If there's been a theme running through this blog, it's been the importance of science and critical thinking. The main focus of this emphasis on skepticism, of course, has been medicine, which makes sense, given that I'm a doctor and a cancer researcher, but I don't limit myself to just medicine. However, as part of my emphasis on science-based medicine (SBM) as being the best methodology to provide the best patient care that we can, besides the random quackery deconstructions,
I've tended to harp on two topics over the years. First, there's the subject of what Dr. R. W. has called "quackademic medicine"; i.e., the infiltration of pseudoscience in the form of divisions or departments of "complementary and alternative medicine" (CAM) or "integrative medicine" (IM), where what used to be correctly considered quackery and pseudoscience is being "integrated" with scientific medicine. Indeed, I once even went to the trouble of compiling what I like to call my Academic Woo Aggregator, namely a list of medical schools that teach, research, and support quackademic medicine. It was last updated over a year ago and desperately needs a new update. Unfortunately, the thought of delving into the research necessary to identify more medical schools to add to that list fills me with a deep sense of depression; so I've been procrastinating. The second area that I've emphasized is how the federal government supports pseudoscience in the form of the National Center for Complementary and Alternative Medicine (NCCAM), the studies of pseudoscience that it funds through our tax dollars, and how powerful interests protect it.
Medical science is being corrupted by the creeping infiltration of pseudoscience into the very foundations of the most respected fortresses of scientific medicine. Harvard. Yale. M.D. Anderson Cancer Center. None of them are immune. What really bothers me, though, is that it's happening with almost no pushback. Rare is the complaint. The AMA is weak and hampered by its history of being more interested in protecting its turf than protecting patients. State medical boards are useless. In some cases, they even license quackery like naturopathy and homeopathy. Criticizing the infiltration of woo into medicine generally garners the same reaction as farting loudly in a room, only not as polite.
And that's exactly why I applaud Dr. Lloyd Oppel and the British Columbia Medical Association. They've done what far more medical associations ought to be doing:
The British Columbia Medical Association is criticizing Vancouver's Langara College for training the public in therapies that are "medically useless" and potentially harmful.Dr. Lloyd Oppel, who monitors alternative health practices for the BCMA, says that he has watched for a decade as Langara's roster of holistic health courses has progressed from recreational classes to career training. The publicly accredited college offers more than 50 classes in things like iridology (divining health from iris reading) and bone breathing, as well as a three-year certificate program qualifying practitioners of integrative energy healing to work on the public.
Speak it, brother!
Now, I know what iridology is. I know what "energy healing" is. But what the hell is bone breathing? Apparently, it's this:
C
enturies ago, the Chinese knew that to have a healthy body one had to have a healthy marrow. By visualising the breath going through the centre of hollow bones they aimed to encourage the body's natural healing powers. For the Christian 'bone-breathing' is a simple, effective way of bringing in the body as one's best ally in prayer.This exercise, based on practice of Tai Chi, the ancient eastern contemplative dance, is gradually becoming familiar in this country through evening classes and residential courses.
The purpose of the dance is to harmonise movement and breathing, to bring the whole being into a state of balanced tension between the vital energies of Yin and Yang, respectively the 'in-breath' of earth and the 'out-breath' of heaven. Various preliminary breathing exercises are used to prepare for the dance itself. The sequences described below are based on awareness of the bone structure of the body.
Ah, yes, the appeal to ancient woo, complete with appeals to "vital energies." There's nothing better. But I digress.
What Dr. Oppel has done is something that is done all too infrequently. He has directly attacked how a college has embraced woo. Worse, as the article describes, it looks as though Langara College has embraced woo for the most cynical of reasons:
Doug Soo, dean of Langara's Continuing Studies, says he is used to hearing his holistic-health offerings criticized by the science and medical communities. He began developing the non-credit courses in 1997 because alternative health practitioners came to him requesting it. Most complementary therapies are taught through privately owned colleges, and Mr. Soo saw a way to give Langara a unique market niche.
He says that all courses are approved by Langara's board of governors and its education council, a committee comprised of faculty, staff and students who review the curriculum. Continuing education courses are run for-profit, unlike academic and career courses in the regular program, which are publicly subsidized.
Now if major medical societies in the U.S. and the rest of the world would get on the ball and behave similarly. They don't, at least not for the most part. At least they don't do it nearly often enough or vociferously enough. Even the WHO's recent condemnation of the One Quackery to Rule Them All, Homeopathy, in retrospect to me came across as lukewarm. It required the goading of The Voice of Young Science and Sense About Science, and even then it took a couple of months and the WHO only condemned the use of homeopathy for "life-threatening conditions."
Maybe we need a new medical organization that is devoted to science-based medicine. Certainly the ones we have don't fit the bill.
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Orac, I've just been reading Goldacre's "Bad Science", and I'm curious. The placebo effect can be powerful and effective. Yet our healthcare system effectively strips medical professionals of the ability to wield the placebo effect for their patients. This leaves much of the power of placebos and of developing a therapeutic relationship to the SCAM practitioners who have the time and are less regulated.
The public WANTS placebos - wants faith-based (or "energy-based" or "ancient Chinese-based" or whatever) treatments. The public wants doctors who have 30 minutes to sit and listen and discuss their various issues and complaints. People respond to this, and it is often the alt med guys who have the time and the style and the rap and the ritual to impress the patient. The theater of alternative medicine definitely helps some people heal themselves, or at least helps them believe they feel better.
Should science-based healthcare be changed to allow the use of placebo and to encourage better doctor-patient relationships? Can the use of placebo be regulated without ruining its effectiveness?
Who should control the placebo turf, and what is the right way to train doctors or practitioners on its uses?
Yay! Thats my province! That makes me insanely happy to see that happening here. I wonder what makes the situation different here than in other places? Or is it just the one doctor thats making a difference?
I work my school newspaper, I wonder if he'd give me an interview, to find out.
But does it really? The placebo effect was first defined in terms of medical practice. There is every reason to believe that the effects of active therapies ride on top of the placebo effect. Although it is worth noting that there is considerable debate over just how powerful the placebo effect is for most conditions. The strongest evidence is for pain, and even there the effect does not seem to be huge. Much of the apparent response to placebos appears to be due to artifacts like regression to the mean, which cannot be used therapeutically.
If the placebo effect were a drug, I don't think the clinical evidence would be considered adequate to approve it for treatment of much of anything, except maybe pain and perhaps some psychiatric conditions. And we have plenty of active, fairly benign therapies for pain, which reinforce the placebo effect with a direct biological action.
"The Public" also wants heroin, unicorns, rainbows, and free cheese, but what your opinion of what the public "wants" isn't all that relevant.
"The Public" also wants heroin, unicorns, rainbows, and free cheese, but what your opinion of what the public "wants" isn't all that relevant
I think you will find that the public actually want jetpacks, meals in a pill and monkey butlers- but personally I'd settle for free cheese and a new heart every six months or so!
"By visualising the breath going through the centre of hollow bones..."
Visualising? I don't like fancy neologisms taking the place of basic words. Why not simply say "imagining"?
As a medical student I can talk to you about medical training in general and being trained on the use of placebos. You mention two things which can be ferreted apart. The first "The public wants doctors who have 30 minutes to sit and listen and discuss their various issues and complaints. " You probably wouldn't even get a complaint from Orac on. What most people need to realize is that this is medicine. The CAM crowd pretty much runs on the foundation that allopatric doctor's are poopyheads. They are the only health "professionals" who per norm insult the rest of the health care staff. My role model for bedside manner was even a surgeon who was amazing at talking to patients and reassuring them before a procedure while still being honest at straightforward about the possible risks and complications. Our time doesn't get cut short because we are just lazy. We don't get to pick our pay-rate like naturopaths do and have obligations as per medicare and insurance reimbursement to see a certain number of patients per hour. We all want better doctor patient relationships. Hopefully health care reform will help with that.
Secondly, the placebo effect that you seem to be talking about is the anti-thesis of this genuine conversation about health. You don't talk to a diabetic about energy lines. It boils down to sugars and exercise, and if you do a really good job covering what their body really does they knowingly change their own life-style. Informed consent isn't about covering our asses for legal reasons. Physicians are quite literally manipulating someone else's physiology. We do stuff to people. The reason why we have informed consent is to make sure that the patient knows what they are taking, are aware of the risks and benefits, and can compare those risks/benefits with their own values. I don't push placebos because that would involve lying. It would require doing something to their body without them knowing about it. The deception or at-least obfuscation that you are taking about, the theater if you will, is extremely paternalistic and just wrong.
I do agree that people living in this over-stressed and over-stimulated society need to be listened to and feel cared for. How to do this from an ethical, effective and economical standpoint is the trillion dollar question.
As a recovered moonbat who has experienced Reiki, Acupuncture, Aromatherapy, Energy Medicine and other assorted "modalities", I can say one thing, they all felt good. Feeling cared for and listened to was what I needed and so the placebo effect was strong, but then again, I didn't have a freekin' thing wrong with me. I was what they call "the worried well".
It's kind of embarrassing to divulge my woo-addled past here on ScienceBlogs (and at my local Skeptics in the Pub group), but I've found that my experience as a former magical-thinker brings much needed perspective to the conversation having been on both sides of the topic.
Ask you Doctor if Placebo⢠is right for you . . . oh, wait, now you know it's Placeboâ¢. Nevermind.
that would probably work better for my budgies than for me. they've actually got hollow bones, and as much as i like the little guys, i don't really want such.
Well, you know how doctors sometimes recomend bed rest and drinking plenty water....
What the public wants and what it should have are usually two different things. Unfortunately, over the past thirty years or so, nearly every entity in society (US society, at least) has thrown in the towel on consumer goods, the media, entertainment, politics, education, three of the military services, and medicine, and decided that it's just not worth it to maintain standards anymore.
OK, I'll climb off my soapbox now.
But a question not just for Orac but for anyone who can answer it; is "traditional" Chinese medicine still widely practiced in the People's Republic or Taiwan? I have read elsewhere that traditional medicine, in the Chinas, is for those who can't afford the real thing.
Effectively, this is mostly placebo, but at the benign end of medical placebo use. It relieves the patient's anxiety a bit (the doctor isn't worried; it can't be that bad), and gives the condition time to resolve of its own accord, (or for additional symptoms to emerge to allow a real diagnosis). The treatment is probably slightly beneficial, and at worst benign. But there is no deception involved, and it costs the patient nothing, so it does not violate medical ethics.
Of course, these days you generally can't simply ring up your personal doctor if you have a headache or an upset stomach--this kind of therapy is more likely to be dispensed by a nurse practitioner at a walk-in clinic at CVS.
Hence regression to the mean can in fact be used theraputicaly.
The problem is the public consumes advertorial perception managing propaganda like this http://www.commonground.ca/iss/217/cg217_langara.shtml rather than an article on Science Based Medicine. CommonGround is a woo promoting rag that sells all sorts of trinkets and potions... created by true believers for true believers. It can be found taking up counter space in many a diner and coffee shop in Vancouver (the location of Langara). The only way to compete against this stuff, is with a similar format free weekly mag that wittily promotes science over woo, and takes up equal counter space in the public houses...
"By visualising the breath going through the centre of hollow bones..."
- sounds like a sort of primitive flute.
I imagine many have seen this before, but I figure it's worth posting:
http://www.theonion.com/content/node/39081
When I was doing occasional Yoga classes a decade or more ago, this was the kind of thing the more New Age-y teachers often liked to do in the last 5 minutes of a session as a kind of "warm down" / relaxation / breathing exercise routine. I guess if one was being polite one might call it a meditation technique. But I am truly amazed that anyone would teach a whole course of it as a healing modality, complete with a hefty overlay of what we Brits would call "neo-spiritual bollocks".
Next stop: the healing power of astrology. Oh dear, too late - check out course NM 526 here.
Orac, I admire people like you and Steven Novella, and others, for standing up for science-based medicine. Clearly, this is an issue that isn't nearly as prevalent as it should be. But what I don't understand is why none of you (that I'm aware of) are active voices in your respective medical associations?
"The placebo effect can be powerful and effective. Yet our health-care system effectively strips medical professionals of the ability to wield the placebo effect for their patients."
We have to consider what is really meant by placebo. In a trial, the placebo effect is essentially net of all of the effects that go into getting medical care MINUS the actual treatment.
Giving 'treatments' that are actually sham treatments to harness all of the psycho-physiologic effects that accompany treatment requires dishonesty. Once the 'secret' gets out, the placebo effect and the practitioner's credibility would be lost.
I guess this is how SCAM artists (to use a Mark Crislip term, Supplements, Complimentary and Alternative Medicine) are able to get away with it. The dishonesty factor may not be relevant because many SCAM artists actually believe that the effects that they are seeing are more that just placebo effects.
It should be noted that the subjective condition of mild depression responds to SSRIs with an effect that is not above the placebo effect. This effect seems to wane after 6 months as many placebo effects do (presumably because as the novelty of the treatment fades, so does the patient's expectation). It would seem to me that the best placebo based treatments are those that involve high expectations and a bit of a ritualistic practice, such as homeopathy and acupuncture. Once the novelty turns into routine, then the effect fades.
It is possible that the placebo effect is to some extent a conditioned response that does not depend upon the patient's conscious knowledge that a treatment is or is not active. Nevertheless, conditioned responses require reinforcement to maintain --in this case, presumably due to the often beneficial effects of active drugs. Relying on the placebo effect alone for therapeutic efficacy would effectively build up "resistance" -- actually extinction of the conditioned component of the placebo response. The result would be both a diminished response to actual placebos and also a diminished therapeutic effect of active treatments, which would no longer reap the additive benefit of the placebo effect.
Orac:
If you want to update your list of woo-friendly medical schools, some of the work has been done for you. Are your familiar with The Consortium of Academic Health Centers for Integrative Medicine? Their website lists member organizations. They list 44 in the US and Canada.
Check it out at
http://www.ahc.umn.edu/cahcim/about/home.html
@Wholly Father
That's a VERY interesting list. One thing I noticed is that it seems very slated towards the really big names in academic medicine: Harvard, Hopkins, Duke, Penn, UCSF, University of Washington, Columbia, Yale, Michigan, Stanford. They're basically all there.
Anyone care to guess why this is? Can we just assume that these schools are all intensely hungry for grant money and don't care where it comes from. NCCAM dollars still count under your total research funding for the school. The more research dollars you have, the more elite you are of a research institution. At least from a US News persective.
Also, I suppose woo is a pretty easy way to extract a few more dollars from patients as well. Not many insurance issues since it's not generally covered by insurance.
But a question not just for Orac but for anyone who can answer it; is "traditional" Chinese medicine still widely practiced in the People's Republic or Taiwan? I have read elsewhere that traditional medicine, in the Chinas, is for those who can't afford the real thing.
Since I'm in China now, I can answer this question somewhat authoritatively.
In a word, you're correct. In the cities, you can choose either traditional (mostly herbal) treatment or "western" treatment. In rural areas, availability of "western" medicine is more limited, but it's still there. And yes, the western kind is more expensive, but not as costly as it is here (adjusted for median income levels).
I have an American friend who is in a neighboring city's hospital studying traditional Chinese medicine, including identifying suitable wild plants, learning their uses, diagnosing patients, and so on. His woo-detecting powers, I am sad to say, are weak, but he's earnest.
One of my Chinese friends in Beijing broke her ankle. Her doc gave a choice of surgery, to pin the bones together, or to keep the ankle in a hard cast to heal by itself. The surgery would have been about 10,000 RMB (about $1450), which she could afford. She chose to stay with the hard cast and the doc said that was OK, too. The doc would have used a local anesthetic, not acupuncture, BTW.
Another friend here has a tumor in her abdomen of some kind that has to be excised. We don't know if it is benign yet. She will have surgery, western style, in about two weeks to remove it. She's a government worker, and can also afford the procedure.
Many of my students are from the countryside and get a lot of traditional medical advice from their families. (A piece of sausage in your tea to ward off H1N1, for example) China is still a developing country, so it will take long years before knowledge of modern medical procedures penetrates the interior.
fortunately, this doesn't actually have any affect on REAL medicine. While Langara College is duly accredited, and part of Vancouver Community College, the Continuing Studies department is basically community night school. The courses don't actually transfer to university or count towards anything other than being able to say that you've taken a course in airy fairy woo.
that said, I've noticed over the years more and more courses of this sort being offered at Langara, which is disappointing, since the main school is actually a pretty good university transfer and trade school.
There is also the question of the ethics of a public, accredited college taking students' money for courses of dubious value â whether in the main school or in continuing studies. For shame. Write to the college with your displeasure at geninfo@langara.bc.ca.
And a pony.