Dec 29 2008
The following is a response to many comments left on the Skeptic Blog in reply to my previous post on the skeptical battleground of so-called alternative medicine. There are too many comments for me to reply to individually, so I will answer all the main points raised here. Many of the usual points on the pro-CAM side were raised, and even though I have gone over all of them before on NeuroLogica and Science-Based medicine, it is worth reviewing them here.
Doctors are bad
Many of the comments made the basic point that the popularity of CAM is the fault of evil, uncaring, incompetent or dangerous doctors. These comments took one of two forms – using negative claims about doctors and medicine to explain why CAM is popular, and using them to justify CAM. These are similar but distinct claims. The latter claim, that CAM is legitimate because scientific medicine “doesn’t have all the answers” or is uncaring or corrupt, is a non sequitur. The position of CAM critics like myself is that CAM treatments are unscientific, not proven, and often already proven to be unsafe or ineffective. There should be a single science-based standard of care for all medicine – not a double standard where fraud and unscientific claims can flourish. If we are currently not doing an adequate job enforcing the standard of care that is not a justification for abandoning it – it just means we need to figure out how to do a better job.
The claim that people are attracted to CAM because of the failings of scientific medicine seems to be the default assumption on the part of CAM apologists, but there is little evidence to support this claim. In fact what few surveys that have been done show that dissatisfaction with scientific medicine is a minor factor in using CAM. Users site the desire to feel as if they have control over their health care and philosophical reasons for their choice of CAM. Also, 85% of CAM users continue to use scientific medicine and use CAM only to “complement” their health care. They are not choosing CAM instead of mainstream medicine – they just want to explore all their options.
So motivations for CAM use are more complex than the simple-minded propaganda of “doctors are bad.” But there is a kernel of truth to this claim. It is true that the experience of mainstream medicine can often be cold and complex. The current ethical standards of informed consent mean that doctors are obligated to tell patients the unpleasant truth. Tests are often unpleasant to endure also.
Further, managed care has put tremendous pressure on the health care system and as a result office visits are generaly shorter than they have been in the past. The bottom line is this – the system is paying for less medicine (especially for E&M – evaluation and management), so patients are getting less medicine. Many older physicians in the 1990′s simply retired, because they literally could not afford to keep their practice open. For medical practice not based on procedures revenue is down by about 60% over the last 20 years.
Of course, if patients are willing to pay out-of-pocket then they can get as much time as they want with their physicians. This is the model of so-called boutique clinics, or some spciality clinics. It is also the model of most CAM providers, not by coincidence.
My point is that the answer to the challenges of the overwhelming costs and subsequent compromises of modern medicine is not to abandon the scientific standard of care. Again – that is a dangerous non sequitur. In fact, CAM just worsens the problem by diverting funds away from standard medicine.
Also, I acknowledge that CAM practitioners have largely mastered the psychological aspects of a positive therapeutic relationship. Those are the selective pressures they have been under – to tell their clients what they want to hear. They are not constrained by science, by informed consent – in short, by the truth. They are free to give a simple explanation for every client that walks through their door, to claim that they have the answer for everything, and to design their treatments to be pleasant rather than effective. Being disconnected from science and ethics can be very liberating.
There were also some specific claims made that I want to address. Tracy wrote:
The problem with EBM is it takes too long and doesn’t take the human cost of its long delays, or the format of its trials, into account.
The current regulatory setup is incredibly slow and somewhat unethical. Its unethical to give dying people placebos in trials, yet its what has to be done right now.
This is both misleading and a logical fallacy. It is another form of the argument from final consequences – people need treatments, therefore they should get them. But what if no such treatment exists? Does that mean it is ethical to make up a fake treatment?
The statements are also false. The delay of doing clinical trials is definitely taken into account. It is even possible to get experimental treatments on a compassionate basis for terminal illnesses. Researchers and ethicists have actually spent decades being quite thoughtful on all these issues. Also – it is unethical to withold a proven treatment from someone to put them in a trial – so no one gets a placebo instead of a proven treatment. Preliminary open (no placebo) trials are often done before placebo-controlled trials, and if a treatment were dramatically effective it would be fast-tracked. When possible the placebo arm is limited to 1/3 of study patients so that the chance of getting a placebo is minimzed. Also, trials are monitored so that if a treatment is proven adequately to work before the trial is scheduled to conclude it can e stopped early so that that the treatment can be made available right away. In other words – every effort is made to get effective treatments to dying or suffering patients as quickly as possible.
But Tracy’s type of comments are common – people who don’t have any actual experience in medicine or clinical research base their conclusions on assumptions and second-hand information, or perhaps what they see on tv. But they have no relationship to the actual ethical standard in medicine.
Paula made a similar point when she wrote:
When people do not have satisfactory solutions to their ailments from traditional medicine, what would you skeptics propose they do? Just sit around and die?
Of course not. Take any reasonable action. The more desperate one’s situation, the greater the justification for speculative and risky treatments. But this is already incorporated into the ethics and practice of scientific medicine. There is a line, however – do not abandon all science and reason.
There is also a hidden assumption in Paula’s point – that short of a cure there is nothing to do but go home and die. This is almost never the case. When a terminal disease cannot be cured there is often a great deal we can still do to maximize the duration and quality of life. It is far better to focus your efforts on that – get the most out of the time you have left -then to spend your remaining days spending your family’s money searching for a cure that does not exist. I have seen patients spend tens of thousands of dollars on unsafe and unpleasant treatments outside the country, grasping for a sliver of hope that turned out to be a false hope. They typically greatly regret the experience. It is like hitting a drowning man over the head with a sledgehammer.
Some blamed the popularity of CAM on the for-profit nature of “corporate” medicine. This is certainly part of the anti-medicine propaganda. Also, as is commonly the case, there is a kernel of truth. Conflicts of interest are a problem – but they are recognized and are largely being delt with. Contrary to one commenters claims – doctors do not get “kickbacks” from pharmaceutical companies. Kickbacks are illegal. Large gifts from pharmaceutical reps for listening to their sales pitches have mostly already been weeded out. Small gifts are on the wane also – mainly due to internal criticism by doctors who feel it taints our reputation with the appearance of conflict. They probably have a point. But, to be clear, medical decision making is largely driven by the standard of care – not financial conflicts of interest. Actually, the biggest conflict probably comes from managed care, which provided a huge incentive not to treat.
This is a tangential issue – but it is impossible to design an incentive-neutral system. Whoever pays for health care will be motivated to minimize it, and whoever profits will be motivated to maximize it. You can shift the incentives around, but you cannot eliminate them.
And, let’s remember that the whole argument is the fallacy of inconsistency. CAM is largely a for-profit cottage industry. They are just good at attacking their competition.
Doctors kill patients
Several commenters brought up the fact that many patients die from either medical mistakes or adverse drug reactions. David Paterson specifically concludes that patients would have a better outcome going to a witch doctor than a medical doctor.
This argument, however, is based entirely on a fallacy – considering only the risks and not the benefits. Dr. Harriet Hall wrote an excellent recent post on one of the studies David cited, making that same basic point. First, the numbers cited are likely greatly exagerated, but that is a side point I don’t have time to go into today. Even if we take them at face value – the point is that medical decision-making is all about risk vs benefit. In order for any treatment to be considered ethical and part of the standard of care it must demonstrate benefit in excess of risk. Standard of care also includes giving informed consent regarding the calculation of risk vs benefit.
Clinical trials are designed to look at the net effects of a treatment – if the only variable is the use of a specific treatment vs a placebo, what are the final outcomes for the patients?
In fact, my primary criticism of CAM is that they generally have not gone through this analysis. Most CAM modalities (I know I am lumping here, but remember I am against the CAM category – every treatment needs to be considered individually, but I am responding to the CAM proponents) have no proven benefit or have not demonstrated benefit in excess of risk.
It is therefore absurd to criticize scientific medicine in favor of CAM over the issue of risk.
The issue of risk management is medicine is a legitimate and serious issue. But there already exists mechanisms within mainstream medicine to address the problem of mistakes and failures to meet the standard of care. A great deal of progress has already been made, but we do need to do much better still. The answer largely is in putting into place redundant systems that minimize error. This is increasingly necessary as the practice of medicine becomes more complex.
Of course, if all you are doing is waving your hands over a patient there is not much that can go wrong – but there isn’t much that can go right, either.
CAM is preventive
Some of the commenters made the point that CAM focuses more on prevention. This is simply not true. All of the real effective preventive health measures, like diet and exercise, were discovered (and continue to progress) through scientific medicine. Primary care doctors routinely advise patients to quit smoking, lose weight, eat a healthier diet, etc. Blood pressure is often managed by reducing salt, high cholesterol by dietary changes, and diabetes by going on a diabetic diet and exercising regularly. Aspirin is routinely prescribed to prevent heart attacks and strokes. In my own practice I advice withdrawal of dietary triggers (like caffeine) or hydration to manage migraines, change in “sleep hygiene” to manage sleep problems, and stretching, exercise, gentle massage and moist heat to manage back pain. I routinely check certain vitamin levels and prescribe supplements as needed. The list goes on.
It is simply absurd to argue that doctors do not emphasize life-style changes or prevention. These have already been built into the standard of care. Such interventions are also often the low-hanging fruit – that’s where we start because it is easy and low risk. Medical management is used when the lifestyle changes are not enough, and invasive options, like surgery, are a last resort.
More importantly – we question what we do, we conduct research to find out what the best options are, and we change what we do based upon that evidence. CAM practitioners do not change what they do in response to scientific evidence. They certainly have never abandoned a worthless modality.
Can we do better? Of course. That will always be true. But we are doing better. Simply taking a snap shot of the current state of medicine and arguing that any deficiencies warrant abandoning science as the standard of medicine is absurd.
I know I did not get to every point. I could have written a dozen articles this length addressing every side point raised in the comments. But I hit the highlights – the points that are most commonly raised. I don’t expect this entry will end any debate. This is too complex and emotional an issue.
I do want to emphasize my central theme. Most of the comments were distractions from the central issue – the public is best served by medical practices that are safe and effective. The best way to maximize safety and effectiveness of medicine is through a standard of care based upon the best science available. Magic and false hope are no substitute.
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