Jun 16 2011
A few weeks ago I was interviewed by journalist David Freedman for an article on so-called complementary and alternative medicine (CAM) he was writing for the Atlantic. I get many such requests, and I’m happy to provide the science-based medicine (SBM) perspective – but I always have to worry about how such articles or documentaries will turn out. Journalists (regardless of medium) often have a story in mind and can build the facts around that story. So I wonder – how much of an influence am I having on the story, or am I just providing sound bites that will ultimately serve whatever agenda the journalist has going in?
The article has now come out in the Atlantic, and the title pretty much says it all – “The Triumph of New-Age Medicine.” Ugh.
Freedman does try to be fair – he quotes me at length, as well as Steven Salzberg, who is also skeptical of CAM. But in such an article framing is everything. If you consistently give one side the final word, you can use the words of the other side just to set them up to be knocked down. You give the superficial sense of balance, but the agenda comes through loud and clear. That is essentially what Freedman did with his article. Also – clearly he is now steeped in CAM apologetics, and can rattle off the standard rationalizations they have to offer.
Here is his premise in a nutshell: Mainstream medicine has “lost that loving feeling”, the “touchy feely” side of medicine. Meanwhile, now that we have conquered many life-threatening illnesses, the population is aging, and health care is shifting to more chronic illness. He quotes Elizabeth Blackburn to make this point:
But medicine’s triumph over infectious disease brought to the fore the so-called chronic, complex diseases—heart disease, cancer, diabetes, Alzheimer’s, and other illnesses without a clear causal agent. Now that we live longer, these typically late-developing diseases have become by far our biggest killers. Heart disease, prostate cancer, breast cancer, diabetes, obesity, and other chronic diseases now account for three-quarters of our health-care spending. “We face an entirely different set of big medical challenges today,” says Blackburn. “But we haven’t rethought the way we fight illness.” That is, the medical establishment still waits for us to develop some sign of one of these illnesses, then seeks to treat us with drugs and surgery.
Standard straw man argument against SBM. This is largely a false premise. First, the medical system has had decades to slowly adapt to the slowly changing face of health care – and we have. Of course it has not been fast enough, and there are many flaws in the system (just like every complex human system). But our resources have shifted to managing these chronic illnesses.
And it is completely a false charge to say that mainstream medicine waits for illness to happen (the “preventive medicine” gambit of CAM). Preventive care is a core part of primary care and many other specialties as well. There is tons of research looking into ways to reduce risks of heart attack, stroke, cancer, and other diseases. Further, physical-therapy type interventions, lifestyle changes, as well as legitimate (not pseudoscientific) nutritional interventions are part of mainstream medicine. The “drugs and surgery” claim is patently false.
But now that Freedman has set up his cartoon version of mainstream medicine, he then follows with how wonderful CAM is – because they care about their patients, and spend time with them. This is an utter false dichotomy, of course. But there is a kernel of truth here – in that CAM practitioners do often spend more time with their patients. But Freedman entirely misses the real reason (even though I told him) – it has everything to do with resources and reimbursement.
The system is currently set up to minimize physician time with patients. It is not well reimbursed. There is a saying that applies in many contexts – don’t tell me what you value, show me your budget. What the system pays for is what it values – and face time with a physician is not adequately valued in the system. CAM practitioners, on the other hand, often charge cash and (since they don’t have any real medicine to offer) give their time and attention in exchange. They don’t have insurance companies looking over their shoulders. And, a fact that is often missed, denied, or glossed over – their income is often comparable to that of physicians. The average chiropractor salary in the US is 129k. The median salary for an internist is 160k (but it’s only 80k for a solo practitioner). (Many specialists make more, but we are talking about managing chronic illness – which is the purview of the internist.)
I acknowledge that the current demand requires a system that can provide more time with patients than the current system allows. There are ways to fix this – proposals that have already been made and to some extent incorporated. One mechanism is increased use of physician extenders – APRNs, LPNs, etc. Therefore you get the best of both worlds – the physician’s time (and therefore expense) is used efficiently, while the bulk of the time with the patient spent by a trained practitioners who specializes in patient education, preventive management, nutrition, and lifestyle risk factors. This can be (and increasingly is) all done within a scientific framework. In addition we need to adjust the reimbursement scheme so that this kind of time with patients is sufficiently reimbursed. If you pay for it, it will happen.
The solution absolutely is not discarding all of the principles of science in medicine (even common sense) and wrapping some kind of practitioner attention and maybe some basic common sense lifestyle advice around an elaborate pseudoscientific ritual. But that is exactly what Freedman concludes.
To make this case he makes all of the standard CAM apologetic deceptive and logically flawed arguments. He argues that science cannot test the practitioner effect on patient outcomes. This is wrong – this has been measured in controlled trials (Orac points this out also in his nice take down of the Freedman article). If it has an effect – it can be measured.
What the research shows is that the time and kind attention paid by the CAM practitioners is the entire effect. Patients respond to hope, they respond to attention. The ritual of nonsense that is acupuncture, homeopathy, therapeutic touch, or any similar magic-based system is entirely irrelevant. It adds nothing to the interaction, or to the patient outcome. All the elaborate philosophies of human energy or “like cures like,” all the training about acupuncture points – is all entirely worthless. We now have a large and growing literature of research that clearly leads to this conclusion.
But Freedman and others would endorse all of this demonstrably absurd and false nonsense, which adds nothing to patient care, because of the non-specific effects that come with the practitioner interaction.
This, he argues, is a better solution than just increasing the practitioner interaction of SBM, which has proven real effects also.
Freedman also completely ignores the potential harm of CAM (other than a quote from Salzburg which doesn’t really capture the full phenomenon). What is the harm that comes from instilling patients with magical thinking when it comes to health and illness? What is the harm from indoctrinating patients against SBM? They may think they feel better from their chronic aches and pains, but then when they get a serious illness they are likely to trust the Guru that made them feel better instead of the science-based medicine that actually has a chance of helping. Just browse What’s the Harm? for some examples.
The closer we look at CAM the less impressive it becomes. The core claims have never been plausible and have utterly collapsed under scientific investigation. The magnitude of the much-praised placebo effect is actually not that impressive, and no greater for CAM practitioners. And there is much more harm and risk than is claimed – once you actually start to keep track, rather than just relying on anecdotes and propaganda.
Freedman seems to have been overwhelmed by the finely crafted propaganda of the CAM industry. The “triumph of new-age medicine” is not in patient outcomes, or in filling any perceived gap in science-based medicine. The triumph is in pulling off a massive con. They have managed to put together a very slick package of logical fallacies, misdirections, misconceptions, and outright deception that is very effective. They have an excuse for every failure, and have managed to successfully attack their critics – even science itself.
Sowing confusion is easier than careful explanation, however. And it is remarkably easy to sell people something that they want. The appealing lie will always be hard to counter with harsh reality.
A journalists job, however, is to tell the harsh reality. Freedman failed in this regard. Despite his intentions, in the end his article was just another advertisement for an industry of pseudoscience.
Note: A written debate about the article is being hosted by the Atlantic. You can read Steve Salzberg’s entry, and others, here.
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