May 13 2011
The struggle for the very essence of modern medicine continues. The vast majority of health care professionals carry on, largely oblivious to the fact that a small cadre of upstarts are trying to change the nature of modern medicine – to make it less science-based and more friendly to not just unconventional treatment, but downright unscientific notions.
Andrew Weil is one of the more prominent figures in the complementary and alternative medicine (CAM) movement, although he prefers the term “integrative”. He and co-authors, Scott Shannon and Bonnie Kaplan, wrote a commentary in which they call for changes in the way medical decision-making (MDM) is taught and practiced. It’s a very sly commentary in that- whenever you focus attention on any complex issue, like MDM, there are thoughtful criticisms you can bring to bear. But they use this as an opportunity to do what CAM proponents typically do – build a straw man of modern medicine and then propose a watering down of the much needed scientific standards on which medicine is built.
The value of efficacy lies mainly in its ability to indicate potential for effectiveness accurately. Sadly, in the drive to emphasize the importance of delineating clearly sound measures of clinical effectiveness, modern medicine has come to equate RCTs as the final arbitrators of clinical decision making. As discussed below, RCTs are but one tool to sort out these complex questions. In integrative medicine (IM), particularly, with its emphasis on patient variables and practitioner participation, evaluation of efficacy is not sufficient.
First, the straw man: While EBM does focus on standardized methods for determining efficacy, it is also very careful and explicit to point out that efficacy is just one factor to consider in informing MDM. Practitioners need to incorporate that into individual decisions about the patient, and no EBM proponent ever argued (to my knowledge) that personal factors should not be taken into consideration.
But CAM/integrative proponents like Weil like to pretend that they invented any notion that has to do with patient-centered medicine. This is historical revisionism, deceptive new-speak, and marketing spin all rolled into one.
But more insidious than their deceptive self-promotion is the subtle error in logic made at the end of the key paragraph. Weil et al argue that efficacy is “not sufficient” to determine MDM. This is, of course, true, as any experienced clinical doctor should be able to tell you. But – it is necessary. Weil confuses not sufficient with not necessary – or at least that the factor of efficacy can be watered down by other concerns so that treatments which might shine in other respect can still be used even if they lack proven efficacy by EBM criteria.
That, of course, is the essence of the CAM movement, watering down the science of medicine. This is all done under the guise of patient-centered medicine, but that is a bait-and-switch. The real purpose and effect is to slip unscientific modalities into modern medicine, and their strategy is sadly working – because most of the profession is asleep at the switch, sedated by the comforting words about patient-centered and individualized medicine.
Weil and his co-authors spend much time on safety considerations, but this is largely window-dressing. His comments are largely correct, but are facile – of course we have to consider safety in choosing a treatment, and we do. I think the emphasis on safety, to which he alludes, comes from the claim that many CAM modalities are very safe – precisely because they do nothing (like homeopathy and therapeutic touch). What Weil misses is that risk and efficacy tend to go hand in hand – not always, but there is a relationship because doing nothing is safer (at least in terms of direct harm) and also tends to have less efficacy. While treatments that have a greater ability to affect the body physiologically will also tend to have greater risk. So Weil takes a legitimate issue (safety), then pretends like this is not already an issue well covered in standard medicine, and uses it to promote unscientific modalities on the sly.
He then attacks randomized controlled trials (RCTs) – the nemesis of CAM because CAM modalities usually do not fare well under RCTs. He correctly points out that RCTs are not perfect, specifically they are artificial and cannot always be directly extrapolated to the general population (again – already recognized, nothing new here). He then repeats the fallacy he committed above -suggesting that because RCTs are not perfect, and therefore by themselves not sufficient, they are somehow optional or there are better option. What option? – observational data. Weil in the past has promoted “uncontrolled clinical observations” – a fancy phrase for “anecdotes.”
And so we come to the real purpose of this commentary – to promote the use of uncontrolled clinical data over RCTs. CAM proponents desperately want this because uncontrolled data is highly unreliable and prone to bias (a claim Weil tries to refute with a single reference that does not make his case), and therefore it can more easily be manipulated to seem to give support to treatments that do not work.
The commentary by Weil and his co-authors contains nothing new. In my opinion it is the same debate we have been having for years, just disguised in a very slick way. CAM proponents are clearly getting better at hiding their true intentions, as they continually try to slip their philosophy past the goal-posts of academia.
RCTs are not sufficient, and they are imperfect, but they are the best way to ensure that we are at least dealing with treatments that have an effect and a known safety profile. We then can bring other information to bear to incorporate those treatments which pass the bar of RCTs into clinical practice.
Weil wants to twist this around to reduce the role of RCTs, which stand as a much needed barrier to ineffective or worthless treatments. I would agree with Weil on one thing – we do need to add another consideration to the equation of EBM. But the factor I would add is that of plausibility – looking at all the scientific evidence to determine the prior probability that a treatment is safe and effective. Weil does not mention this factor because CAM proponents fear plausibility even more than the RCT. Guess why.
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