May 13 2011

Andrew Weil Attacks EBM

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.

They write:

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.

Conclusion

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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19 responses so far

19 Responses to “Andrew Weil Attacks EBM”

  1. daijiyobuon 13 May 2011 at 9:53 am

    Re: “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”,

    it’s interesting that CAM claims professionalism status — as, essentially, medicine — and yet the very transparency that the professions, particularly medicine, and science requires

    they cannot meet. Though they claim such status.

    Here’s an example via 2 naturopathy schools, [fully-accredited regionally and also through a federal specialty accreditation]:

    NCNM though absurd and irrational [since when does the science-ejected survive scientific scrutiny!] is yet transparent about their ‘philosophy’ [see http://www.ncnm.edu/academic-programs/school-of-naturopathic-medicine/about-naturopathic-medicine.php ];

    yet Bastyr [established after mother-school NCNM by NCNM graduates the next state over] comparatively isn’t [see http://www.bastyr.edu/education/naturopath/about/principles.asp ].

    Re: “CAM proponents fear plausibility even more than the RCT. Guess why”,

    I’ll hazard a guess:

    because once you peel it all back and establish that CAM claims are quite mostly based on magic beans and unicorn tears…

    the conversation suddenly becomes quite awkwardly silent.

    -r.c.

  2. elmer mccurdyon 13 May 2011 at 2:32 pm

    A pox on both your houses.

  3. wlondonon 13 May 2011 at 4:36 pm

    Good to see criticisms of objections to RCTs. My only concern is that the suggestion that RCTs are necessary comes off as implying they are ALWAYS necessary. They’re only necessary when it is reasonable not to dismiss the possibility of confounding factors and biases that would be serious threats to validity. Alternativists correctly point that we don’t need RCTs to establish that parachutes work well for their intended purpose of avoiding injury and death when one jumps out of airplanes under certain circumstances. From there, they like to argue that RCTs aren’t needed for what they like to promote. The problems with their argument are: (1) it doesn’t consider questions of confounding and bias, and (2) parachutes are plausibly life saving in light of scientific knowledge while many favored hypotheses of alternativists are not clearly promising and often are preposterously implausible.

  4. Watcheron 13 May 2011 at 5:00 pm

    There’s a vaccine for that.

  5. nybgruson 13 May 2011 at 5:01 pm

    There is a CAM symposium at my medical school in a week’s time. I hardly ever attend lectures, as I find them very low yield, but I am thinking I may go to this one – to be a concientious heckler. I think I am well prepared enough to handle most false claims, bait-and-switch, and double-talk from Neurologica, SBM, and RI and maybe it is time to put that to the test. I’ll have to remain respectful whilst simulataneously finding and demonstrating error in the lecturers presentation (which shouldn’t be too hard, in his prior lectures he touts acupuncture as a great modality and in a private conversation with me after he said that there must be “something” to reiki, since advanced practitioners get better results than their less practiced counterparts “exactly like an attending gets better results than an intern”).

    Any tidbits of advice for me Dr. Novella?

  6. ccbowerson 13 May 2011 at 7:50 pm

    “Weil confuses not sufficient with not necessary”

    This is right on the money, and a common tactic (or perspective for a less loaded word). Point out a limitation or minor flaw, and you can throw the baby out with the bath water.

    “…no EBM proponent ever argued (to my knowledge) that personal factors should not be taken into consideration.”

    True, but have they argued that plausibility should not be taken into consideration? That seems to be a common thing you complain about with EBM, but I don’t know that EBM proponents said that plausibility doesnt matter.

  7. ccbowerson 13 May 2011 at 7:52 pm

    “CAM proponents are clearly getting better at hiding their true intentions”

    I suspect that this is a heterogeneous group, but I wonder what the true intentions of the big names in this group. Particularly people like Weil, Oz, Mercola, etc. They are obviously all intelligent people… are they deficient in some way, or is it some ideology that overpowers any desire to be objective?

    I remember Dr Dean Edell on his radio show used to mention that if he were feeling up to it he would occasionally confront certain MDs (he didn’t name names but implied that they were among this group) and ask them to explain themselves:

    (Paraphrasing what he asked them) …how can you promote things that have no evidence? You most know this is nonsense…Didn’t you learn about evaluating evidence in medical school… etc etc.

    Apparently mostly they would state that they weren’t harming the patients, and rationalized that if they catered to this group at least they would also be open to the more rational suggestions that really matter in their health. Unfortunately they underestimate the harm they cause by confusing the rational with irrational.

  8. elmer mccurdyon 13 May 2011 at 7:57 pm

    Sorry, that was a stupid comment. Bye.

  9. daedalus2uon 13 May 2011 at 9:31 pm

    nybgrus, I think you should practice saying things with a straight face

    “What is the physiology behind that magic xyz?”

    “How is this magic water different from a placebo?”

    “How can one safely dispose of homeopathic medicines if they get stronger the more they are diluted?”

    “How do we know this magic treatment works if it can’t be tested?”

    I think you should use the term magic a lot, and when they object but can’t explain the physiology ask how they know it isn’t magic? Why is magic the wrong term to use?

  10. ccbowerson 13 May 2011 at 10:31 pm

    In addition to what d2u said, how is tap water not the most powerful homeopathic medicine ever created? Or do all the different dilute chemicals cancel each other out?

  11. ccbowerson 13 May 2011 at 10:38 pm

    I think that second question gives them an out. Perhaps you are better off raising a glass of tap water and declaring it the most powerful homeopathic medication in the world

  12. nybgruson 14 May 2011 at 3:21 am

    The thing is this guy is pretty slick. He angrily pounds the desk and yells that there is evidence goddamnit! for CAM. And he eschews those that don’t have evidence – at least during class. It was only in our private conversation he brought up reiki. He stated to me he thinks homeopathy is BS. He walks that line and promulgates the false dichotomy and pulls a few of the less crazy things under the tent. I need to bust him on his “evidence” – my real question is, how can I do so, in front of a class of 300 people, without making myself look like a foolish student just making waves for the sake of it?

  13. BillyJoe7on 14 May 2011 at 4:59 am

    ccbowers,

    “…how is tap water not the most powerful homeopathic medicine ever created?”

    Because it hasn’t been succussed. ;)

  14. Steven Novellaon 14 May 2011 at 12:31 pm

    cc. Yes they decry plausibility all the time. In my live debate on homeopathy Rustom Roy referred to it as “Novella’s law of plausibility” – suggesting that I invented the notion of plausibility as a trick to argue against CAM.

    This comment recently appeared in the topics thread:

    “Dr. Novella, it’s ironic that you claim to be of “science-based” medicine when you in fact sherk the principles of science, and by your own admittance, by tryting to create your own new scientific paradigm: “plausibility.” “

  15. daedalus2uon 14 May 2011 at 1:49 pm

    I think you don’t ask for “evidence that it works” but instead ask for “evidence that distinguishes it from placebo”.

  16. ccbowerson 14 May 2011 at 2:44 pm

    Steve-

    You didn’t read your own quote carefully. I was referring to EBM proponents, not quacks or CAM proponents.

  17. Steven Novellaon 15 May 2011 at 12:16 pm

    Oh – I was confused because I never said that EBM proponents decry plausibility, only that CAM proponents do.

    EBM proponents play lip-service to plausibility, but in practice do not adequately (if at all) incorporate proper consideration.

  18. ccbowerson 15 May 2011 at 1:18 pm

    Steve-

    I am of the opinion that plausibility enters the equation when a given researcher decides what he or she is interested in exploring. A logical person will gravitate towards the more plausible explanations that they are interested in (and on average this happens). Certainly there are people who are interested in things that are not plausible, but this should be viewed as poor quality research. In practice research dollars has a greater effect than it should ideally, and this is one major way how plausibility gets pushed to the side.

  19. titmouseon 17 May 2011 at 8:13 am

    CAM bitches don’t know about Bayes’ Theorem.

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