Orac note: Congratulations on California and everyone who reads this blog who helped pass SB 277 to protect California's children. Here's hoping Governor Jerry Brown signs the bill! I had a big talk to give this morning that required a massive rewrite of my slide set last night; so there wasn't time for the usual Insolence. Some of you might have seen a different version of this post elsewhere. Some of you might not. Either way, I hope you can enjoy!
Two weeks ago, I attended the Center For Inquiry Reason for Change Conference, where I participated in a panel on—what else?—alternative medicine with—who else?—Harriet Hall and Steve Novella. Before the panel, we all gave brief talks on areas that we consider important. As you might expect, I chose to give a brief introduction to what I like to call "quackademic medicine," defined as the pseudoscientific medicine being practiced and studied in academic medical centers. As I like to do in order to drive the point home about just how bad it's become, I chose a couple of truly egregious examples of just how much quackery has infiltrated medical academia. First, I mentioned how the Cleveland Clinic has embraced reiki, which, as I've described many times before, is in reality faith healing that substitutes Eastern mysticism for Christian beliefs. Although I could have buried the audience in examples, the other example I happened to choose was this:
#Energytherapies offer support in healing for #cancersurvivors #LivingWithCancer http://t.co/AUyX8cLj4w pic.twitter.com/0N30G7VL65
— Mayo Clinic (@MayoClinic) June 7, 2015
Yes, that is exactly what you think it is. It's the official Twitter account of the Mayo Clinic promoting "energy therapies," of which reiki is one of the most popular varieties. Basically, these are "therapies" in which it is claimed that the practitioner can either (1) manipulate the "life energy" fields of the patient (e.g., healing touch) or (2) channel "healing energy" into the patient from a source (e.g., reiki). And here was the Mayo Clinic promoting this magical mystical nonsense, linking to an article on its official website entitled "Energy Therapies Offer Support in Healing for Cancer Survivors":
Reiki assists in balancing your physical, mental, emotional and spiritual well-being. The practitioner works with your body's energy field to bring the energy into balance and create a sense of calm and peace.Healing Touch uses the same principles with the goal of balancing the energy in and around your body. With Healing Touch, the practitioner also uses hand movements on or slightly above the body to clear and balance the energy fields around the person.
Not surprisingly, this promotion of mysticism (and, yes, "healing touch" and reiki are nothing but pure mysticism) provoked a reaction. One of these was from our very own Clay Jones:
@MayoClinic You're an embarrassment to our profession.
— Clay Jones (@skepticpedi) June 7, 2015
Grant Ritchey, a dentist who has blogged for Science-Based Medicine from time to time in the past, also chimed in:
.@drflanders @skepticpedi @MayoClinic Why would the esteemed Mayo Clinic stoop to unproven quackery? Marketing? Looking at the bottom line?
— Grant Ritchey Jr. (@SkepticalDDS) June 7, 2015
They weren't alone in protesting, either.
It was at this point that a physician named Michel Accad, MD, a cardiologist in San Francisco who has his own blog and has contributed to KevinMD.com, chimed in. Oddly enough, we just met him before this week when he laid down a fallacy-filled post based on a false premise asking whether "Western" medicine has lost its soul. However, before that on Twitter, he expressed one common complaint about science-based medicine:
@skepticpedi @drflanders @MayoClinic Patient finds benefit; no apparent harm; who am I to judge...?
— Michel Accad MD (@michelaccad) June 8, 2015
This is an attitude that is at the very heart of how many misunderstand what Science-Based Medicine is. It is also a pernicious attitude that leads so many physicians to become and remain what Val Jones once so famously called them, "shruggies." They know that modalities like reiki and the rest of "energy medicine," homeopathy, acupuncture and the vast majority of traditional Chinese medicine, and much of what is being "integrated" into medicine under the rubric of "integrative medicine" range from, at best, being at best scientifically unsupported to, at worst, being pseudoscientific or mystical nonsense, but they do nothing. They do not object. They do not complain. They shrug their shoulders.
If only Dr. Accad had simply expressed no more than a "shruggie" attitude. Instead, he decided to write a post entitled "Is medicine a scientific enterprise?" It's a post full of straw man characterizations of SBM, appeals to "science isn't enough," and attacks on what he calls the "Flexnerian error of scientific medicine." Because Dr. Accad perfectly encapsulates fallacious objections to SBM, I thought his post, which quotes several of those Tweets above as a jumping off point, would itself represent a good jumping off point to correct some of the misconceptions about SBM that are out there.
Is medicine a scientific enterprise?
Let's start out with the title of Dr. Accad's post, "Is medicine a scientific enterprise?" I counter that this in itself is the Burning Man-sized straw man around which all of Dr. Accad's other straw men gather as it burns. No one argues that medicine is purely a scientific enterprise, which is the argument that Dr. Accad is countering. Even we here at SBM do not. None of this stops Dr. Accad from forging bravely ahead into the burning straw:
The outrage, of course, reflects the belief held by some that medical care should be "scientific" and purged of all "nonsense." This idea is particularly popular among enthusiastic champions of a peculiar view of science as the sole and omnipotent purveyor of all real knowledge. Some of those involved in the tiff were undoubtedly of that persuasion.
But apart from holding sway in the minds of Richard Dawkins devotees, the notion that medicine should be a scientific undertaking pervades, to varying degrees, the entire health care community. After all, it is on the basis of this idea that Abraham Flexner boldly constructed the report which gave birth to our health care system a little over a century ago.
It was at this point that I was tempted to respond to Dr. Accad: "You say that as though it were a bad thing," but I resisted the temptation. Oh, wait. No I didn't. I actually did use that line when discussing this at the CFI conference. Never mind. Sarcasm aside (seriously, what does Richard Dawkins have to do with medicine, other than as part of a two-part documentary he did for the BBC back in 2007?), there's more of the straw man. Specifically, the straw man is the implication that supporters of SBM (like us) think that doctors should all be Mr. Spock rather than Dr. McCoy and approach patients with nothing more than pure science and logic. It's a caricature of Richard Dawkins, and it's a caricature of SBM and its advocates, pure and simple—and an exceedingly lazy one at that—using Richard Dawkins as an all-purpose bogeyman for "militant" advocates of science because he has been such a staunch advocate of science and has also spoken out against alternative medicine in the past. Never mind that advocating science-based medicine is certainly not what Dawkins is best known for.
Yes, we of "that persuasion" do argue that the best medical care should be based in science, because the fruits of applying science to medicine—something that really didn't happen in a big way until around 150 years ago—are there for all to see. For example, infectious diseases are prevented by vaccines and cured by antibiotics. Infant mortality has plummeted, largely due to decreases in death due to infectious diseases that in Abraham Lincoln's time it was not uncommon for a mother to bury four or more of her children. Even in 1900, one in seven children did not make it past age one. Life expectancy has increased markedly from that same time, when it was 46 for males and 48 for females. Now the same figures are 76 and 81, while death rates from heart disease and cancer have been falling. Though, of course, it's certainly not just science in medicine but also science in public health that brought clean water and better sanitation into cities that were cesspools of disease in the 19th century. There are many other examples of how the application of science to medicine has benefited humanity enormously.
But what does "based in science" mean? There's the rub, as they say. I will explain in a moment (hint: it doesn't mean what Dr. Accad apparently thinks it means), but first let's look at a bit more of Dr. Accad's complaint:
Now, the idea that medicine should be a scientific enterprise–even to the slightest degree–is an erroneous idea. Medicine itself cannot be viewed as scientific for the simple reason that the aim of science is to acquire knowledge, whereas the aim of medicine is to heal. These are two distinct ends. Furthermore, a scientific enterprise is best carried out with dispassion: observation and experimentation. Healing, on the other hand, is best accomplished through personal involvement: caring.
Can you say "false dichotomy"? Sure, I knew you could.
Unfortunately, Dr. Accad's thoughts on the matter did not become clearer once he was freed of the tight constraints of Twitter, for he is positing a false dichotomy. Again, he seems to be arguing that one can't apply science to medicine without losing the "human touch," to which I respond, quite bluntly: What a load of fetid dingo's kidneys! There is nothing—I repeat nothing—in science-based medicine that excludes caring for patients as a human being or being what so many proponents of "integrative medicine" like to refer to as a "healer." Nothing! Let's just put it this way: You can be an empathetic, caring doctor who uses nothing but science-based medicine, and you can be a tone-deaf, uncaring practitioner who incorporates reiki, homeopathy, and all manner of pseudoscience into his practice. The two (practicing science-based medicine versus the empathy-based and potentially-unscientific medicine that Dr. Accad seems to prefer and being an empathetic, caring physician) are not related other than in that those practicing unscientific medicine tend to have to come across as more empathetic and caring because that's all they have other than placebo medicine!
Besides, in the end, effectiveness is what matters. If forced to choose between an empathetic "healer" who holds my hand as I die of sepsis and a wooden, distant doctor who saves my posterior with just the proper application of antibiotics and drainage of pus, guess which one I'll pick. Sure, it would be nice to have both, and fairly often a patient can have both, but, again, the application of the correct science-based treatment that is effective trumps empathy for most people. Don't get me wrong, empathy and caring are very important, but they offer little in terms of actual physical healing if the medicine being practiced has not been shown by science to be safe and effective. Without science-based medicine, a doctor can only be as effective as doctors of hundreds or thousands of years ago; i.e., not very or possibly even worse than the disease. Such was the state of medicine, as full of empathetic "healers" as it was, for thousands of years before the evil Abraham Flexner made it all scientific a hundred years ago.
Of course, what Flexner actually did went beyond emphasizing science in the curriculum of medical schools. If you read the actual report, you'll note that in its introduction Flexner decries the "overproduction of ill-trained" physicians by a "large number of commercial schools, sustained in many cases by advertising methods through which a mass of unprepared youth is drawn out of industrial occupations into the study of medicine." In the end, Flexner made the following recommendations:
- Reduce the number of medical schools (from 155 to 31) and poorly trained physicians
- Increase the prerequisites to enter medical training
- Train physicians to practice in a scientific manner and engage medical faculty in research
- Give medical schools control of clinical instruction in hospitals
- Strengthen state regulation of medical licensure
Again, one wonders what Dr. Accad thinks is so bad about these recommendations. In fact, even he seems to know what science-based medicine is, at least at some level:
Of course, this is not to say that scientific inquiry cannot inform doctors on the proper course of action. It certainly can, should, and does.
Which is all science-based medicine is, the idea that science must inform doctors on the proper course of action. That's all Steve argued in the very first post on SBM and all we continue to argue: for a single science-based standard for evaluating medical claims. Unfortunately, Dr. Accad goes off the deep end right after:
But scientific inquiry can only be subordinate to medical care. It is because one cares for the patient that one seeks the best material ways to cure or treat the body, and scientific knowledge provides valuable information in that regard.
It was at this point that I as scratching my head with a hearty "WTF is this guy talking about?" What on earth is he referring to about scientific inquiry being subordinate to medical care? After all, when it comes to clinical trials (i.e., scientific inquiry), whether Dr. Accad realizes it or not, scientific inquiry is already subordinate to medical care. Medical ethics demands no less. That's why it's unethical to do a randomized controlled clinical trial of vaccinated versus unvaccinated children. It would do harm to the children in the unvaccinated arm, who would not receive the proper medical treatment to reduce their risk of deadly disease. That's why we're forced to rely on epidemiological studies to study vaccines and that's why the only randomized controlled clinical trials of vaccines these days involve adding a vaccine to the existing schedule versus placebo, so that both experimental groups get at least the standard of care. That's why cancer chemotherapy trials testing a new drug versus only placebo are becoming rarer and rarer; instead such trials are usually standard of care plus new drug versus standard of care plus placebo. Again, both groups get at least the standard of care. That's what the entire concept of clinical equipoise is about, namely that there has to be genuine uncertainty about which treatment is better before a clinical trial (scientific inquiry) is warranted. In that way, scientific inquiry is and will always be subordinate to medical care.
But that's not what Dr. Accad is talking about, as you will see.
Medicine and the nature of science
Dr. Accad's little diatribe against "scientism" in medicine—which, let's face it, is what he's railing against, although he doesn't actually use the word—would be bad enough, given the straw men torched by just the halfway point. In fact, I'm surprised he didn't use the word, given that his description of critics of "complementary and alternative medicine" (CAM) and "integrative medicine" as believing that science is the "omnipotent purveyor of all real knowledge" is as good a definition of scientism when used as a pejorative (as it almost always is) by advocates of pseudoscience as I've ever seen. Unfortunately, Dr. Accad's understanding of science is—shall we say?—not exactly robust:
First, we should recognize that biomedical science is only scientific in a limited way. When, at the dawn of the modern era, science separated itself from philosophy to take on a decidedly empirical cloak, the human observer could no longer properly be the subject of scientific inquiry, except in an indirect manner. And where physics and chemistry have been able to uncover "laws" of nature, biomedical science generally limits itself to making tentative, statistical predictions on human data aggregates—populations.
Causality in physics (notwithstanding its Humean objections) is not the same as causality in biology, and is even less related to causality in human affairs. Medical care is a pursuit of health for the good of the [sic] another human being, an individual person. That person exists in and expresses a contextualized reality: Mrs. Jones is not a 76-year old woman with cancer, except as a shorthand identification. Mrs. Jones is a being of a rational, self-determining nature and, strictly-speaking, incomparable to any other 76-year-old woman with the same cancer. The scientifically "proven" benefit or ineffectiveness of treatment X is never proven in the case of Mrs. Jones.
Biomedical sciences aren't as scientific as physics? At the risk of repeating myself, what a load of fetid dingos' kidneys! Biomedical sciences are based on chemistry, which is based on physics, because all life is chemistry! Just because there is considerably more variability in repeated observations in biology and biomedical sciences than there is in physics does not make biology any less scientific than physics. As for "laws" of nature, scientific laws are generally of the sort that can be reduced to simple equations, such as E=mc2. In contrast, a scientific theory usually seeks to synthesize a body of evidence or observations of a particular phenomenon. It is, as Jacob Silverman put it, a "grander, testable statement about how nature operates" that, although not reducible to a pithy statement or equation, "does represent something fundamental about how nature works."
And guess what? There are theories in biology and medicine that were derived from those very "tentative statistical predictions" on populations. There's the theory of evolution, for example, which infuses all biological science, as well as phenomenon in medicine such as the evolution of bacterial resistance to antibiotics and tumor cell resistance to chemotherapy. There's the germ theory of disease (of course), a major advancement in the late 1800s from which flowed much of the initial success of scientific medicine. Over time other theories emerged, such as the theories governing molecular biology, which lead to theories about the genetic causes of diseases ranging from inborn errors of metabolism to cancer.
Nor does SBM conflict with patient autonomy, as Dr. Accad's example of Mrs. Jones, the 76 year old woman with cancer, implies. Indeed, as I've argued time and time again, SBM is necessary for true patient autonomy. It is because Mrs. Jones is a rational, self-determining human being that she deserves the best information we as physicians have available about her disease, the treatments available, the risks and benefits of these treatments, and the pros and cons of these treatments relative to each other as the basis to make a collaborative decision with her physician on how to treat her disease. Without that information, she can never provide true informed consent, only misinformed consent (as I like to put it). And, yes, Dr. Accad, science really is the best means of answering these questions in medicine. (If a better means exists, Dr. Accad certainly hasn't suggested it—just like every other doctor defending quackery like reiki on the basis of "science isn't enough.") It is true that Mrs. Jones brings her own values and unique situation to the interaction with her physician. For instance, she might have decided that at 76 she values quality of life over remaining quantity of life and therefore doesn't want to suffer harsh side effects or take major risks. Alternatively, she might desperately want to live long enough to see her grandchild marry and be willing to take chances to see that happen, if medicine can make it possible. However, she cannot properly incorporate her life values and experience into the question if someone is telling her that magic will do her good, particularly if that person is wearing a white coat and is speaking with the authority society gives physicians for their knowledge of medicine.
Now, those of you sympathetic to SBM, be sure to put down your drink if you have one and swallow whatever it is you're drinking. I don't want to be responsible for any ruined keyboards. You have been warned.
Dr. Accad argues next:
Secondly, to circumscribe medical care inside the realm of science limits the autonomy of the patient. Perforce, "scientific medicine" in the Flexnerian sense separates the physician from the patient, because the latter becomes an object in (or a subject of) the scientific enterprise, and therefore, at some level, must be deemed incapable of judging the value of the care received: no one asks the falling apple if it would prefer to be considered under the law of universal gravitation or under the general theory of relativity.
The Flexnerian notion of scientific medicine, then, brings to the fore the "information asymmetry" in the doctor-patient relationship and justifies State intervention by way of licensing laws. In turn, licensing laws give credence to and materialize this asymmetry. Patients, as object of scientific medicine, can no longer freely choose their care as the State intervenes to ensure safety and efficacy according to objective, scientific norms.
The claim that "Flexnerian" medicine causes the patient to become an object of the scientific enterprise and incapable of judging the value of the care received is a straw man so massive that, were it to be burned, not only could it be seen from space but the smoke it would produce would single-handedly accelerate global warming by several decades. In fact, it is science that has shown that human perceptions alone are unreliable and that the various effects that are often bundled together as shorthand under the term "placebo" effects do mean that patients will frequently feel better subjectively after an intervention that can't do anything physiological, such as homeopathy. I would argue that it is the job of a physician to do better than that whenever possible, as placebo effects are an incredibly low standard to hold ourselves to.
Patient autonomy ≠ permission for physicians to recommend pseudoscience
The real problem with Dr. Accad's attitude, however, boils down to an issue that he did not really address: What is the obligation of a physician with respect to his or her recommendations to patients? All his misunderstanding of what advocates of science-based medicine actually argue and his apparent lack of understanding how biomedical science actually works are painful for me to read, but what's very noticeable by its absence, other than in that Tweet, is upon what Dr. Accad thinks we should base our recommendations to patients on, if not the results of biomedical science? To be fair, Clay did try to bring up this issue of patient autonomy and the problematic ethics of not providing science-based information to patients and, worse, of offering mystical pseudoscience (like "energy medicine") to patients as though it had scientific validity:
@michelaccad @drflanders @MayoClinic Not about judgement of patient. It's about ethics of lying to patient.
— Clay Jones (@skepticpedi) June 8, 2015
@michelaccad @drflanders @MayoClinic @ScienceBasedMed Patient's don't have true autonomy if they aren't given science-base information.
— Clay Jones (@skepticpedi) June 8, 2015
Unlike Dr. Accad, I do have a big problem with physicians and hospitals, particularly academic medical centers, peddling unadulterated nonsense like reiki to patients because that's not what patients come to us for. They come to us for our best evidence-based recommendations, and, as Clay and I have argued, without that they cannot have true autonomy to give informed consent because, lacking that and in particular if the information they are given is just plain wrong (or, as Clay put it, unadulterated nonsense), they lack the necessary information to make an informed decision. Embracing and recommending pseudoscience represents a profound betrayal of our patients.
Think about it this way. Medicine has historically only been as good as the science behind it. Back when Hippocrates and his followers were revolutionizing Greek medicine, they made a number of advances, not the least of which was overturning the widespread belief that disease was caused by the gods or supernatural forces, thus introducing the concept that disease could be treated once it was understood how it comes about. Unfortunately, Hippocrates and his followers could go no further because they didn't have a testable scientific framework into which they could put their observations. Hippocrates posited humoral theory, in which disease was thought to be the result of imbalances in four "humors." Traditional Chinese medicine had a similar concept. True, they substituted five elements for four humors, but the concept, namely that disease was the result of an "imbalance" of these humors or elements, was very similar.
For many hundreds of years afterward, medicine remained more or less stagnant. Bleeding, cupping, violent purging, endless botanical abstracts, heavy metals, and the like reigned as the preferred treatments, with all sorts of learned treatises written on the benefits and harms, the pros and cons, of each. Advances were few and far between until 1800s, when medicine began to embrace science. Indeed, Lewis Thomas in his book The Youngest Science, dated the beginning of the era of scientific therapeutics to the beginning of the antibiotic era in the 1930s, noting that, until the discovery of chemotherapy for infections, clinicians quite literally had almost nothing to offer the patient other than rest, good nursing care, and draining abscesses there were any. He had a point, although the earlier discovery of insulin could just as easily been used as a starting point.
It is true that there are many problems with science-based medicine, and we have written about quite a few of them right here on this very blog over the last seven and a half years. One of the worst is how the reimbursement model has changed to the point where doctors are disincentivized from spending more time with their patients, which makes it very difficult to actually deliver that human touch, to be the healer that Dr. Accad so pines for. However, to paraphrase Ben Goldacre, just because there are flaws in aircraft design does not mean that flying carpets work, and just because there are problems with science-based medicine does not imply that we should embrace or tolerate physicians recommending unadulterated nonsense like reiki to patients to fix these problems. Dr. Accad claims that "scientific medicine is truly nonsense," but it's clear that he does not know what scientific medicine actually is, which is why he constructs a straw man version of it that is nonsense. Contrary to what people like Dr. Accad and Dr. David Katz argue, it is not necessary to reject science and embrace pseudoscience in order to be a caring, empathetic holistic healer. Physicians can—and should—be such healers using science-based medicine.
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Causality in physics (notwithstanding its Humean objections) is not the same as causality in biology, and is even less related to causality in human affairs.
Causality. You keep using that word, Dr. Accad. I don't think it means what you think it means. It's true that the concept of causality imposes strict constraints on what physics allows, in a way that does not apply to theories of biology or human affairs. However, that is at most a difference of degree, not kind. The basic framework that event B is a direct consequence of prior event A is the same.
Medicine itself cannot be viewed as scientific for the simple reason that the aim of science is to acquire knowledge, whereas the aim of medicine is to heal. These are two distinct ends.
And his evidence that these ends are incompatible is what, exactly? It's common for people to advance multiple goals through a single activity. Just because I get paid to do scientific research doesn't mean that said research isn't interesting in its own right (this is of course one of the many flaws in the "pharma shill" concept). Earning an income and advancing human knowledge are two distinct ends, but both are served by working where I do.
Medicine itself cannot be viewed as scientific for the simple reason that the aim of science is to acquire knowledge, whereas the aim of medicine is to heal. These are two distinct ends.
Good grief. Does this Accad not have any appreciation as to the advancements in medicine thanks to the acquisition of knowledge via the scientific method? I have patients in my practice with hemophilia. Hemophilia used to be an almost 100% fatal condition with death occurring in childhood. What changed that for hemophiliacs in the 1960's and onward? Is sure wasn't reiki or acupuncture or homeopathy or naturopathy or chiropractic. None of that pseudoscientific garbage did a single thing for hemophiliacs. It was a scientifically methodical approach to hemophilia, understanding the genetics and the biochemistry of the the blood clotting cascade. Today hemophiliacs have life spans that are near normal to those without hemophilia.
Accad is an embarrassment. to medicine and science.
Orac's reference with respect to the reimbursement model strangely enough gives some support to the position he is criticizing:
Isn't the question: Why should someone be payed $500 an hour at least to tell fat people they should lose some weight, or smokers they should quit, and so on?
And then there's the question: If all those doctors seeing six patients per hour get payed the same for seeing three patients, what happens to the other three patients?
The US spends twice as much as other developed countries for the same or worse outcomes. It is the practice of medicine that needs to be more scientific.
Woo medicine is just a distorted reflection of conventional medicine.
As sadmar and others mentioned for the "Has western medicine lost its soul", Accad seems to hold libertarian beliefs,
Even has an article on mises.org:
https://mises.org/library/mayo-clinic-and-free-market
In this light, his "what's the harm" view is ... though I don't agree with it ... understandable.
.
"The US spends twice as much as other developed countries for the same or worse outcomes."
You keep saying this, as though it is an across-the-board truth. It is not, and I will point out again that the US has better cancer outcomes (particularly breast and colorectal) than any other country in the OECD. The US leads the world in health care research. The US does very well on perinatal mortality. I could go on, but I suspect it's futile.
Actually, when you adjust for lead time bias, it's not true that the US has better cancer outcomes than Europe; its outcomes are comparable. See:
http://scienceblogs.com/insolence/2012/04/24/more-cancer-care-isnt-alwa…
I sometimes suspect alternative medicine's inclusion in some places is more marketing than anything else: "Your one stop shop for real and imaginary healing."
As a person too familiar with illnesses with few treatments, I get incredibly frustrated when I am offered woo, and even more insulted if it comes from a physician. "Have you tried placebos?" (just insert reiki, acupuncture, healing touch or whatever in the placebo place). It honestly makes me feel like they believe the illness is imaginary when they offer imaginary healing.
Thanks, Orac. That's a great piece.
"Healing, on the other hand, is best accomplished through personal involvement: caring."
Holy Crap! What's so caring about charging patients for pretending to treat them so that they end up not only broke, but dead also?
Besides, in the end, effectiveness is what matters.
Very true.
I had an orthopaedic surgeon that was a jerk to include having a minion try to set my broken ankle with no anesthesia. However, the hardware he later placed in my ankle was set expertly and that is what is important. I only had to live with his jerkdom for a few weeks but the ankle repair I have to live with the rest of my life.
Thanks for this timely post in the wake of the integrative medicine pow-wow that happened on Twitter this past week- which included the NCCIH and Dr. Richard Besser of ABC News.
The NCCIH said "We don't promote the use of approaches that haven't been studied rigorously" , even as they promoted acupuncture for various conditions.
And then there was the assortment of hospitals promoting integrative medicine as treating the "whole person", for example by using acupuncture and reflexology.
There were embarrassing statements from the Cleveland Clinic, NCCIH, University Hospitals in Cleveland, UCSF Osher Center for Integrative Medicine, Pitt Health Sciences, and Brigham and Women's Hospital
I did like that Dr. Besser corrected one of the tweets, but there wasn't a lot of pushback on other unsubstantiated statements.
@Orac: If you ever get tired of being a snotty 70s plastic box, perhaps you'd consider a classic 60s full-bore Vincent Price Witchfinder General? Cos if the Mayonnaise Clinic hasn't earned the right to be tied to a stake and set on fire, I don't know what has.
DGR@4: Another patient-fleecing snakeoil salesman, in other words. Next stake!
DGR: I had Accad pegged as a kind of idiosyncratic Libertarian on a first read, what with his references to economics and all. After “Is medicine a scientific enterprise?” Dr. Accad wrote another post with more of the same titled "How Western medicine lost its soul". And I thought it was, well, bizarre he was connecting the seemingly Libertarian stuff to "soul". But then, on SBM, Dr. G. pointed out Accad's in the Catholic Medical Association, and has published in it's journal. And that rung a bell for me as I know there's a thread of Catholic theology (not necessarily universally shared by catholics, or well known to the typical parishioner) that opposes social regimes seen to remove the individual's freedom of choice — this being a major theme in the novel A Clockwork Orange, (but NOT in Kubrick's film adaptation).
And indeed, when we look at Accad's objection to 'science' in medicine — "limits the autonomy of the patient...separates the physician from the patient... the latter becomes an object... — we see these really aren't about 'science' per se, but about medical authoritativeness in general, in which science now just serves as a tool (or excuse). 'Medicine' has lost it's soul because it has cultivated doctor/patient relationships that remove moral choice from patients. It seems Accad isn't advocating laying off CAM out of a warm, fuzzy, kinder and gentler thing, but rather out of a notion physicians have a moral imperative NOT to act in ways that foreclose patients making their own moral choices — e.g. buying into Reiki or TCM, which are probably sins in and of themselves in terms of putting faith in false idols, or something.
Not that Accad states any of this clearly, and he does seem to have mucked it up into a goulash with incommensurable bits of secular economics and philosophy, yielding quite the WTF. If his little quasi-essays are getting circulated on the Web as defenses of psuedo-science, that's probably due to the fact they're vague enough people can read their own confirmation biases into them. So trying to parse Accad is just "for fun", and for skeptics, the issue would be what we learn from what people think he's saying...
Placebo effect in medicine is what "greasy grace" is in religion. Keeps 'em happy.
@Delphine #5:
You could go on, but I suspect it would be futile for very basic reasons.
The US is certainly capable of providing some of the very best healthcare in the world -- if you can afford it. The rest of us (in the developed world, certainly, but also beyond) try to save as many lives as possible without bankrupting families and still abandoning their loved ones to die.
@Mike #11:
They're quite correct: acupuncture has been studied rigorously. It just has't been shown to have any effect beyond placebo, yet they still offer it. But they didn't say that, so strictly speaking the spokesgit wasn't lying and everyone's happy...
Rich: "spokesgit" is now my favorite new word of the day. ;-)
It seems chelation-for-autism quack Jeff Bradstreet died on the 19th, and alex jones and the other cranks are already spreading strange notions about why and how that happened.
has: "Cos if the Mayonnaise Clinic hasn’t earned the right to be tied to a stake and set on fire, I don’t know what has."
:-(
It is one of the very few places that does the surgery for my son's genetic heart condition. The other is the Cleveland Clinic. It is very specialized because it involves draining the heart, cutting into the aorta, pushing aside the leaves of the aortic valve and scooping out the extra muscle with a special shaped scalpel. It is kind of done blind.
When we were there three years ago the absolutely only "woo" I saw was the relaxation CD sent with the pre-surgery material, and a business side card taped to the wall across from the nurses station.
The treatment there was spectacular from the cardiologist, surgeons, nurses, re-hab folks and even the cleaning staff. Still it is a weird place, and one of the most surreal trips we have ever had. The storm that blackened the skies, dumped lots of rain and lightening was entertaining. Especially when a resident poked his head into the family room and asked me "Did they just announce a tornado alert?" Yes, they did. Oh, and after that storm I noticed all of the chairs in the surgery waiting lounge all of the chairs were lined up to view out of the window that took up the entire wall.
So it is okay to criticize their alternative med offerings, but don't forget they actually do some very good real medicine. I am sure many of those are not too keen on quackery.
Even though they are the largest non-profit in the USA, they will bend over to the will of their biggest donors. Some of these are the wealthy worried well, and there are rooms named after them (including the spectacular storm viewing room at St. Marys). These donors help pay for the social workers and uncompensated care they give, like to the woman who we helped move her things to a room paid for by the Mayo Clinic as she recovered from surgery due to a bacterial infection that took away lots of her shoulder/arm muscle.
By the way, they had internet access terminals for us to use, along with wifi (which we needed to communicate with our insurance company because hubby's car was totaled by an uninsured driver just a few days before we had to be there) ... so you can search this blog for 2012 postings where I put my location at a "medical mecca."
Forgive bad English. Me hate hot weather, me need to finish almost 700 page book on Alan Turing by Monday. Am on page 425, so I need to read more tonight, because I really want to go on a garden tour tomorrow in idiotic non-June Gloom heat.
Well, yeah. Mrs. Jones is an N of 1. As am I, as are you. No scientifically “proven” benefit or ineffectiveness of treatment X is proven for anybody unless they've actually used treatment X. So how does he decide what treatment to suggest for Mrs. Jones or anybody else? A ouija board? Divine relevation?
"Congratulations on California and everyone who reads this blog who helped pass SB 277 to protect California’s children. Here’s hoping Governor Jerry Brown signs the bill! "
ATTENTION CALIFORNIANS!
BIG HOME SCHOOL HAS A BIG TENT! COME JOIN US! (no shedding allowed)
See our new PSA:
https://www.youtube.com/watch?v=VM6uqj0_jQc
Let's see, by that reasoning chemical engineering is not a scientific enterprise, as its aim is to synthesize and purify chemicals, not to acquire knowledge. Nor is architecture. Nor is aeronautical engineering. The list goes on and on.
Now, the idea that medicine should be a scientific enterprise–even to the slightest degree–is an erroneous idea.
Some tell my university; all this time they've been offering degrees in Veterinary Science.
Here's the secret of "energy." Ready?
_Emotions_.
The use of the word "energy" in quack "healing" modalities is the result of the conflation of colloquial language with scientific language, unfettered by any degree of critical thinking or relevant knowledge of psychology.
No doubt most of us are familiar with people who have said something like one of the following, or have said something like this ourselves:
"I have a lot of energy today."
"I really like Alice, she brings good energy to meetings."
"That song gives me great energy."
"Don't go to that part of town at night, there's been a lot of bad energy recently."
"Bob's been feeling lousy lately, he could use some good energy."
"That film left me feeling energized..."
There are two things going on here. One of them is the use of "energy" to mean "emotions" or "feelings." Try substituting those words in the quotes above, for example, "I really like Alice, she brings good feelings to meetings." See how that works?
The other is the use of "energy" to refer to alertness and arousal. Here we see the overlap between "energy" as synonym for emotions, and "energy" as referring to an objective biochemical state of the organism, for example, "I'm going to have another cup of coffee, I need some energy."
This usage refers to the stimulating effects of e.g. caffeine, theobromine (chocolate), and sugar, and in other contexts such as sports and combat, adrenaline. These kinds of substances have measurable biological effects. Sugar is obvious: it is literally the "energy source" for cells, in the most basic physical/chemical way. Anything that dumps sugar into your bloodstream is going to literally "give you energy" via cellular metabolism.
What the quacks do:
They conflate across the spectrum from "energy as feelings" to "energy as biochemistry" to "energy as healing," by assuming that inducing certain emotions in patients will have an objective effect on their health status. In simple terms, they make the error of conflating "feeling better" with "getting better."
It's actually the opposite of "mysticism," which is concerned with abstract ideas about the deity or ground of being. It's "concretization," which in comparative religion terms translates to "fundamentalism" or literalism.
But it gets worse: They also assume that the emotions they intend to convey, have some kind of objective existence that can be conveyed successfully to others. In simple terms, analogous to "if this song makes me feel good, it'll make you feel good too," irrespective of our individual tastes in music.
For example if a patient shares their belief system, then yes there is a reasonable chance that the patient will experience the intended emotions. This is the basis for the wholly conventional and harmless practice of religious people having their clergy visit their bedsides. Intelligent clergy members understand that their role is one of personal support rather than medical intervention, and as long as that's the case, all's well.
(If I found myself in a Catholic hospital for any length of time, I might ask if there are any Jesuit students or priests around who'd like to come in and hang out, because even though I'm not Catholic, I find Jesuits are generally smart people with wide-ranging education and interesting philosophical ideas.)
But very often the patient does not share the quacktitioner's belief system. "Wait a minute: you're going to make gestures in the air with your hands, and I'm supposed to feel something?" In those cases the intended emotions aren't conveyed, end of story.
I wonder about this:
Usually we think of quacks as being in it for the money. But some of them may also be in it for the proselytizing and the personal reinforcement: seeking to convey their _belief-system_ to patients, and seeking their own emotional reinforcement when they succeed. Humans naturally seek to persuade other humans to believe as they believe; up to a point it's OK but beyond that point it's obnoxious, and beyond another point (such as when speaking with patients about their health) it's deeply unethical.
On the other hand, the availability of magical healing in hospitals might persuade some patients to obtain actual best-practices care that they might otherwise eschew in favor of home visits by their preferred type of quacks. So what do we do about this?
There must be some data to indicate whether or not integrating quackery does or does not influence which real medical facility patients chose, and whether it does or does not change compliance. --oh, duh. of course there isn't, because patients and institutions don't make these choices based on data.
I read on a message board tonight of a patient in a clinical trial who had to suspend treatment for 1 week because her liver function tests were abnormal. Her naturopathic "not-a-doctor" who is, don't cha know, an "oncology specialist," tells her to try milk thistle.
Either they didn't understand that patients are not supposed to use supplements or vitamins while on a trial, which is unlikely, or they thought, screw the trial.
My guess is that the patient didn't understand, and that the "naturopathic doctor" didn't care, since nd's know more than MD's, don't cha know?
Now I realise where I have been going wrong. Its Reiki before medication with the acutely psychotic person
@sadmar:
Err, Libertarians are not necessarily Objectivists. So him speaking about "soul" is not that much out of character.
As for his ideas coming from Catholicism, I could guess why a reading of RC theology stressing individual choice might be popular in the US, but while "freedom of choice" might be important in some theodicies, OTOH Catholics must not tolerate Evil, at least not too much.
Funny thing is, if he is a politically Conservative (in the US sense) Catholic, he is most likely in favor of repealing Vatican II with extreme prejudice. Which would make for even less toleration...
Postscriptum:
Please note that following the interpretation about choice by sadmar, Accad would also have to be, well, quite literally pro-choice, which AFAIK is not the stance of the CMA:
http://www.priestsforlife.org/media/interviewisajiw.htm
BTW, the interview makes for some interesting casuistry concerning pregnancies threatening the life of the mother:
Chris #19:
Great post. Thanks for the important reminder. I posted some tl:dr about Big Pharma conspiracy theorists not understanding the complexity of large institutions, which always go in a variety of directions at once. So while one tenticle of a pharma might act in a truly evil way promoting a new proprietary psych med, that means NOTHING for the production of the MMR. By the same token, the 'integration' of a bit of quackery may be trivial in terms of what a bit medical organization like The Mayo or Cleveland does overall. I mean, how would we judge a (hypothetical) clinic that provides cutting-edge life-saving treatments on a sliding scale, making them affordable to regular folks, but ruthlessly enforces low wages and union-busting discipline on its custodial staff. The labor practice is hideous and should be condemned, but we don't want to throw out the baby with the bathwater, eh?
______
Gray Squirrel #25:
[standing ovation] To everything you said. And for realizing the last question IS worth addressing, even though a 'good' answer may be elusive.
_______
mho #26:
Institutions may not care how adding some 'integrative' quackery influences patient choice of facility enough to collect data — though I might guess since the bottom line is involved they do, and they're just not going to share their market research (or even admit they do market research). But it seems skeptical critics might want some data on that, and maybe they ought to find a way to collect it themselves.
_______
Trottelreiner #28:
Yes (obviously). I tl:dr'ed on Accad, Burgess, Catholicism, etc. on another blog page, and observed — at least a little — how esoteric if not WTF? this particular theological principle is likely to appear to rank and file parishioners.The Church has a long history of rendering "must not tolerate evil" as acting with the State to legislate against those-things-we-find-evil. And if you dig in to the specific Catholic 'freedom of choice' argument, it isn't totally inconsistent with that — to say Accad is influenced by a thread of theology doesn't mean he's getting it right. Though I'm no expert on Catholicism or theology (hah! understatement there...), I'd guess the argument might go: writing God's wishes into man's law may act as a deterrent to Evil, but rather than preventing choice, it functions primarily as retributive punishment for bad choices. The problem in Clockwork Orange is science (the Ludivico treatment) mucking with Alex's head to the point where he behaves mechanically, rather than from an acceptance of moral principle. If Accad finds anything in medical regulation or the "information asymmetry" of the doctor-patient relationship analogous to that, that's a head-scratcher to me...
As for 'Libertarians', I'll go Honest Abe on 'Objectivism' and say that calling a cult of personality a philosophy doesn't make it one. And since in practice the big 'O' was 'whatever Ann Rand says it is this week', if the 'Libertarians' pick-and-choose from her corpus, her 'thought' is only getting what it deserves.
My point on Accad was basically that his particular intellectual mish-mash is oddball outlier stuff, reflective of nothing in particular, and it's only significant due to what the people passing it around on the Web are seeing in the verbal inkblot.
@sadmar:
Well, RC theology (and philosophy) is quite a big corpus, and you can interpret it in quite some ways. I'm not saying this idea is outside the scope, it's just that the logical conclusion would be Black Masses on the church floor, because people need the freedom of choice, right? ;)
Which actually might be an issue with faith healing, Reiki has a Japanese Buddhist and Chinese folk religion background, and while Catholic priests (AFAIR some Jesuits) played quite some part in popularising Zen in Europe[1], there is also a history of banning Chinese folk religion in converts:
https://en.wikipedia.org/wiki/Chinese_Rites_controversy
TL;DR, I just think it's just as likely to explain Accad's ideas by Libertarianism as with Irenean theodicy. Expecially since the former are also quite diverse and have their lunatic fringes. I already mentioned the Cult of Ayn, then there are the ones calling for legalising child prostitution...
[1] It's been some time since I thought about trying out Zen meditation, so I might be mistaken.
Meh; Mikao Usui was allegedly a "Japanese Buddhist," and he supposedly went around monasteries in preparation for his ultimate reiki-enlightenment or whatever, but he himself didn't really have anything to do with Zen, and neither does Reiki. As a matter of fact, the whole idea flies pretty much in the face of the Zen philosophical position.
I myself have been sadly remiss lately - I was back to it for a while this spring - and keep meaning to get to the Temple, which I think would be good for me, but I have been fairly swamped with work lately. That's going to calm down a lot in a few days, though.
It's worth trying, although you really have to keep at it for quite a while to see any "results," and, tbh, it's pretty boring compared to what people imagine it will be like. I mean, really, it's sitting and staring at a wall. And breathing.
I can scarcely imagine what sorts of ideas people would show up with.
But anyway, I'm delighted that this prompted me to discover that this Buswell joint is available.
@JP:
Sorry for giving the impression Zen and Reiki were intertwined, it was more to show Christians are not necessarily hostile to Asian practices. It's just that I find it somewhat funny when the X-tian Religious Right becomes somewhat too understanding towards certain magickal practices.
Not that they usually care that much about consistency. ;)
Generally speaking, I guess Catholics would be somewhat more open towards Asian cultural technologies than e.g. some evangelicals, where I know of one martial arts practitioner who became accused of using magickal powers when he did some tricks. But it might be interesting to engage sincere Christians with the "you're practising a foreign religion"-argumentation.
BTW, German wiki says Usui was Tendai, but gives no sources. And itÄs been some time since I read about different Japanese Buddhist schools.
There is also an article here:
http://www.cesnur.org/2003/vil2003_menegotto.htm
Mind you, I'm an agnostic, I just try to make my argumentations suit my opponent/partner in discussion/whatever.
Oh, and BTW:
https://en.wikipedia.org/wiki/Reiki#Catholic_Church_concerns
leading to
http://www.usccb.org/about/doctrine/publications/upload/evaluation-guid…
I'm pretty sure that reiki has been denounced in both circles.
@Narad:
Well, yes, but do you really think plain karate is tantamount to dealing with Ruinous Powers[tm]? When the teacher in question, who told me the story, is a quite well grounded fellow SF nerd and IT guy with wife and kids (OK, I know quite a few of these things don't usually go together...).
Even if you buy into the Xtian stick, that might take it too far...
No problem; it's just that I find that most people are walking around with a vague notional blob of "Eastern Mysticism" in their heads, and I am always happy to provide a little differentiation and de-blobify the situation whenever the opportunity arises.
That could be; Tendai is pretty "out there," IIRC. Usui mostly seemed to style himself some sort of independent shaman/healer/magic man/Jesus or something, though, as far as I can tell.
I'll freely admit that I'm not at my sharpest today, but are you referring to the CESNUR item or something? I hadn't looked at that until now, and I'm not seeing how karate enters into things.
I do of course enthusiastically recommend Circle of Iron, of course.
@Narad:
I was trying to characterise the attitudes of two subsets of Christianity towards foreign cultures.
I know one karate teacher whose pupil showed his physical accumen to his Freikirchlich family. Resulting in him not going to the karate lessons again, because they thought it unleashed "supernatural" powers in him. Depending on the mythology of said group, that might mean dealing with demons etc. No comment.
Compared to this, most Religiously Conservative Catholics I know would not object that much to karate, though maybe to some of the violence in movies. And AFAIK some of the first Zen masters in Europe were Jesuits. Reiki though might get you in the comfy chair, if I read the paper by the USCCB right. And justly so.
@JP:
I feel your pain...
Though I also wouldn't argue the different "religions"[1] or cultures are TOTALLY distinct; it's a general problem, OTOH there are marked differences between different, err, "tribes", on the other, members and academics of said "tribes" might overstate the difference for a variety of reasons. I'm only mentioning "identity politics". For an example somewhat closer to home, see the differences between Orthodox and Roman Catholics:
https://en.wikipedia.org/wiki/Eastern_Orthodox_–_Roman_Catholic_theological_differences
Depending on whom you ask, the differences are smaller than between Catholics and e.g. Lutherans or High Church Anglicans, or as big as between their side and e.g. Muslims.
In the Japanese context, AFAIR Buddhism originally had a hard time in China, but later on absorbed some Chinese, err, deities[see 1 again]. Which AFAIK it passed on to Japan.
Coming back to the context of Reiki and Christianity, in official Christian theology all spiritual healing might come from God, but the actual practitioner might act quite different.
Oh, and [1]:
If I'm not mistaken, Chinese beliefs are notoriously hard to categorize, giving rise to nomenclature like "Chinese Universalism" or "Chinese folk religion". And then, ask a Japanese if he's a Buddhist or Shinto... ;)
C'mon, man, do I really have to start pulling out the Steven Heine and so forth?
Please just define your terms.
^ You're not suggesting that Buddhism migrated from Japan to China, are you?
I'm pretty sure that, for instance, ISKCON, the Rajneeshis and Vajrayana Buddhism are all totally different things, despite being nominally "Eastern." "Eastern Mysticism" is a fantastically, yet typically, Eurocentric idea in which "all of that stuff out there that isn't us" is just a big blob.
I'm pretty darn familiar with the distinction and the similarities between the Roman Catholic Church and the Orthodox Churches, and I've never heard either of those positions from anybody in either camp, tbh. The distinctions are in fact real and definable.
I'm afraid your grasp on the history here is vague and mistaken, at least as far as I can tell.
You're mistaken, or just being overly vague.
@Narad:
I was thinking about this:
https://en.wikipedia.org/wiki/Four_Buddhist_Persecutions_in_China
AFAIK, Buddhism was originally seen as a foreign religion in China. Which might seem somewhat ironic today.
As from where it entered China, AFAIK that is somewhat controversial. My bet would be on Central Asia, e.g. the Silk Road and the Kushan empire, though that's just a hunch. At least the chronology would fit somewhat.
As for Japan, Buddhism entered Japan from China, and it seems like the "un-Chinese" Buddhism was something of a vector for Chinese culture there:
https://en.wikipedia.org/wiki/Edo_Neo-Confucianism
As for "deities", sorry, I remembered dimly something about the Jade Emperor, but I was mistaken. Still, there was some influence of Chinese folk religion:
https://en.wikipedia.org/wiki/Ghost_Festival
See: Fox koan.
Aw, geez, still?
@JP:
Yes, but what about Vajrayana and Tantric Hinduism or shamanism? What about ISKCON and other Vaishnavas, or even Tantric Vaishnavas:
https://en.wikipedia.org/wiki/Vaishnava-Sahajiya
And what's with those and Vajrayana, again?
I'm most likely as much against mistaking cultures and traditions through ignorance or as some New Age jam as you, problem is reality might not be that clear-cut.
For the first one (little difference), take this ruling on intercommunion:
https://www.ewtn.com/expert/answers/intercommunion.htm
For the latter, of course that was somewhat extreme and actually quite a fringe view, let's just say Russian Ufo believers are not that different from their Western counterparts when it comes to strange ideas.
Sorry, it's been some time. As mentioned to Narad, I just find it somewhat ironic that Buddhism was branded "un-Chinese" in China for some time. And became a vector for Chinese culture to Japan.
As mentioned, it has been some time, and I might be mistaken, but I just remembered that using Western notions of mutually exclusive organized religions doesn't work that well in East Asia. E.g. Japanese following both Shinto and Buddhist rites.
Please note that I'm totally with you against the eurocentric/New Age notion of one "Eastern spirituality". It's just that I think we shouldn't go to the other extreme and think said groups as totally different. Actually, it's the old "Lumpers-splitters" problem again:
https://en.wikipedia.org/wiki/Lumpers_and_splitters
If one wants to distinguish from syncretism, yes.
Then again, my clocks are all running down, so I'll check out.
The comment was a personal reference to having been "stuck" on that one for a long time, and how people keep randomly bringing it up to me (a couple times completely out of the blue) now that the old man is dead.
^I will note that the Br'er Rabbit story about the tar baby - not exactly a Buddhist story, either - has also been in rotation in a similar manner. I have a couple fond recollections of having it recited to me in sanzen with character voices.
You want to slap me? ;)
Actually, it's the term "syncretism" I have some beef with. Let me explain...
Once upon a time, little Trottelreiner learned about it and the funny religions in the age of colonialism that tried to provide a meeting where never the twain shall meet. And he somewhat absorbed the condescending attitude of the indologists et al. of old.
A lttle bit later, not so small Trottelreiner realized that his own culture was also the product of syncretism. Germanic culture meet Roman one, Christianity what happens when the goyim try to act Jewish etc.
And then, still a little bit later, somewhat medium size Trottelreiner realized those "original" cultures were also products of syncretism. Which left still growing Trottelreiner with a beef with people talking about "pure" cultures...
Sorry, done ranting, back to program.
Obviously there are no "pure" cultures; my point was that there are real and definable distinctions between, say, schools of Buddhism as they exist now, as real and definable as the distinctions between various Protestant sects, between Protestantism and Catholicism and Mormonism, etc. Heck, once people start talking about "Eastern Mysticism" (leaving off the definition of the word "mysticism" for the moment) they might as well be lumping together Spinoza, Martin Luther, the ancient Druids, David Hume, etc.
Zen Buddhism, broadly speaking, just doesn't have much in common with Reiki - it goes against its whole philosophical grain. Supernatural beliefs of any sort are at best tolerate and seen as irrelevant to Buddhist practice within Zen philosophy; Eihei Dōgen, the founder of the Soto school, was even pretty adamant that reincarnation is a non-Buddhist idea grafted onto Buddhism from outside sources, although, of course, there are debates about that.
You could say he was defending the "purity" of Buddhism or something, or you could say that he was simply defining the philosophical stance of his school of Buddhism.
I had brought it up before.
@Trottelreiner:
No, I was referring specifically to "Still, there was some influence of Chinese folk religion."
Like I said, my bags are sinking low. Try here, work out that Toyokawa Inari thing, and call Bön in the morning.
^ In the sense that I thought you thought I was being tedious.
It is not as if either of us ever misinterpret the other, after all.
But, but, but, JP! How can any of us misinterpret each other? Aren't we all just a Hive Mind, and part of the Borg? Or is this "independent thought" thing something you are gifted with as you rise in the ranks? (I remain always in awe of our dear DW's comments).
I am not part of the Borg but am One with The Body.
Joy to you, friend.