and especially in bipolar disorder (eg Evidence-Based Mental Health 2002;5:44; doi:10.1136/ebmh.5.2.44).

    Lithium has a low therapeutic index, which means that there is a narrow concentration range between a therapeutic effect and a toxic effect. In this case (like anti-rejection drugs and warfarin for prevention of blood clots), we closely monitor the concentrations of lithium(cyclosporin/warfarin) to make sure we have optimal therapeutic levels.

    Why you think closely controlled concentrations of drugs for diseases which are devastating when left untreated are comparable to uncontrolled concoctions of neurotoxins administed for non-serious conditions (that can be controlled with safe drugs) I do not know.

  21. #21 Philip Tan-Gatue, MD
    November 19, 2009

    @ Dave
    Not AZT per se, although it is highly toxic… the prescribed doses when it was first approved was way too high.

    @ Ian

    No I am not kidding, and I never said lithium doesn’t work. I just said the exact mechanism is not known (at least when I went to med school a few presidential terms ago).

    And yes, we agree it has a low therapeutic index.

    My point is that if we can give drugs that are easily toxic if misadministered yet effective then we should be careful about using the same argument about chinese medicine.

    About that story about hong kong people getting aconite poisoning, I’m sure I read that somewhere I think about two years ago. It was in a newspaper article calling for regulation, since at the time (I don’t know about now) apparently people could just “re use” old prescriptions or buy herbs over the counter based on what they know. I do remember reading that majority of those with aconite poisoning either got adulterated herbs (poorly prepared) or overdosed on their own. Again, though without numbers I understand why my argument would be weak in others’ eyes.

    Sadly, such a practice is also prevalent even in conventional drugstores here in the Philippines. I’ve seen people go right up to clerks here and ask for oral steroids without prescription, and they are sold them… (okay off topic there)

    Ian, I have seen hospitals in China where “eastern” and “western” drugs are given side by side in cancer treatment. Research has shown that these “toxins” in hardly uncontrolled decoctions (strictly speaking chinese medicine formula soups are decoctions, not concoctions) help shrink tumor size faster combined with chemotherapeutics then either herbs or chemo alone. (Again I’ll have to google for the study – am citing these from memory atm)

    I’ve seen Chinese herbal preparations made from such simple items as licorice root, cinnamon twig, and two more everyday non poisonous herbs permanently cure a chronic rhinitis that western med couldn’t touch. Again, anectodal evidence, yes, but somehow anectodal evidence is easier to accept when you’ve seen it for yourself.

    I admit I cannot answer the specifics about aconite poisoning since I am not a chinese doctor, I am an M.D. exposed to it and who studied it as an outsider. But I have seen enough to draw two personal conclusions: in the hands of skilled practitioners, this stuff can be amazing. In the hands of idiots, they can be very very lethal.

    On a side note, this is why I object to the Philippine government’s “demotion” of herbal products as “food supplements”. This “fools” the public into thinking that such herbal products are “natural” ergo safe. As I’ve said before, I’ve seen people get kidney failure from ginseng. I’ve seen them get fractures from steroids. The difference is right now there’s little liability for the ginseng distributor because legally his product is a “food supplement” and not a drug.

    Oh, about “non serious” conditions. A migraine is considered non serious by those who don’t suffer from it. I was in hell. triptans didn’t work. I got addicted to pain meds… well not like Greg House but you know what I mean. those “neurotoxins” with “uncontrolled doses” got me headache free for five years and counting. How can I NOT put weight on that? Granted, you don’t have to believe me, but I discourage people from putting it down until trying it for yourself. (and for the record, yes I have been victimized by a quack acupuncturist here in Manila who actually did the unthinkable and made my shoulder ache WORSE)

  22. #22 Philip Tan-Gatue, MD
    November 19, 2009

    Let’s summarize what I seek here:

    I don’t expect you to believe what I believe about Chinese medicine. That would be asking you to accept my word like a papal bull. That is not science, that is blind faith.

    What I do hope to expect from sincere inquirers is to acknowledge the fact that there exists enough evidence for Chinese medicine for a lot of people to take it seriously.

    I do not expect you to believe that all Chinese medicine doctors are skilled practitioners. That is so untrue. A lot are idiots who, like you say, only want to sell their herbs (which are probably poor quality and rotten and indeed likely to poison you.)

    But I do hope to expect from sincere inquirers that there are indeed good practitioners out there able to handle diseases that conventional medicine has a hard time with, or are able to provide an adjunct treatment to conventional medicine.

    However

    I do concede that it is difficult to standardize dosages exactly in Chinese medicine, and I understand that makes it hard for some people to place trust in it.

    I also do concede that it is difficult for other MDs to accept Chinese medicine because there are quacks out there (like that “meridian” detection system by computer probe – tried it out pretending to be a patient and not a doctor and had to bite my lip trying not to laugh aloud at the “results”)

    What I will not concede is the idea that Chinese medicine is inherently useless. I’ve seen and experienced too much both in myself, and my patients, to see otherwise. Needing of more standardization, yes. Needing of more regulation, definitely. But to be dismissed as easily as (okay, I’ll say it) homeopathy or reiki?
    Nope.

  23. #23 Julius Beezer
    November 19, 2009

    Reducing the elements of life into variables to be studied statistically is a seductive activity, and long may it continue.

    But the more the truth is reductive, the greater the problem each individual has reintegrating these truths back into their own life practices.

    As the pharmaceutical, nutra-ceutical, herbalistic, and chi-tastic fields of endeavour become ever more linked to a class of healers utterly dependent on capitalism, the greater the danger that the truth will become secondary to the exigencies of marketing, and its inevitable concomitant, the half truth.

    You can square the circle by doing cost-benefit analyses of different interventions, but this does require the dismal pricing of human life and well-being, and in any case is flawed in world where there are such gross disparities of basic living conditions.

    When 800 million members of my human family are living in food insecurity, I look at you lot and think of angels dancing on the head of a pin.

  24. #24 jesmith
    November 19, 2009

    Wow – what a pile of biased comments on a really good and unbiased article.In 1991 statistics showed that there were no deaths caused by herbs or supplements, there were a few caused by the humble potato and more caused by prescribed pharmaceuticals than there were by shootings and stabbings combined.
    There are 10.000 cases of paracetamol toxicity annually so I guess a lot of people work really hard and drink a lot of alcohol. The banning of the herb Kava started in germany where the only Kava Kava was actually standardised and prescribed by doctors to patients who – yes drank a lot of alcohol and took prescribed drugs. In America where Kava Kava was and still is used in its more natural form by millions of people there were no negative reports and no ban.
    need I go on – I have to get back to my successful herbal practice in which I have not killed anyone to date – no pharmaceutical company could make that claim

  25. #25 Ian Musgrave
    November 19, 2009

    jesmith wrote:

    In 1991 statistics showed that there were no deaths caused by herbs or supplements

    [citation needed]

    In a 2005 study, 14% of patients attending traditional Chinese therapists rported adverse events from their medication.

    jesmith wrote:

    I have to get back to my successful herbal practice in which I have not killed anyone to date

    How would you know, you don’t track adverse events.

  26. #26 Ian Musgrave
    November 19, 2009

    Philip Tan-Gatue, MD wrote at 21#

    I never said lithium doesn’t work.

    They why did you write “and with low therapeutic evidence – lithium”.

    Philip Tan-Gatue, MD wrote at 22#

    I don’t expect you to believe what I believe about Chinese medicine.

    . Not an issue here, the issue is this statement by Hardy “”It’s very uncommon that any herb with traditional knowledge behind it will be as toxic as a new drug.””. This is plainly untrue. In the one of the several examples we were discussing, aconitine found in several traditional Chinese medicines is a neurotoxin far more toxic than newly developed drugs. Even with “thousands of years” of experience people still get poisoned by it in traditional remedies.

    Yes, we have drugs with a narrow therapeutic index, but these drugs are only used where the disease is sufficiently dire to warrant treatment with such a drug, and then only with very careful measurement.

    In contrast, traditional Chinese medicines that use the neurotoxin aconitine uncontrolled levels of aconite in them, which are then boilded to produce an uncontrolled reduction in levels of neurotoxin, which are never monitored in the patient.

    If you can’t see the difference between a medicine given in a defined defined dose and the concentration of which are rigorously monitored to ensure that safe levels are present, and a compound of which you have no idea what levels are present in the medicine, you need to sit down and have a hard think about what a medicine is (oh yeah and risk levels, we restrict drugs with narrow therapeutic index to diseases that justify the risk, headaches don’t justify the risk of using uncontrolled levels of neurotoxin.)

  27. #27 Dianne
    November 19, 2009

    Dr. Tau doesn’t believe in lithium’s efficacy? Interesting, since it’s a traditional medicine: IIRC, its first reported use was a town with high lithium levels in its water supply advertising its water as good for your mood (along with, no doubt, a number of other things from arthritis to cancer.) Isn’t this the kind of folk knowlege he’d been claiming should be the basis for medical care?

  28. #28 Dianne
    November 19, 2009

    Okay, I’ll bite. What’s wrong with AZT?

    HIV can develop resistance to it quickly when it’s given as monotherapy. Hey, you asked!

  29. #29 Dave Ruddell
    November 19, 2009

    @Dianne, oh I know I asked! Actually, I was trying to suss out whether or not we had an AIDS denier on our hands (AZT causes AIDS!!11!!). I already knew that it can be pretty toxic, and that when originally given as monotherapy, the doses were very high. Of course, given the alternative, it’s use was justified at the time(IMH(non-professional)O).

  30. #30 Philip Tan-Gatue, MD
    November 19, 2009

    @ Ian
    My apologies, when I wrote low therapeutic evidence I meant low therapeutic index. The context of the sentence I wrote makes more sense now, yes? I meant that we don’t exactly understand the pharmacodynamics, and it has a low therapeutic index, but what the hey it works, so let’s use it.

    and I just called my herbalist friend. She says she seldom uses aconite in her formulas. Her favorite is Chai Hu (bupleurum)

    @ Dianne
    I hope I have clarified my position on lithium. My apologies for my slip of the fingers. And If by Dr. Tau you were referring to me, it’s Tan-Gatue. It’s the fujianese pronunciation of Chen Yati, which was my great grandfather’s name which he anglicized into a surname when he migrated here more than a hundred years ago.

    and I sincerely hope you are not implying that I put no weight whatsoever into conventional medicine, being an MD myself who just prescribed azithromycin to my whole household for pharyngitis. I simply accept that an eclectic approach may be warranted – taking the best of all worlds.

    I believe I have reiterated over and over that I neither accept “alternative” medicine as a whole nor do I deny that many “alternative” doctors use patient guillibility to make money.

    I also have reiterated over and over that I believe not in turning my back on conventional medicine but in letting the two work together.

    And Ian, Dianne – you say headaches don’t justify the risk. Have you had status migranosus? Have you had the pain so bad that you cringed when someone TALKED to you in a darkened room? Has your head throbbed so hard that you wanted to knock it on the wall, break it open like an egg, and hope you die just to make the pain stop? I have. I even got delayed a year in med school because I couldn’t take the constant headaches anymore.

    Just trying to drive home the point that while you may think some people’s illnesses might be trivial, they’re quite real and quite SERIOUS for us.

  31. #31 Dianne
    November 19, 2009

    Dr. Tan-Gatue: My apologies for my careless error with your name.

  32. #32 Alan Smith
    November 19, 2009

    Doctors are ignorant of the wide range of CAM therapies available and the research that’s been done. For starters, if a treatment didn’t work it wouldn’t survive for decades, hundreds or thousands of years. If it was as lethal as many drugs the story would be on the front page of every newspaper in the country.

    For example, how about the 100-year-old Alexander Technique? Last year in a U.K. study on back pain it was more effective than mainstream medicine’s treatment of physical therapy + pain killers + muscle relaxers and chiropractic.

    There are 300+ listings in 138 categories in the book UnBreak Your Health and most doctors are aware of about 10% of the treatments. If a treatment can help your patient why wouldn’t you use it? After all, even the placebo effect is effective for 30% of people so if a CAM therapy activates healing for 30% of your patients, why not use it?

    The fact that cannot be ignored is that CAM therapies do work, whether doctors want to admit it or not and regardless of whether the square peg fits into the round hole of current science. After a disappointing trip to the Mayo Clinic I found therapies that helped me so it’s not a theory, it’s a fact for me. Doctors need to open their minds and do what’s best for their patients.

  33. #33 jenstate
    November 19, 2009

    I think traditional and alternative therapies can work together. I have used traditional medicine all my life to treat my asthma and allergies. They are fairly severe and I am on several medications including Advair, which has pretty terrible side effects. I also eat healthy, maintain a very healthy weight, and exercise all the time. I still suffer so I’ve decided to try an alternative therapy called BAX 3000. I’ve never used alternative medicine before, but I figured it’s worth a try. I’ve done my research and figure i have nothing to lose (except some money) and everything to gain. The fact is there are many compelling testimonials on their website (www.biovedawellness.com) and the therapy is FDA approved as a stress reduction therapy. I won’t stop taking my traditional medications, but I’m in a place where I’m willing to try something new. I guess if you’ve never been that sick or had terrible reactions to medication (I’ve had migraines and anaphylaxis)you might not be willing to try something different. It’s really a matter of personal experience and then doing your homework.

  34. #34 Ian Musgrave
    November 19, 2009

    Alan Smith wrote at #32:

    For starters, if a treatment didn’t work it wouldn’t survive for decades, hundreds or thousands of years.

    Yes, yes it can. Leeching and cupping survived for centuries, and they are worse than ineffective. Echinacea is a herbal remedy for colds and flu, used for centuries, completely ineffective. Same for Saw Plametto and a long, long list of other herbal therapies.

    Humans are *really* good at fooling themselves, which is why we have developed science-based medicine, to make sure we don’t fool ourselves into believing something works when it doesn’t.

    Many herbal therapies do work, but the problems with herbals is effectiveness and quality control. Willow bark can reduce headaches, but the preparations vary wildy in effectiveness and the effective preparations have more side effects (mouth and throat ulcers) than a controlled dose of aspirin or paracetamol. St. Johns Wort is a halfway decent anti-depressant, with exactly the same side effect profile as things like prozac (if your source has a constant amount of active ingredient, otherwise sometimes it works, sometimes not, sometimes toxic).

    Alan Smith wrote at #32:

    If it was as lethal as many drugs the story would be on the front page of every newspaper in the country.

    No it wouldn’t, herbal and naturopathic groups are really go at ignoring the side effects of herbals.

    We only know of side effects of many drugs because we have very rigorous adverse event reporting mechanisms (and they are not lethal in the way aconite is). We are aware of serious side effects of herbals, but they are greatly under reported because herbal practitioners don’t have the adverse event reporting measures we have in place for normal medicines.

    Did you know Black Cohosh has serious liver toxicity? Sure does, but you will find it hard to get that information via herbalist sources. And that is just one example.

  35. #35 Ian Musgrave
    November 19, 2009

    Philip Tan-Gatue, MD at 30# wrote:

    Have you had the pain so bad that you cringed when someone TALKED to you in a darkened room? Has your head throbbed so hard that you wanted to knock it on the wall, break it open like an egg, and hope you die just to make the pain stop?

    And in my case I go blind as well, my vision wipes out in a wall of multicoloured lights. But the heart of it is that although you wish you could die, you are not actually going to die of migrane. Unlike stroke, or rejecting your kidney.

    Would you accept a BigPharma drug for migraine that had the same lethality and side effect profile as aconitine containing herbal medicines? If you do, fine, but most people have a double standard, rejecting, even being afraid of, safe drugs with modest side effect profiles, while embracing drugs (herbals) which have worse safety and side effect profiles (or better safety profiles because they are inactive and just fancy placebos).

  36. #36 Tsu Dho Nimh
    November 19, 2009

    Philip –
    How is the person with the prescription, and the pharmacist filling it, supposed to make sure they have the right substance for TCM?

    Do the pharmacies test to make sure they have the right plants, test for adulterants, and test for potency? That testing was a part of old-time pharmacy practice. Unless you gather your own, as Navajo herbalists do, you can’t be certain what is in the bundle of leaves without testing.

    How many instances of TCM and ayurdevic products contaminated with powerful modern drugs have we had this year? How many with heavy metal contamination?

    I have read TCM formulas at supposedly reliable sites that have a blithe attitude to the genus and species of the herbs they use. They have a list of plants they use as if they were equivalent, some of which might have the useful compound and some which don’t. You might as well swap Salvia officinalis for Salvia divinorum.

  37. #37 Ian Musgrave
    November 19, 2009

    jesmith at #24 wrote:

    There are 10.000 cases of paracetamol toxicity annually so I guess a lot of people work really hard and drink a lot of alcohol.

    I missed this bit, you do realise that in the UK alone, there are over a million working age alcoholics?

    In fact most cases of paracetamol toxicity are due to deliberate overdose*, followed by alcoholism. 10,000 seems like a lot, but given the frequency that paracetamol is used, and the populations of the UK and USA, the paracetamol case rate lies between 0.07% (UK) and 0.02% (USA), still lower than the lower bound of hepatotoxicity for Traditional Chinese Medicine (0.2%).

    *Only 0.1% of all paracetamol *overdoses* resulted in death in the US, I’m not sure why people try and use it for suicide, possibly because it is so spectacularly unsuccessful.

  38. #38 Ian Musgrave
    November 20, 2009

    One thing that it is important to emphasise is that people very much overestimate the toxicity or adverse events from conventional drugs (maybe they all have visions of anticancer drugs stuck in their heads*) and very much underestimate the toxicity or adverse effects of herbals (maybe they see all herbals as camomile tea).

    It is very hard to get people to have a concrete feel for the rarity of adverse events in most drugs. Take the paracetamol example above, it sounds like a lot of adverse events (again, this is anything form being worried to going to hospital to have things checked out to being admitted to hospital, more of the former than the latter), but when you realise that in the UK in one year around 40,000,000,000 (yes, that is not a typo, it really is 40,000 million) paracetamol tablets are purchased, the adverse event rate pales away.

    In another way to think about it, there is one adverse event for every million paracetamol tablets taken. And consider that this figure is grossly inflated by people trying to commit suicide by taking a paracetamol overdose (for some reason most people think an overdose of paracetamol will put you to sleep, it won’t).

    Meanwhile, the hepatoxicty of Kava is relatively high, any conventional drug that showed a hepatotoxicity as high as Kava would be pulled from the market, as Kava was.

    The reason we kow so much about the toxicity of paracetamol (aside for the people who try and kill themselves with it), is we have a strict reporting system for logging adverse events with a centralised adverse event database.

    If you are a herbalist, and the nice old lady who has been coming in for months for Ginko doesn’t turn up again, are you going to investigate to find out if she is in hospital, or died from Ginko induced catastrophic bleeding? (yes, this is one of the adverse events of Ginko). Are you going to report this Ginko related event to the database? The lack of a specific reporting system for herbal medicine events or specific adverse event labelling is part of the reason so many people think herbal medicines are safe.

    People don’t even of medicines are drugs, a good and very intelligent friend of mine had a very serious drug reaction, because she didn’t think the herbal preparation she was using was a drug, and took it with a prescription drug that it was as contraindicated for.

    If Herbal drugs had to undergo the same lableing requirements that standard medicines do, people would soon understand that herbs aren’t some magic fluffy bunny elixir.

    *although the modern anticancer drugs such as Givec don’t make you throw up or lose your hair, but Glivec only really works for Chronic Myeloid Leukemia.

    Yeah, and more people die from prescription drugs than are killed by stabbings and shootings, again you have to think about exposure, there are over 270 million people in the US, most will take a prescription tablet at least once, a year, others are on them all the time. A crude case fatality rate is 0.03%, and this value is inflated by people poisoning themselves with prescription drugs for suicide, people accidental killing themselves by combining prescription drugs trying to get high and a range of other factors. Presciption drugs are a lot safer than you think.

  39. #39 Philip Tan-Gatue, MD
    November 21, 2009

    (hopes my comment will be posted this time)
    @ Dianne: no harm done.

  40. #40 Philip Tan-Gatue, MD
    November 21, 2009

    @ Ian

    I agree with you here. Herbs are not all chamomile tea, although at least in Chinese medicine most are relatively harmless. As you said, there are indeed Chinese herbals which can be ridiculously toxic, just as some western meds can have low therapeutic indexes. I think at these points we can agree.

    I think our differences in opinion come from a) what degree of evidence one is willing to accept b) what is our end point to conclude if a therapy is effective or not and c) how each of us weighs risks.

    for a) many MDs accept the double-blind randomized controlled trial. So do I. I also understand it’s limitations. I do know however, that I am more willing that some to accept anecdotal evidence provided that it is well documented by an M.D. or other reputable non-quack. (of course the definition of quack varies from person to person…)

    b)what is our end point? I noticed that for many MD’s it’s a laboratory value. For me that is important but one can never have exact numerical values for such subjective complaints such as pain relief. Using myself as an example, the numbers don’t mean squat to me because my head still felt like cracking even after all the triptans.

    c)weighing risks. it is a valid point you made that by decocting at home one cannot really standardize measurements in chinese medicine with the precision we’d want in our western drugs. I’d like to counter a bit though in that even though the measurements are not exact, they do fall within ranges. Do we measure ingredients in cooking down to the exact milligram, or microgram? Yet we know it worked because the recipe produced a good dish.

    I wish I could find some numbers regarding the rate of prescribing of “toxic” herbs like aconite. I’m sure we can do that by doing a retrospective chart review of outpatient and inpatient records in Chinese Medicine hospitals like the one I visited. Everything’s computerized now. And yes, they record adverse effects, at least in China.

    And about the Gingko thing, these days people don’t even need to go to a herbalist for Gingko Biloba… they can just go to the shop. That is not good, as a) we don’t know if it’ll be useful for the old lady and b) you are right, there is no monitoring.

    That’s why there is a need for proper training and licensure fo herbalists.

    @ Tsu realistically, Chinese Herbalists are supposed to be trained in identifying the ideal version of the herb. Now I don’t know how it’s done in other countries, but in China there are GMP certified pharmaceutical companies behind them, ensuring proper specimens, etc. If someone gets poisoned because of error in preparation or storage then by all means sue them. Chinese Medicine Hospitals get their supply of raw herbs from these companies, prepacked by gram.

  41. #41 Philip Tan-Gatue, MD
    November 21, 2009

    @Ian

    “People don’t even of medicines are drugs, a good and very intelligent friend of mine had a very serious drug reaction, because she didn’t think the herbal preparation she was using was a drug, and took it with a prescription drug that it was as contraindicated for.”

    VERY VERY MUCH AGREED. In the Philippines, this happens because the Bureau of Food and Drugs (BFAD) only classifies western drugs as “drugs” while it classifies everything else as “food supplements”. People are then lulled into a false sense of “it’s natural so it’s safe”. Which is definitely total nonsense.

  42. #42 D. C. Sessions
    November 21, 2009

    @8:

    Again, that’s where we rely on 2000 years of experience.

    Paging Dr. Jay Gordon!

  43. #43 D. C. Sessions
    November 21, 2009

    What does TCM have? We think a bunch of TCM practitioners used this herb (because their description kind of sounds like it) and no one reported lots of deaths from it, so it must be ok. In other words because there are not very many anecdotes of it being harmful, it must be safe.

    In other words, it has the same basis for being judged safe and efficacious as the ayurvedic administration of heavy metals.

  44. #44 D. C. Sessions
    November 21, 2009

    I am tempted to call into question the testing for safety and efficacy of “science” based medicine. All I need to do is say a few words. AZT. Vioxx. Bextra. Of course these are exceptions, but they do prove that the system is not infallible.

    And yet you cite examples where it didn’t fail.

    Just to pick one, Vioxx: parts-per-million risks from long-term use were picked up in postmarket surveillance in a matter of a few years. Please present some non-laughable argument for how “2000 years” of folk medicine in China would have caught the same effect.

  45. #45 D. C. Sessions
    November 21, 2009

    Okay, I’ll bite. What’s wrong with AZT?

    They say it causes AIDS!

  46. #46 D. C. Sessions
    November 22, 2009

    Doctors are ignorant of the wide range of CAM therapies available and the research that’s been done. For starters, if a treatment didn’t work it wouldn’t survive for decades, hundreds or thousands of years.

    You mean like bleeding?

  47. #47 Charles
    November 22, 2009

    Acupuncture is clearly proven for treatment of nausea and vomiting, among other conditions, based on randomized controlled trials and meta-analyses. An RCT done at Duke University Medical Center has shown that it is superior to ondesetron. Acupuncture research has met the gold standard of science:
    http://acupuncture.com/education/theory/mechanismacu.htm

  48. #48 Don
    December 10, 2009

    The problem with doctors is they’ve come to believe in their pharmaceuticals like pastors in faith healing. How many doctors prescribe statins even in situations where there’s no known efficacy. Or look at the resistance to EECP, even though studies show it often works as well or better than by-pass surgery.

    Look at the changes in chocolate and wine, which we just knew a few years ago were both bad for us.

    A doctor’s training just blinds them to any facts that don’t fall within the narrow training they’ve been given. We need a mix of more open minded ideas to ensure the widest array of possibilities.

  49. #49 Sue
    December 10, 2009

    PalMD writes: “don’t trust sources with significant investment in an alternative therapy”.
    How about: “don’t trust doctors with significant investment in pushing conventional meds”.
    Doctor: “I’m an expert in Fosamax; I give talks on it”.
    Me: “I follow the dosing requirements but wake up with reflux”.
    Doctor: “That’s a function of ageing, not the drug”.

    In my experience, too many doctors are no better than the snake oil guys.

  50. #50 PalMD
    December 10, 2009

    The three most dangerous words in medicine:

    “In my experience…”

  51. #51 Calli Arcale
    December 10, 2009

    Yes, that is a big problem. Pharmaceutical companies have very talented marketing departments; they know how to manipulate doctors. (And with recent relaxing of rules on advertising, they are manipulating patients directly as well, which is even more effective.) A growing number of hospitals and clinics are banning pharmaceutical “schwag” from their facilities. No more Post-it Notes in the shape of a Nexium capsule. No more Viagra ties. No more piles of pens advertising everything. But I think the most insidious influence is one the hospitals and clinics will have a hard time fighting — free continuing education hours. Medical boards are well aware that medicine is a constantly changing field. New stuff is being discovered all the time, and like Don alluded to, it’s important for doctors to not just be tied into what they’ve been doing for thirty years. They have to see the latest research. Thus, doctors are required to get a certain number of hours of continuing education every year. These aren’t expected to be as extensive as a full semester-length university course; no doctor would have time for that. Instead, they’re expected to be conferences and lectures and such. Medical schools of course offer a lot of these classes, but being businesses themselves, they have to charge for them.

    This gives a great opening for pharmaceutical companies. They can make wonderful friends with doctors by offering to take care of that bill for them. Just giving a bit back to the system, right? Well, no, because of course they’re paying for lectures and conferences which will highlight their products. It’s actually very similar to the offers us regular folks occasionally get: free dinner if you sit through a talk about how wonderful it is to invest in timeshares, Amway, etc. It’s an old and difficult to regulate form of advertising.

    They’ll even sweeten the deal. In addition to an educational talk that might qualify for continuing education hours, they may include a lavish catered meal, a show, etc. I remember going along with my dad on some of those. GlaxoSmithKline took me and my dad pheasant hunting, gave us a nice steak dinner and a free dose of LYMErix, and then showed a lecture about the lifecycle of the Borrelia parasite.

    In my line of work, I’d be fired if I accepted a gift like that. But it’s commonplace in medicine. It’s mostly prescription drugs and devices that are marketed that way; they’re targeting the main medical decision makers for their products. For OTC stuff and all manner of supplements, they don’t spend a lot of time targeting doctors. Instead, they go directly to you and me. I think the reason Big Pharma is able to do it is because doctors tend to be less wary of scams, probably because they’re very well educated and responsible for life-and-death decisions, so they make the mistake of thinking they must be too smart to fall for that.

    I wonder if the rise of corporate medicine will be what finally drives it out. While individuals aren’t good at spotting systematic attempts to influence people, many corporations employ people who are just as sneaky, and who will recognize these tactics and try to counter them. I have reservations about the idea of corporate medicine, but maybe this is one area where it could do good.

    In my experience, too many doctors are no better than the snake oil guys.

    Many of the snake oil guys *are* doctors, just as many of the supplement manufacturers also make pharmaceuticals. Another problem with the false dichotomy of “medicine/alternative medicine” is that people start thinking everything has to fall in one category or the other. But it’s not so.

  52. #52 Calli Arcale
    December 10, 2009

    Addendum:

    All doctors are not equally susceptible to this sort of marketing. Like any group of people, they vary. But their education clearly does not make them immune, and as seen in many other groups, greater education is often correlated with a greater susceptibility to certain types of persuasion. This is probably because us college educated types think we’re too smart to fall for stuff.

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