Jun 17 2011

Follow Up on Atlantic Article

The Freedman Atlantic article I wrote about yesterday continues to generate discussion – too much for me to simply respond in the comments of a blog. The issues raised go to the heart of the CAM controversy, and so they are worth exploring in detail.

The author of the article, David Freedman, has written follow up posts in a debate thread on the Atlantic, but I think he mainly restates his premises. He has also left a comment on my blog here, and another at Respectful Insolence. In the comments he takes the gloves off a bit, and gets more to the point – so I would like to respond to those comments.

On Neurologica he writes:

As the author of the Atlantic piece, I’d like to point out a few things. It’s true that the author of an article can score points by framing things a certain way, and no doubt I did that in my piece. But let’s look at how this post is framed. Apparently, according to the post, the point of view in my piece is that of the CAM apologist, while the (true) opposing point of view is that of mainstream medicine, as represented by Steven Novella.

This is not quite fair. This is my personal blog – I have never presented it as anything other than my personal opinions and analysis. That is pretty much accepted for a personal blog (and Freedman admits his lack of familiarity). With regards to what mainstream medicine believes, I have written about this before and will summarize my analysis again to be clear in this discussion. I spend a great deal of time talking to academic and private physicians about this issue, so I think I have some insight. When I was interviewed by Freedman he certainly seemed honest and fair – I just think, despite his efforts, he got a distorted view of the status of CAM.

Most physicians are what we would categorize as “shruggies” when it comes to CAM. They don’t really know what it is, they are not steeped in the data or the discussion, and they largely know what proponents tell them – it’s all about “patient centered” medicine (the “touchy feely” defense). They are not aware of the misinformation being promoted by CAM practitioners, nor the rank pseudoscience.

I have told the story before of my experience at Yale. In a meeting of respected academics whose job it was to craft the curriculum for students, we discussed the idea of the content of a CAM course. The other physicians were all shruggies – they liked the “patient centered” approach and didn’t see the harm. I pushed the issue, however, until we actually cracked open a syllabus and read what was going to be taught by the “integrative” physician who was going to teach that class. The relevant physician read quietly for about ten minutes while the rest of us continued to chat. He then looked up, a bit stunned and even outraged, and said, “This is all nonsense.” He was shocked, and the prior discussion had not prepared him for the level of abject pseudoscience that was about to be taught to our students. Later he confessed to me that he did not believe me about CAM (he thought I was being dogmatic) until he read that syllabus – and then he realized it was far worse than even I had made it seem.

Those are some of the physicians Freedman spoke to – shruggies who have bought the CAM propaganda (that portion of the propaganda crafted to sell CAM to academics). But – when I refer to “mainstream medicine” I am also referring to the standard approach to science and evidence in medicine. What we want is to just apply this standard approach to everything – and not accept the double standard being promoted to carve out exceptions for CAM. From his article it is clear that Freedman has bought into this as well – saying that standard research methods cannot test the nonspecific benefits of the therapeutic interaction (wrong, it has).

Freedman goes on:

In fact, mainstream medicine is becoming increasingly open-minded about the benefits of alternative medicine for some patients, even as it becomes more painfully aware of its own limitations. The many highly credentialed, mainstream physician-scientists I interviewed for the article express fairly typical views. I assure you they weren’t carefully selected to meet any criteria. (Nor did I manipulate or carefully select their quotes, as I also did not do with Steven Novella’s quotes, as he was gracious enough to acknowledge.)

As I said – most “highly credentialed, mainstream physician-scientists” don’t have a clue about CAM. A few of them are proponents, and they have been tireless in promoting CAM and seeking legitimacy. And I acknowledge, they have been successful. But Freedman wrongly interprets their political success as resulting from actual legitimacy, when I think at SBM we have clearly argued that it is a failure of logic and science but a success in marketing only.

Indeed, I went to the trouble of seeking out and interviewing the two people I felt are the most highly credentialed, articulate, passionate opponents of alternative medicine in the country, namely Steven Novella and Steven Salzberg. (I don’t consider David Gorski to be article and thoughtful on the subject, he’s just rabid, and I was sorry to see Dr. Novella compliment his venomous comments.) Those two people were carefully selected to powerfully represent the anti-CAM point of view–I had no idea how the others I interviewed felt about alternative medicine, they just turned out to be very open-minded to it. (As did many others I interviewed, but didn’t have space to include in the article).

Acknowledged. But our criticisms come from the fact that, at the end of the day, you got the bottom line story wrong. It’s understandable – it is a complex situation. I think part of the problem you give evidence of below (which I will get to soon). Yes, you did interview me and Salzberg for the article, and did quote us. But you didn’t, apparently, really take our opinions seriously enough, or explore our position to adequate depth. In fact – you seem to have dismissed them.

So I’d suggest a more honest framing of this post might have positioned me as highlighting the views of much of mainstream medicine, opposed by an increasingly small minority of hard-core, won’t-give-an-inch opponents of all aspects of alternative approaches. The growing interest in the benefits of some aspects of alternative medicine (while we can all agree the physical treatments themselves work only through the placebo effect) isn’t about CAM apologism or journalistic manipulation, it’s about a strong trend within mainstream medicine, and one which is leaving Steven Novella and other intensely anti-CAM voices increasingly marginalized.

And there is the dismissive belief that colored Freedman’s article. I never accused Freedman of journalistic manipulation – rather, he chose a framing based upon his reading of the situation. His reading – in the opinion of this blogger – was dead wrong, and it affected his entire piece.

Let me correct Freedman’s flawed logic above. Most of medicine are not proponents or critics of CAM – they are uninformed shruggies. The proponents are a small minority, and always have been. They may be increasing a bit – but just a bit, but they are not in the majority. As I said above – when CAM is actually exposed to most physicians, they are shocked and their scientific sensibilities are offended. In the UK, for example, David Colquhoun has been very successful in getting CAM programs closed by simply sending the syllabus to the board of directors. They had no idea – and were scandalized by what was being taught at their school.

Defenders of science-based medicine (SBM) are not an “increasingly small minority.” In fact, our numbers are growing. Both sides are recruiting from the “shruggies” – the CAM advocates definitely are off to an early lead – but we are catching them (SBM is largely a reaction to the CAM movement, so yes, we are playing catch up).

When I lecture to neutral physician audiences, the reaction to my pro SBM (anti-CAM) talks are mostly positive, and there is typically 1 or 2 individuals who take the CAM side. Like any survey – it all depends on how you frame the question. If you ask a physician – what do you think about holistic, patient-centered integrative approaches, they are likely to say, “that sounds nice” (especially if they don’t know what that really means). But if you ask them – should we change the standards of evidence in medical research in order to allow for treatments that violate basic laws of physics, or that cannot demonstrate efficacy in double-blind studies – you will probably get a different response.

Like it or not, Freedman took the apologist stance to CAM and SBM. He got it wrong – and he should not be surprised that the promoters of SBM are pushing back.

Freedman also left a comment on Orac’s blog post about the article. In it he concisely lays out his position, so I thought it would be useful to dissect it. He writes:

As the author of the Atlantic article that has Orac and this crowd so hot and bothered, let me share a few observations and thoughts that I suspect will be completely lost on you.

Freedman starts off with a solid ad hominem attack. The term “hot and bothered” implies that our reaction (since he addresses his comment consistently to “this crowd” and not just Orac, I think it’s safe to assume that the authors of SBM are included) is an emotional one. This is meant to dismiss the very substantive criticisms we have leveled at the standard CAM position and Freedman’s article.

He follows up with another not-so-veiled insult – he suspects his observations will be lost on us. So we’re not off to a great start. Freedman later acknowledges he is not used to the rough and tumble world of blog comments – but I don’t think that excuses his approach here.

He continues:

First, it’s interesting that all of you are deeply confident you know so much more than the dozens of highly credentialed, highly regarded physician-researchers I interviewed at several of the world’s most renowned medical centers and academies. (I only quoted a portion of these interviews in my article, due to space limitations. And let me anticipate Orac’s claim that I misquoted or distorted or spun or quoted out of context, as was his claim with my Ioannidis article, by pointing out that such claims reveal a deep ignorance of the fact-checking process that goes on at most well-regarded magazines, and especially at The Atlantic. Every single person quoted had an opportunity to correct the record ahead of time–as did Ioannidis, by the way.)

This is mostly cheap rhetoric. You can imply that anyone who disagrees with you is overconfident in their opinion. This is the “arrogance” gambit. Why not just accept the fact that we have a different opinion – one we have collectively written thousands of articles about to articulate and defend. This is just another ploy to dismiss our position – it’s emotional, closed-minded, and arrogant. Freedman has clearly learned much from the CAM apologists.

He then slides (ironically) into a classic argument from authority. He spoke to highly regarded physicians, so that means his position is correct. But citing the credentials of the people he interviewed is not a shield from the very legitimate criticism we have leveled against Freedman (which he never really addresses) to how he synthesized that information.

These top scientists almost to a person agreed with my four main points: Most mainstream drugs don’t help most patients much with chronic, complex disease;

Great – let’s get to the meat of his position. The first main point shows the power of framing. It assumes as a premise that mainstream medicine is limited to drugs. This is an exaggeration. Mainstream medical science identified the nutritional and lifestyle risk factors of the major chronic illnesses, and continues to explore how they can be prevented and mitigated with a host of modalities – not just drugs.

Further – what does he consider chronic complex disease? Drugs work wonderfully for hypertension. They also work well for diabetes, headaches, seizures, and other common ailments (which also are helped by a host of lifestyle changes). But yes, there are many diseases that we have not cracked yet. Give the research time – research is making steady progress, so there is no reason to give up the scientific approach to medicine just yet. And as we solve more diseases, it’s likely that more will take their place (until we find the cure for everything).

The implication – which he later spells out – is that the need for more effective treatments for chronic illnesses means we need to adopt a new strategy. This is not necessarily the case – the current strategy is still be the best option around, as imperfect as it is. But he is setting up the standard CAM false dichotomy – mainstream medicine is inadequate for problem X, so therefore let’s use CAM. This assumes that CAM has anything to offer, has more benefits than risks, and that there are no other options – all bad assumptions.

alternative treatments don’t work better than placebo;

Finally, we agree on something. The scientific evidence clearly shows that the core CAM modalities are elaborate placebos.  But of course, this too is a setup for what is to come – that placebo medicine is valuable. I have already dealt with this canard at length here and at SBM.

Briefly – placebo effects are mostly illusions and artifacts of data collection, not a real physical effect. Further, they are substantial only for subjective complaints, not hard outcomes. Further, interventions that actually work also include placebo effects – so you don’t need to use fake medicine in order to get them. Justifying fake medicine with placebo effects is also unethical and deceptive, and erodes the professional-patient relationship.

And finally – and probably most significantly – placebo interventions cause tremendous downstream harm by convincing patients that nonsensical treatments have real effects. They are then more likely to rely on ineffective placebos when they have a serious illness, and not just a chronic complaint.

alternative practitioners do a better job on average than mainstream physicians in investing time and effort with patients to get them to adopt healthier lifestyles and have better attitudes about health;

I would love to see some evidence for this – I am not aware of any. This sounds like just the opinion of “respected” CAM advocates, which Freedman acquired through a process of confirmation bias. It is probably true that many CAM practitioners spend more time with patients than mainstream doctors. This does not mean better time, or that the outcomes are better.

Many CAM practitioners advocate a large amount of misinformation – about nutrition, lifestyle, and other interventions. They are mixed with common sense information that most people know anyway, or that any primary care doctor can tell you.

This is the bait and switch of CAM. They sell themselves as health care lifestyle coaches, and then give some basic information (nothing really value added) mixed in with a boat load of demonstrable nonsense. This is all used to justify the nonsense, which is really the core and bulk of their intervention.

I deal every day with patients who have been ministered to by the CAM providers that Freedman finds so impressive. They are filled with misinformation and misconceptions. They waste tremendous time and resources on interventions that are of no value, or may be even harmful. These useless interventions often displace more evidence-based interventions. And these are the patients that are still coming to see a mainstream doctor.

The bottom line is this: who do you want giving you advice about taking care of your health – someone who is steeped in magical thinking, immune to evidence, and contemptuous of rigorous science, or someone who is mainly science-based? Yes there are big problems with the delivery of health care. But we should fix those problems, not throw out the basic principles of science and evidence that have taken us so far. We don’t need to endorse nonsense in order to improve preventive and chronic care.

and these lifestyle and attitude changes can significantly reduce the risk of complex, chronic disease as well as relieve the hard-to-treat pain and discomfort of many different disorders.

The only aspects of CAM modalities that are of any use are the ones that have absolutely nothing to do with the CAM modalities themselves, their underlying claims or philosophies, or the elaborate rituals they contain. The only value comes from basic interventions – such as relaxation, talk therapy or kind attention, and basic lifestyle advice – that is already part of science-based medicine. If we need more of this in medicine, which is a reasonable conclusion, then let’s provide more resources for these modalities. Others have pointed out that managed care has decreased reimbursement for psychological interventions. Maybe that is a large part of the problem, and we need to allocate more resources to dealing with anxiety, depression, and stress – rather than just treating their physical effects.

It is my contention, based upon the evidence and my professional experience, that the net effect of CAM intervention is very negative. For every benefit from relaxation or more exercise, there is a greater negative from taking excessive or untested supplements, wasting money on pointless detox or other regimens, and from anti-scientific attitudes such as anti-vax propaganda (yes, CAM practitioners are much more likely to be anti-vax than science-based practitioners).

All of these points are backed up by mainstream studies, aren’t even all that controversial, and, as I say, are endorsed by physician-researchers whose credentials and reputations are, well, let’s be charitable and say “at least as solid as,” those of Orac. (I happen to agree that the Nobel Prize or any other credential or affiliation doesn’t confer a monopoly on insight or the truth, but on the other hand it’s genuinely shocking and appalling to me to see the combined word of so many highly regarded people dismissed with a wave of the hand.)

I dealt with this misconception above. What the evidence shows us is that CAM modalities largely offer nothing – they don’t work. What is unique to CAM does not work, and what does work is not unique to CAM – CAM adds nothing of value, but takes much away.

Frankly, the unwillingness of Orac and this crowd to consider for a moment the possibility that there may be some aspect of alternative medicine other than any direct physical action from its core treatments that might be helpful to many patients, especially in light of all the evidence and widespread, highly informed opinion that this is so, perfectly embodies everything that science is supposed to oppose: closed-mindedness, deep bias, hostility to disagreement, reckless disregard for reason and evidence that don’t support a favored conclusion, and a total lack of humility with regard to what one knows for sure.

Yikes – the “closed-minded,” “arrogant,” and “authority” gambits all rolled into one. This is nothing but projection. He nicely describes the CAM field – they know their stuff works, and they use science to support what they already know – not to find out IF it works.

Science-based medicine changes our recommendations all the time – as new evidence comes in. News flash – that is what it really means to be open-minded. CAM practitioners are closed-minded because they still believe in homeopathy and acupuncture and therapeutic touch even when the evidence shows that they do not work, and their basic mechanisms have been disproved.

It is Freedman who is being “reckless” with the evidence, and his accusations fail even by taking a casual stroll through the SBM website. We have written many articles carefully examining studies, evidence, logic, and arguments. We are not being dismissive – that is a totally cheap shot. That is the kind of thing someone writes when they cannot account for the pages and pages of carefully reasoned arguments and analysis that we have put forward.

We may be wrong in one or more aspects of our position – just show us the evidence or a better argument. But don’t be shocked if we are not impressed by distortion, logical fallacies, and rhetoric. I don’t think Freedman is making up these distortions – he is getting them ultimately from the CAM proponents. He has just been taken in by them.

What you are defending here isn’t science, folks–it’s what I call “scienceology,” a quasi-religious faith in a set of closely held beliefs that are dressed up in the trappings of science and kept immune to any counter-evidence or -opinion. When a person genuinely operating in the true spirit of science hears a counter-argument or counter-evidence, he or she thinks, “Hmmm, let me consider this carefully to see if I need to rethink or modify my position”; when a scienceologist hears a counter-argument or counter-evidence, he or she thinks, “Hmmm, what’s the best way to viciously trash this so I can continue to believe in what I absolutely know to be true?” Which one applies to you, would you say? — David H. Freedman

More projection – a nice description of the world of CAM. (As an aside, Freedman did not need to invent a new word – the word he is looking for is scientism.)

Conclusion

Freedman has no new argument or evidence to offer. He did not actually address the position of defenders of SBM who took issue with his article. He instead has put forth standard CAM apologetics (yes, that’s my framing).

His core argument is also absurd on its face. The world of CAM is demonstrably full of nonsense. At the end of the day – how is prescribing homeopathic nostrums, or sticking needles in people, or moving your hands above their body doing anything useful? The evidence does not show real benefits for these interventions (placebo or not) – that is a distortion of the research by CAM proponents. But Freedman has bought to the lie. To be fair – he is just a journalist, and that’s what the “experts” told him. He failed to realize that mainstream doctors are mostly not experts in CAM, and they have been largely taken in as well. He did speak to me and Salzburg, but failed to really learn our side of the controversy.

We have endlessly documented the many distortions of the the process of science, use of bad evidence, dismissal of better evidence, reliance on suspect logic, and overall intellectual dishonesty of the CAM industry.

But they have bamboozled Freedman and many like him by falsely taking credit for the nutritional and lifestyle interventions that were discovered by scientific medicine. They then proceed with the standard false dichotomy – there are problems with mainstream medicine, they argue, so accept us as the solution.

But CAM is no solution. They are a cure that is far far worse than the disease.

I will end with an open appeal to Freedman. I get that you are a sincere journalist and that you waded into a complex controversy and did the best you could in good faith. I will grant you every benefit of the doubt. But now is when journalistic integrity really gets tested. What others and I are saying (with varying degrees of politeness) is that you got the bottom line wrong.  I think I have spelled out in this article why that is.

You did not appreciate the depth of the controversy. Nor did you realize that you are dealing with a very sophisticated marketing and propaganda campaign on the part of the CAM industry – one that has even taken in many respected academics.

Let me give you an analogy – that of creationism/intelligent design. They too have a very sophisticated marketing and political campaign. They have been very successful in confusing a large portion of the public. Their arguments are increasingly sophisticated. They are just promoting academic freedom. Opponents to freedom are all closed-minded – they are circling the wagons around a “theory in crisis” that they cannot support with evidence. Critics of evolution are being “expelled” for pointing out that the emperor has no clothes. They just want to teach the strengths and weakness of scientific theories.

Someone entering this debate without much prior knowledge might not immediately see “academic freedom” as a code for teaching religious dogma is science class. The NCSE, a watchdog group on creationism, is steeped in the tactics of the creationists. They can see the coy tactics for what they are.

The CAM movement is analogous to the creationist movement, except they have been more successful in hiding their true beliefs and agenda. That’s the real story, and Freedman missed it.

But now is his opportunity to step back and say – gee, this controversy is more complex than I thought. Maybe I need to rethink my analysis. Or he can dig in his heels and dismiss his critics as closed-minded and arrogant. That strategy has worked for the CAM apologists – but I don’t recommend it.

 

Other responses: In Forbes, and Respectful Insolence.

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59 responses so far

59 Responses to “Follow Up on Atlantic Article”

  1. banyanon 17 Jun 2011 at 9:18 am

    Excellent, detailed article. Like everyone else who follows your work, it amazes me that you have time to produce stuff like this of such quality with everything else you do.

    Freedman often falls for arguments for authority. I wonder if that’s because he’s a journalist and the bread and butter of journalistic investigation is going to experts and asking them questions and then reporting what they say. When experts compete, it’s not clear what a journalist can do except say that there is a debate. When the majority of experts say CAM seems like a pretty good idea but a minority says it’s all nonsense, the minority might seem like dogmatic holdouts, even where they’re the only ones that have actually looked into the question.

    Although Freedman denies it, I also get the impression that the result he reached was the one he found most comfortable given preconceived bias. He already has his own word for “scientism” and all…

  2. daijiyobuon 17 Jun 2011 at 9:21 am

    Re: “what we want is to just apply this standard approach to everything – and not accept the double standard being promoted to carve out exceptions for CAM.”

    Yes.

    No ‘epistemic charity’.

    -r.c.

  3. daijiyobuon 17 Jun 2011 at 9:37 am

    Also, regarding “and these are the patients that are still coming to see a mainstream doctor.”

    I’d like to see a study of sCAM providers and what:

    a) healthcare they personally use when they are REALLY ill;

    b) their life expectancies / morbidities are if they eschew all forms of regular medicine and only use ‘the other stuff’.

    Hulda Clark comes to mind: claims for decades she has the ONE CAUSE identified, and ONE CURE for cancer….

    and dies of cancer. And I think she falls under ‘b’, because she didn’t apparently use ‘the best stuff’ but instead used ‘the other stuff’.

    -r.c.

  4. cervanteson 17 Jun 2011 at 10:04 am

    Let me suggest a more proactive response to this particular category of piffle. It is true that physicians in general are not trained in counseling about behavior change, and are not very effective in helping patients achieve better health related behaviors. It is also true that they don’t necessarily offer a lot of empathy and emotional support to patients. There’s plenty of research on both counts.

    So when CAM proponents bring in this Trojan Horse, it works for them because medicine doesn’t already have the pony. It seems to me that an appropriate focus for proponents of science based medicine ought to be the perfectly real elements of the physician-patient relationship and physician-patient communication which are indeed related to outcomes and are amenable to scientific study. Instead you just dismiss these issues with a “Yeah yeah, we get that.”

    To the extent that your foes have indeed identified a shortcoming in medicine as it is often practiced, you ought to respond by acknowledging the legitimacy of that criticism and undertaking to do something about it, just as you undertake to promote scientifically based diagnostic, pharmaceutical and surgical practice.

  5. Steven Novellaon 17 Jun 2011 at 10:41 am

    Cervantes – That hand is way over played. Most patients are happy with their doctors and just think it’s the other doctors who are not empathic.

    Yes – there are problems with the system. And we do advocate fixing them.

    But keep in mind – CAM is not a reaction to those apparent deficiencies. It is a rebranding of what used to be called health fraud. It is just looking for marketing strategies, and playing off deficiencies in mainstream medicine, real, imagined, and exaggerated, is just part of the ploy.

    CAM would be doing what it is regardless. It is just another producing looking to carve out a niche.

  6. Skepticoon 17 Jun 2011 at 11:03 am

    Freedman’s article was quite a litany of cheap shots and logical fallacies. No actual evidence for CAM, as far as I could see. It’s depressing to see a supposedly serious journalist still making these basic logical errors that we have been deconstructing for many years now.

    Freedman: you were just describing yourself in your article.

  7. mufion 17 Jun 2011 at 11:27 am

    It is just looking for marketing strategies, and playing off deficiencies in mainstream medicine, real, imagined, and exaggerated, is just part of the ploy.

    Based on my experience of friends, relatives, and neighbors who embrace alt-med claims to one degree or another (some of whom have been practitioners), I have never detected even a hint of such cynical thinking. What’s more, most of them embrace mainstream (if not SB) medicine to one degree or another – just not 100%.

    These folks are clearly looking for something more than what they feel they can get out of mainstream medicine, and when I try to point out the logical fallacies in their arguments (however warmly and politely), they usually dig their heels in more deeply.

    So I think cervantes’ “Yeah yeah, we get that.” comment is appropriate. But, to reframe it: There are demonstrable limits to what scientific skeptics can achieve with cold facts and rationality alone.

  8. Steven Novellaon 17 Jun 2011 at 11:59 am

    Mufi – what little research there is on this specific question suggests that people seek CAM because of their world view – their ideological prior beliefs, or because of positive testimonials. Not because they are dissatisfied with mainstream medicine.

    My point is – deficiencies in mainstream medicine are not driving people to CAM, which popped up to fill the void. CAM existed, and has shifted its marketing over the decades to exploit criticisms of mainstream medicine.

    Of course the typical CAM user says that mainstream medicine is not meeting their needs – they are being told they need a holistic approach and SBM doesn’t do that.

    This brings up another question – some people who use CAM are seeking something spiritual from medicine. Is it medicine’s job to meet such spiritual needs?

    But most people simply try it because they were told it might work and they feel they have nothing to lose. Of course – it doesn’t work, and they do have something to lose.

  9. jaranathon 17 Jun 2011 at 12:25 pm

    I hate to say it, but I think you’re probably a bit too charitable with Freedman, Steve. Reading both his comments at Orac’s and here, it seems as if he had a far stronger commitment to CAM than he let on. I’m not sure he really did engage with you in good faith.

    What’s hardest for me to accept is his advocacy of CAM in the context of his own “four main points”. Even if we concede them as fact (and I very much agree with your analysis), I don’t see that leading to his conclusion without an existing bias. I asked him at RI and repeat here:

    Mr. Freedman, please reconcile these two statements:
    “alternative treatments don’t work better than placebo”
    and
    “there may be some aspect of alternative medicine other than any direct physical action from its core treatments that might be helpful to many patients”

    Please also explain how your four main points favor CAM over medicine with enhanced patient interaction.

  10. Todd W.on 17 Jun 2011 at 12:27 pm

    I don’t consider David Gorski to be article (sic) and thoughtful on the subject, he’s just rabid, and I was sorry to see Dr. Novella compliment his venomous comments.

    Way for Mr. Freedman to dismiss Dr. Gorski based solely on his tone. He’s essentially saying, “The way he speaks offends me, therefore he has nothing of value to say on the subject.”

    Mr. Freedman, if you go through life like that, you’ll miss an awful lot of valuable information on a wide range of subjects.

  11. mufion 17 Jun 2011 at 1:01 pm

    what little research there is on this specific question suggests that people seek CAM because of their world view – their ideological prior beliefs, or because of positive testimonials. Not because they are dissatisfied with mainstream medicine.

    Steve, believe me, I share your frustration here, but I don’t see a necessary contradiction between my anecdotes and the research that you recall – particularly given that a “positive testimonial” basis simply implies trust and an open mind – too much trust and open-mindedness, perhaps (or, rather, not enough critical thinking), but not necessarily ideology in the dogmatic sense.

    But even in the dogmatic cases, I have to ask: From whence came the worldview? I would not rule out a personal history of disappointing experiences with qualified healthcare professionals as the answer.

  12. steve12on 17 Jun 2011 at 1:02 pm

    Freedman acknowledges that CAM is simply a placebo effect, but goes about arguing as though it’s more than that. To me, this evinces a lack of effort in thinking logically.

    As is pointed out about, he is using appeal to authority by citing physicians who are ambivalent about or unfamiliar with CAM. Shouldn’t a journalist take the next step and ask the question “How do you know that?” ? Freedman may not be a scientist, but this one should be right in a journalist’s wheelhouse. Simply counting experts on each side is lazy, quite frankly.

    Imagine the different direction this story takes on if he asks that question – a question that only one side can answer.

  13. cervanteson 17 Jun 2011 at 1:05 pm

    Dr. Novella, I think you are inappropriately dismissive of my point. As a matter of fact, I am an NIH-funded investigator who studies physician patient communication and I have more than a dozen peer-reviewed publications on the subject. It is true that most patients say they like their physicians — although that is often after a bit of doctor shopping, they are likely to have encountered some they didn’t like along the way — but that is beside the point. About half of the time, people do not take medications as prescribed. Doctors have almost no success getting people to eat better and increase their physical activity, and more often than not completely miss substance abuse, domestic violence, and other psychosocial problems. Most opportunities to offer empathy or emotional support are just missed, and when patients raise emotional or real world problems, physicians are often avoidant and change the subject.

    These are facts. I recommend you learn about this subject before you airily dismiss what I say.

  14. mufion 17 Jun 2011 at 1:13 pm

    Correction to myself: “I would not rule out a personal history of disappointing experiences with qualified healthcare professionals as at least part of the answer.”

    It’s easy to overgeneralize here, but my experience with alt-med fans is that they tend towards counter-cultural views in more domains than just medicine (e.g. politics).

  15. tmac57on 17 Jun 2011 at 1:20 pm

    Since Freedman seems to acknowledge that CAM=placebo,I wonder if he would be as sanguine if voodoo,blackmagic and witchdoctors were all accepted into the CAM fold. And why wouldn’t they? Those all have been shown to also have a placebo effects too,and if that is the standard,well then…(shrugs shoulders).

  16. Steven Novellaon 17 Jun 2011 at 1:31 pm

    Cervantes – I was not dismissing the points you just articulated. I was dismissing this as a cause of CAM. The history tells a different story.

    I agree that patients doctor shop – but since most patients can find a doctor they like this probably has mostly to do with style. But I agree – there is a Bell Curve. Some docs are not good, most are mediocre on this score, and some are great. As a profession – we can do much better.

    And that is what we should be focusing on.

    But I will also say that while physicians are bad at changing people’s behavior – everyone is. Every strategy, every system, every approach so far taken has a terrible track record of changing behavior. The conclusion to draw from this – which is the conclusion that psychologists have drawn – is that it’s very difficult to change behavior. It is misleading to portray this as a deficiency of the medical system. And I have seen no good evidence that CAM practitioners have cracked this nut.

  17. mufion 17 Jun 2011 at 1:34 pm

    cervantes said: Most opportunities to offer empathy or emotional support are just missed, and when patients raise emotional or real world problems, physicians are often avoidant and change the subject.

    This account jibes with Daniel Goleman’s research in his book Social Intelligence (i.e. the chapter on healthcare).

    Fortunately, Goleman also (as I recall) reports techniques and programs that demonstrate improved outcomes in this regard, and the institutional reforms that Steve alluded to in his last post play an important (albeit not exclusive) part in that effort.

    I don’t mean to criticize the scientific-skeptical movement. It’s good at what it does (viz. take down refuted and/or implausible claims). But I do mean to point to a probable limitation in its reach and effectiveness, given what we know about ourselves.

  18. Steven Novellaon 17 Jun 2011 at 1:34 pm

    mufi – We are both going heavily on anecdote and confirmation bias. I wish there was better evidence. But what there is does not support the standard CAM party line.

    Getting back to the notion of marketing strategy – here is another analogy. Read the comments by Mike12 – he is pushing the academic freedom line without any hint of the history of creationist strategies. If you were not aware of this history you might think I was cynical by saying that this is just the latest ploy – the evolution of a many decades long strategy by the creationists as a movement.

    Of course this will not be reflected in the current attitudes of one person. You have to know the history. Read some of the articles by Wally Sampson at SBM if you want to learn more about the history of CAM promotion.

  19. mufion 17 Jun 2011 at 1:40 pm

    Steve,

    I’ve been following this blog regularly for a couple of years now (and formerly SBM), so I’m not entirely unfamiliar with this topic. I just don’t think that knowing the history of CAM promotion is sufficient to explain its success, relative to mainstream medicine.

  20. Steven Novellaon 17 Jun 2011 at 1:59 pm

    Knowing the history is necessary to understand their strategy – I did not say it entirely explains their success.

    I don’t have the answer to why it has been as successful as it has – although I think it’s success is hugely oversold. It seems like a multifactorial phenomenon – part marketing, part social forces and culture, part riding along with a broader counter cultural phenomenon. It’s too complex a social phenomenon to have one explanation.

    What I can say is that their marketing has been brilliant, frustratingly so. But it is also as transparent as the creationist strategies to one who has been following it.

  21. cervanteson 17 Jun 2011 at 2:04 pm

    Every strategy, every system, every approach so far taken has a terrible track record of changing behavior. The conclusion to draw from this – which is the conclusion that psychologists have drawn – is that it’s very difficult to change behavior. It is misleading to portray this as a deficiency of the medical system.

    This really isn’t true. There is a large body of research on counseling about behavior change and it finds that there are relatively effective approaches. These include Cognitive Behavioral Therapy, which is appropriate in some contexts; and Motivational Interviewing, for others. MI in particular includes a tool kit of skills that physicians can learn and implement effectively.

    Doctors often get frustrated because their patients don’t follow advice or take their meds, and no wonder, it’s a major reason for poor outcomes. We can in fact do better — it is not hopeless, as you seem to wish it to be. It isn’t just a question of either you got it or you don’t — it can be taught. But it is not now a part of medical education nor is it sufficiently recognized as an essential part of the physician’s skill set.

  22. Steven Novellaon 17 Jun 2011 at 2:15 pm

    cervantes – I did not mean to suggest that it’s hopeless. My wife is a counselor, and I have learned through her, as well as my own reading, about such methods. I agree that they help – and I incorporate as many as I have time for in my practice. Often that is all I offer as a tertiary referral doc – more time to educate patients and motivate them to comply.

    But my point is that people are inherently difficult to change their behavior.

    Cognitive behavior therapy can be effective – but it is hardly practical to engage in CBT in an office visit. It is also my understanding that things like motivational interviewing have mostly short term effects (I could be wrong – I need to update myself on this literature).

    I agree that we need to study how to better improve patient behavior and compliance, and this research has started – but has a long way to go. And I also agree that we need to start incorporating this into medical education and practice.

    In fact – we can replace all the useless CAM curricula now mandated with classes on physician-patient interaction, behavior, and compliance.

    And getting back to the core issue – none of this has anything to do with what CAM practitioners do.

  23. mufion 17 Jun 2011 at 2:51 pm

    In fact – we can replace all the useless CAM curricula now mandated with classes on physician-patient interaction, behavior, and compliance.

    Here, here.

    And getting back to the core issue – none of this has anything to do with what CAM practitioners do.

    There, there.

    Of course, it’s essential to know which practitioners provide effective healthcare and which do not. Inasmuch as practitioners who sell “alternative” treatments fall into the latter category (which is, in my estimation, usually), I estimate that I’ve saved myself a lot of time, money, and anguish simply by avoiding their products & services.

    I only wish that the problem of finding (and accessing) effective healthcare ended there.

  24. Danon 17 Jun 2011 at 4:30 pm

    I’d be really interested to know what percentage of internists would agree with Freedman’s first point that “Most mainstream drugs don’t help most patients much with chronic, complex disease.” The point is so vaguely phrased that it is almost useless, but I get the impression that most internists would consider that statement laughably wrong.

    Does he mean that a minority of “mainstream” drugs actually do help most patients a lot with chronic, complex disease, but many drugs aren’t as effective as those few? That would counter his point on the need for CAM. Is he saying that a majority of all the pharmaceuticals available treat acute and not chronic conditions? That may be true, but is trivial. Or is he saying, as I suspect, that scientific medicine is mostly useless to the vast majority of patients with chronic diseases? That last interpretation, the only one that really helps his case, is patently false.

  25. tmac57on 17 Jun 2011 at 6:06 pm

    If you go on patient attitudes alone,without looking at actual results,I’m afraid that you will be misled.
    Take diets/exercise for example.You can find glowing reports for almost any diet and or exercise intervention/programs that you can imagine,because initially,the hype,and novelty of these programs,plus motivation by newly inducted members,would give the impression that “Hey,this program must really be on to something!” But of course sadly,they arc of such things is all too revealing.Ultimately people lose interest and revert back to their bad old ways.
    I would guess some of the same dynamic is at work with CAM practices.What do you want to bet,that people who seek CAM modalities,will jump from one to the other,while all the while getting at first excited about the “the one true fix” then realizing that not much is better,then moving on to the next.

  26. sonicon 17 Jun 2011 at 6:33 pm

    Dr. N-

    Why you sound dogmatic and the other guy sounds pragmatic– (and please note the word ‘sound’- I’m not suggesting it is that way…)

    Freedman’s core finding is that in places like the Mayo clinic, the dean of medicine is finding-
    “The beneficial effects of alternative therapies on Mayo Clinic patients, he says, have been observable in shorter hospital stays, in lower levels of self-administered painkillers, and in reduced tissue inflammation, which is a general indicator that the immune system is better holding its own.”

    If it is true that they are getting those results, then the pragmatist would say- continue.
    Would you agree- that if the guy from the Mayo clinic is correct- that they are actually seeing improved results- they should keep doing what they are doing?
    (The fact I have to ask the question might be enough to point out the problem).

    What you say is that medicine must not change the methods of gathering data.
    You seem overly concerned that some aspect of medicine (the way treatments are tested) might change.
    And change would be awful because Dogma, dogma, dogma.

    But if the current methods of testing are ruling out treatments that actually get good results, then it is the methods of testing that need change. Pragmatic.

    We must not change the way we do things… dogmatic.

    I hope this clarifies my earlier comment.

  27. sonicon 17 Jun 2011 at 6:36 pm

    cervantes-
    Who is doing the best research on what works for changing lifestyle and behavior?
    I read web pages, but prefer books.
    Is there a good one that covers recent research?

  28. Mlemaon 17 Jun 2011 at 6:46 pm

    Sonic,
    I am a friend of Qigong Master Chunyi Lin. He has been involved in some studies at the Mayo Clinic and U of Minn. I think some of this developed a number of years ago when he moved there from China and began to help people. Many of those people were patients at Mayo, and the doctors there started to get interested when the patients with bad conditions were improving while they were seeing Master Lin “on the side”. Here are two studies that i know he was involved in:

    ” Two new research studies, one by researchers from the University of Minnesota and the Mayo Clinic, have found that external qigong can help patients’ chronic pain. The external qigong treatments were provided by Chunyi Lin. A brief synopsis of each study is below.

    The “External Qigong for Chronic Pain” study* by researchers from the University of Minnesota and the Mayo Clinic is published in the American Journal of Chinese Medicine, Vol. 38, No. 4, 695-703. Read the study abstract on the AJCM website.
    © 2010 World Scientific Publishing Company
    Institute for Advanced Research in Asian Science and Medicine
    External Qigong for Chronic Pain,
    Results from a peer-reviewed, randomized, controlled, clinical study
    Ann Vincent, Brent A. Bauer, et al Mayo Clinic, Rochester, Minnesota
    Jamia Hill, University of Minnesota, Minneapolis, Minnesota
    Objective:
    “Chronic pain is highly prevalent in the general population. Adequate clinical management of chronic pain is an ongoing challenge and a purely pharmaceutical approach has proven inadequate. We investigated the efficacy of external qigong [Spring Forest Qigong technique] as an adjunctive treatment for chronic pain.”
    Conclusions:
    “Subjects with chronic pain who received external qigong experienced reduction in pain intensity following each qigong treatment. This is especially impressive given the long duration of pain (>5 years) in the most of the participants,” writes lead author Ann Vincent, MD, MBBS, Mayo Clinic, Rochester, Minnesota.
    *The research findings should not be construed as an endorsement of external qigong or Spring Forest Qigong by the University of Minnesota or the Mayo Clinic. The Mayo Clinic does not make such endorsements. The research findings speak for themselves.

    Utilizing Spring Forest Qigong as a Self-Directed Treatment for Chronic Pain & Emotional Distress*
    Jane F. Coleman, R.N., PhD
    Professor Emerita, Gustavus Adolphus College, St. Peter, MN
    Study Findings:
    There was a significant decrease in the perception of physical pain and emotional distress for the majority of participants during the study timeframe. Also, symptom variables (sleep, concentration, decision-making, appetite, loss of interest) improved in the majority of subjects.
    Conclusion:
    Both the active exercise and meditative aspects of Spring Forest Qigong proved to be effective self-care modalities for persons with perceived chronic physical pain and/or emotional distress. Subjects demonstrated significant improvement both anecdotally and statistically during the study period.
    *Dr. Coleman’s study has been accepted for publication in the Journal of Holistic Nursing.”

  29. Mlemaon 17 Jun 2011 at 6:50 pm

    Here’s another study, from Harvard for a similar practice, Tai Chi:

    Tactile acuity in experienced Tai Chi practitioners: evidence for use dependent plasticity as an effect of sensory-attentional training.
    Exp Brain Res. 2008 Jun;188(2):317-22. Epub 2008 May 30.
    Kerr CE, Shaw JR, Wasserman RH, Chen VW, Kanojia A, Bayer T, Kelley JM.
    Harvard Osher Research Center, Harvard Medical School, Boston, MA 02215, USA. catherine_kerr@hms.harvard.edu
    The scientific discovery of novel training paradigms has yielded better understanding of basic mechanisms underlying cortical plasticity, learning and development. This study is a first step in evaluating Tai Chi (TC), the Chinese slow-motion meditative exercise, as a training paradigm that, while not engaging in direct tactile stimulus training, elicits enhanced tactile acuity in long-term practitioners. The rationale for this study comes from the fact that, unlike previously studied direct-touch tactile training paradigms, TC practitioners focus specific mental attention on the body’s extremities including the fingertips and hands as they perform their slow routine. To determine whether TC is associated with enhanced tactile acuity, experienced adult TC practitioners were recruited and compared to age-gender matched controls. A blinded assessor used a validated method (Van Boven et al. in Neurology 54(12): 2230-2236, 2000) to compare TC practitioners’ and controls’ ability to discriminate between two different orientations (parallel and horizontal) across different grating widths at the fingertip. Study results showed that TC practitioners’ tactile spatial acuity was superior to that of the matched controls (P < 0.04). There was a trend showing TC may have an enhanced effect on older practitioners (P < 0.066), suggesting that TC may slow age related decline in this measure. To the best of our knowledge, this is the first study to evaluate a long-term attentional practice’s effects on a perceptual measure. Longitudinal studies are needed to examine whether TC initiates or is merely correlated with perceptual changes and whether it elicits long-term plasticity in primary sensory cortical maps. Further studies should also assess whether related somatosensory attentional practices (such as Yoga, mindfulness meditation and Qigong) achieve similar effects.

  30. Mlemaon 17 Jun 2011 at 6:51 pm

    (whoops, didn’t mean to publish a link to e-mail above, sorry!)

  31. Mlemaon 17 Jun 2011 at 6:55 pm

    Now, here’s where we get into the “woo”, in a study, in which Harvard was involved, that suggest that it may indeed be important WHO is administering the “woo”!

    Journal Molecular and Cellular Biochemistry
    External Qi of Yan Xin Qigong induces G2/M arrest and apoptosis of androgen-independent prostate cancer cells by inhibiting Akt and NF-κB pathways
    Volume 310, Numbers 1-2 / March, 2008, Pages 227-234
    Xin Yan1, 2, Hua Shen2, Hongjian Jiang3, Chengsheng Zhang4, Dan Hu5, Jun Wang2 and Xinqi Wu3
    (1) Institute of Chongqing Traditional Chinese Medicine, Chongqing, China
    2) New Medical Science Research Institute, New York, NY, USA
    3) Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
    (4) McMaster University, Hamilton, ON, Canada
    5) Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
    Long-term clinical observations and ongoing studies have shown antitumor effects of external Qi of Yan Xin Qigong (YXQG-EQ) that originated from traditional Chinese medicine (TCM). In order to understand the molecular mechanisms underlying the antitumor effects of YXQG-EQ, we investigate the effects of YXQG-EQ on growth and apoptosis in androgen-independent prostate cancer PC3 cells. We found that exposure to YXQG-EQ led to G2/M arrest associated with reduced cyclin B1 expression and apoptosis in PC3 cells. YXQG-EQ treatment inhibited constitutive and epidermal growth factor-induced Akt phosphorylation, basal and TNF-α-induced NF-κB activation, and downregulated anti-apoptotic Bcl-2 and Bcl-xL expression. In contrast, exposure to YXQG-EQ increased phosphorylation of Akt and Erk1/2 in human umbilical vein endothelial cells (HUVEC), and had no cytotoxic effect on either HUVEC or peripheral blood mononuclear cells (PBMC). These results indicate that YXQG-EQ has profound effects on growth and apoptosis of prostate cancer cells by targeting survival pathways including the Akt and NF-κB pathways.

  32. Mlemaon 17 Jun 2011 at 6:58 pm

    Finally (I may have this one up with the last one) – this is the one that seems to attribute effect to the administrator of the “qi” as opposed to the sham and control administrator.

    Clin Rheumatol. 2008 Jul 25. [Epub ahead of print]
    Effects of external qigong therapy on osteoarthritis of the knee : A randomized controlled trial.
    Chen KW, Perlman A, Liao JG, Lam A, Staller J, Sigal LH.
    UMDNJ-Robert Wood Johnson Medical School, Piscataway, NJ, USA, kchen@compmed.umm.edu.
    The objective of our study was to assess the efficacy of external qigong therapy (EQT), a traditional Chinese medicine practice, in reducing pain and improving functionality of patients with knee osteoarthritis (OA). One hundred twelve adults with knee OA were randomized to EQT or sham treatment (control); 106 completed treatment and were analyzed. Two therapists performed EQT individually, five to six sessions in 3 weeks. The sham healer mimicked EQT for the same number of sessions and duration. Patients and examining physician were blinded. Primary outcomes were Western Ontario MacMaster (WOMAC) pain and function; other outcomes included McGill Pain Questionnaire, time to walk 15 m, and range of motion squatting. Results of patients treated by the two healers were analyzed separately. Both treatment groups reported significant reduction in WOMAC scores after intervention. Patients treated by healer 2 reported greater reduction in pain (mean improvement -25.7 +/- 6.6 vs. -13.1 +/- 3.0; p < 0.01) and more improvement in functionality (-28.1 +/- 9.7 vs. -13.2 +/- 3.4; p < 0.01) than those in sham control and reduction in negative mood but not in anxiety or depression. Patients treated by healer 1 experienced improvement similar to control. The results of therapy persisted at 3 months follow-up for all groups. Mixed-effect models confirmed these findings with controlling for possible confounders. EQT might have a role in the treatment of OA, but our data indicate that all EQT healers are not equivalent. The apparent efficacy of EQT appears to be dependent on some quality of the healer. Further study on a larger scale with multiple EQT healers is necessary to determine the role (if any) of EQT in the treatment of OA and to identify differences in EQT techniques.

  33. Mlemaon 17 Jun 2011 at 7:10 pm

    Dr. Gerg Gerber, Chief of Internal Medicine at SW Memorial Hospital in Houston, Texas, also seems to be a proponent of Spring Forest Qigong (the practice developed by Master Chunyi Lin)

    http://www.youtube.com/watch?v=3Ch4mbXdwEA&feature=related

    people will certainly find fault with some of this.

    All I’m trying to say is, not all alternative med or practitioners are the same. No more than all MD’s are the same. It will sort itself out because people go with what works, at least eventually. We need to protect people from harm. But if something doesn’t hurt, and seems to help, why not? I really don’t think people are foregoing med care (if they can afford it and they can find a good doctor)

  34. Mlemaon 17 Jun 2011 at 7:15 pm

    I’m very very sorry for the excessively long comments. I didn’t have a way to link them. I’m still kinda new to this and perhaps that is a real no no. Please let me know.

  35. Steven Novellaon 17 Jun 2011 at 7:30 pm

    Sonic – you are employing a bit of circular logic. The Mayo clinic says their treatments works, so the research methods that say they don’t must be flawed.

    But the very question is – do they work or not?

    There is a large body of research in psychology, neuroscience, in many fields of science, that have taught it is difficult to get at the truth in science, and self-deception is rampant. We have a long history in medicine of false conclusions that only careful research reveals.

    The methods currently used by scientific medicine evolved over decades from hard work and large amounts of experience. They have been hammered out, debated, and tested. They exist for a reason.

    Then – when these tried and true methods show that CAM treatments don’t work, proponents make up childishly lame excuses as to why they don’t, then do demonstrably crappy studies or point to low grade evidence to back their claims.

    The pragmatist would go with what works – not the shell game of CAM. I am not being a purist. I am advocating just listening to the hard won lessons of decades of science. CAM advocates want to casually toss that aside – and they have no good reasons.

    Their claims are intellectually dishonest, and demonstrably fallacious.

    But we have been here before (creationism, HIV denial, anti-vaxers, the list is long) – they make outrageous unscientific and illogical statement. And then when you call them on it, they call you dogmatic and closed-minded. And if you let their exasperating flaunting of logic get you the slightest bit irritated – then they peg you as emotional.

  36. Mlemaon 17 Jun 2011 at 7:58 pm

    Dr. Novella, I feel your frustration. I’m so appreciative of the work you’ve done to try to discredit homeopathy, and other bogus “medicine”

    From the Freedman article:
    “There’s no official list of what alternative medicine actually comprises, but treatments falling under the umbrella typically include acupuncture, homeopathy (the administration of a glass of water supposedly containing the undetectable remnants of various semi-toxic substances), chiropractic, herbal medicine, Reiki (“laying on of hands,” or “energy therapy”), meditation (now often called “mindfulness”), massage, aromatherapy, hypnosis, Ayurveda (a traditional medical practice originating in India), and several other treatments not normally prescribed by mainstream doctors.”

    to me, lumping all of these modalities together as “alternative medicine” is problematic. It makes it seem like they are all cooperating to provide an alternative to MDs. Also, it makes one think that they are all either legitimate or not legitimate. For instance, can you really compare homeopathy to massage? Also, hypnotism can help people, but how effective is aromatherapy? They need to be taken apart. Different treatments are for different problems. As someone above mentioned, tai chi and similar modalities aren’t really “woo” unless you try to ascribe special curative powers to them. I don’t know any teachers of these that say such things. (Although sometimes the students do! Wishful placebo thinking I guess)

  37. lsmon 17 Jun 2011 at 8:11 pm

    “daijiyobu: I’d like to see a study of sCAM providers and what:

    a) healthcare they personally use when they are REALLY ill”

    Just a telling anecdote: my sister married into a family of chiropracters; her chiropractic husband and father-in-law died of kidney cancer, and her mother-in-law died of cancer as well. To the very end, they all ran around the country, and Mexico, to try different woo, determined to be living proof that CAM works. It was a grueling, ugly end for them, and a tragedy for their families. My sister doesn’t make the connection that Joseph Mercola’s promises to prevent cateracts, arthritis, and breast cancer haven’t worked for her. But my real point is:

    I am married to a research virologist, and am a long time observer of the intensity and complexity of scientific research. My question is: to what degree are practicing MDs (non research) trained to recognize good or bad science? It doesn’t seem like they would have nearly the training that a research PhD or MD/PhD does, in order to recognize all the snake oil that is so cleverly presented to them. Are they “shrugging”, or are they ill equipped to make the right decision? Just wondering. . .

  38. Danon 17 Jun 2011 at 8:15 pm

    Mlema,

    I’ll not go into details on all your studies, I’m sure someone else will, but I do want to point out something that Dr. Novella pointed out earlier. Scientific medicine is not opposed to exercise and relaxation practices, just to unscientific claims about what they can treat or the plausibility of the underlying philosophy.

    Most of your studies’ positive results are easily explained by relaxation and exercise benefits, not the underlying eastern mysticism or unscientific “qi.” I’m sure if we did a study where people relaxed by listening to Thelonious Monk’s music it would show some positive benefit, that wouldn’t indicate that there was some innate “energy of jazz” that heals the body, and it wouldn’t be evidence for CAM. The same can be said for martial arts like Tai Chi. I’ve done karate and Brazilian jiu jitsu for several years and have greatly benefited from the exercise, but that isn’t evidence for CAM. Again, exercise, diet, and relaxation are not alternative medicine. The claim that they are is just a marketing ploy.

  39. banyanon 17 Jun 2011 at 8:22 pm

    “It will sort itself out because people go with what works, at least eventually.”

    Yet people continue to buy rabbit’s feet, lottery tickets, and crucifixes.

  40. Mlemaon 17 Jun 2011 at 8:32 pm

    Dan, I agree with you. And as i was saying to Dr. Novella, i think it’s a mistake to lump some of these things in with others of these things. i would be angry, for instance, if we outlawed “alternative medicine” because of homeopathy and that ended up meaning that tai chi couldn’t be promoted as having health benefits.
    I’m no medical expert. i have to rely on doctors and researchers to find out good from bad. I hope they don’t throw the baby out with the bathwater, which could happen if someone keeps putting the baby in the bathtub!

  41. Mlemaon 17 Jun 2011 at 8:36 pm

    Banyan, do you not believe that people go with what works? OK, the rabbit’s feet I’ll grant you. But lottery tickets? Hey, those work for some people :-) . And crucifixes? Do people wear those for something to work? I see them mostly on rappers and motorcycle guys who wear black leather. i think it’s more of a social thing. (although people used to use them against vampires i guess)

  42. tmac57on 17 Jun 2011 at 9:00 pm

    Mlema-People ‘go with’ a lot of crazy things that ‘work’. Power balance bracelets,homeopathy (aka magic water), reiki (aka waving hands).The list is endless,and there is never a shortage of ‘true believers’ in the most improbable of interventions to tell their anecdotes.So, what are we to do? I for one would like to know that if I choose a treatment,especially for something serious, that there is a substantial mountain of research behind it,and a plausible mechanism for it to work.The question is “Does CAM rise to those standards?” I doubt it,at least for most things.Anything involving exercise or relaxation,I might consider,but then,I can do those things for myself,if I choose to.

  43. Danon 17 Jun 2011 at 9:02 pm

    Mlema, I don’t think anyone is saying we should outlaw alternative medicine. The argument is that medicine should be based on science and not superstition or dogma; if tai chi was shown to be orders of magnitude better than other relaxation/exercise techniques, but only when taught with new age terminology, I’m sure doctors wouldn’t have a problem recommending it over other methods (although I think the good results of tai chi, like other relaxation/exercise techniques, can be explained well without any reference to qi or innate energy).

    Even if alternative medicine was banned it wouldn’t effect stuff like yoga, tai chi, or meditation, since those things are just exercise and relaxation techniques that modern medicine doesn’t have a problem with, as long as practitioners aren’t claiming that those things cure cancer, malaria, autism, etc.

  44. CarlFon 17 Jun 2011 at 10:03 pm

    Mr. Freedman, if you’re still reading: I believe the problem here is that your training did not include much history of science. If you were to study this topic you’d learn the one key thing that made modern science possible: people’s judgement can never be trusted without observational techniques that eliminate the possibility of unconscious bias.

    Alt Med works only if you don’t study it closely–which is a scientist’s way of saying it doesn’t work. People may well sincerely believe in their particular thing, whether it’s Qi or liver flukes or coffee enemas, but that is totally irrelevant unless they have real, scientific, non-subjective evidence for the proposition. In the above cases they don’t. QED.

  45. BillyJoe7on 18 Jun 2011 at 2:45 am

    sonic,

    One day, ONE DAY, you are going to take a stand…I JUST KNOW IT…instead of mediating between sense and nonsense.
    Maybe you read so much you don’t have time to make any decisions between what you read.

    What you need is a good bullshit meter.
    (Unfortunately you can’t buy one)

    :)

  46. ChrisHon 18 Jun 2011 at 3:35 am

    I kind of wonder if Mr. Freedman has read Snake Oil Science. It might shed light on his delusions.

    Now I want the vet I visited today to read it! Veterinarians are not immune to the CAM band wagon.

  47. Icariaon 18 Jun 2011 at 8:28 am

    alternative treatments don’t work better than placebo

    Even this phrasing is subtly disingenuous. They are placebos, sure but, read literally, this also implies that such treatments are twice as effective as the evidence indicates (actual placebo effect + ‘as good as placebo’ effect).

    Also, to echo someone else in the comments, I think Steve’s giving this guy more credit than he deserves; he obviously had strong opinions on this subject before he researched and wrote this article, evidenced by his subsequent correspondence.

  48. Steven Novellaon 19 Jun 2011 at 12:24 pm

    mlema – You are stating the SBM position. We do not even like the category of CAM (no matter what you call it). It’s a false dichotomy. Each modality and each claim should be assessed on its own merits.

    It is the CAM proponents who created and who promote the category, in order to pull the bait and switch. They say “CAM” works, and give examples like exercises, diet, relaxation, etc. And then they try to get things like homeopathy to ride in on the coattails. Orac calls this the “Trojan Horse” approach – but in order for it to work, they need to have this artificial category of CAM.

    So we agree – and you should direct your concerns at the CAM proponents.

  49. Mlemaon 19 Jun 2011 at 3:20 pm

    Thanks Dr. Novella.

    You’re right of course. Each of these modalities needs to be investigated individually and let the evidence speak for itself. Placing ourselves on either side as totally opposed to the other will put ordinary people in the position of having to decide what they think is right all on their own. If someone finds help on one side, they may, to their great detriment, forego help from the other. In my humble opinion as someone who has benefited from SBM and what some will call “woo” medicine, I look forward to the day medical care gives the best of everything to all the people. (sounds really idealistic, I know, but a person can dream)
    cheers

  50. Mlemaon 19 Jun 2011 at 3:32 pm

    PS – I despise the term “new age medicine”.

  51. sonicon 19 Jun 2011 at 5:14 pm

    Dr. N-
    I’m sorry- wow… I didn’t think- I am an idiot.
    I tried to make it clear my last comment was about how the article came across. I really didn’t mean for all the other stuff to come up.
    I completely misjudged the situation.
    And because of that misjudgment I fear I have senselessly upset someone that I really didn’t mean to.
    Well there’s a fine howdayado.
    I understand how frustrating it is to be misunderstood.
    Keep communicating.

  52. sonicon 19 Jun 2011 at 5:15 pm

    Mlema-
    Thank-you—
    If you give the title of the paper, those with interest can look them up. I think that is normal when you have so much. :-)

  53. BillyJoe7on 19 Jun 2011 at 5:28 pm

    Mlema,

    “as someone who has benefited from SBM and what some will call “woo” medicine”

    Some call it “woo” medicine because there is no possible mechanism of action and because there is no clinical evidence from RCTs of effectiveness. In which case, how do you kow you benefited? What you have is an N=1 clincal trial which is close to useless.

    “I look forward to the day medical care gives the best of everything to all the people”

    I hope you mean only treatments which are plausible and have clinical evidence of effectiveness. (The above sounds like it came out of the mouth of CAM)

  54. Mlemaon 19 Jun 2011 at 7:13 pm

    BillyJoe7-
    you are so funny! :-)
    do you work on the side at the argument clinic? (you know, “I came here for an argument”)
    I enjoy your comments very much, but what do you want me to say? How does what I said “sound like it came out of the mouth of CAM” ???)
    Nevermind, please don’t trouble yourself to reply. I’m going to have to forego visiting this site for a while. We can argue some day in the future.
    cheers
    M

  55. BillyJoe7on 20 Jun 2011 at 12:29 am

    Mlema,

    Sorry, I didn’t mean that you meant it that way, only that it is the sort of thing CAM proponents say to have their unproven treatments given alongside science based medicine.

    But my question still remains: how do know you’ve benefitted from “woo medicine”? The point is that you don’t know.
    This is the whole point of science based medicine, that anecdotes are unreliable, and that you need clinical trials to sort the wheat from the chaff.

  56. sonicon 20 Jun 2011 at 7:50 am

    Dr. N-
    You are right, the real question is do they work?

    This reasoning is not circular-
    Premise- The guy at Mayo knows how to adjudicate what is gettng good results-
    Premise- The reporter is accurately reporting ‘good results’
    Conclusion- They are getting good results
    Corallary- Studies that would conclude otherwise are flawed.

    It is possible the guy at Mayo is wrong. Or it could be they are seeing good results for reasons other than he claims. But either way, the fault is in the premise, not the logic.

    It seems that any benefit from some therapies would come from patient attention and/or relaxation.
    If that is true, what techniques should be approved?

  57. nybgruson 20 Jun 2011 at 9:00 am

    wow. I go on vacation for 3 days and come back and this has blown up here, on SBM, and RI. At least it made for an interesting read. There isn’t too much I can add (it has been handled extremely well by both the authors and my fellow commenters) and besides, I am pretty late to the party anyways.

    I would like to address one point though:

    @ism:

    My question is: to what degree are practicing MDs (non research) trained to recognize good or bad science?

    I must preface this by saying it is my opinion and based purely on anecdote and my own experience, but in short, the answer is “not very much.”

    We have EBM classes and are examined on the material. But the reality is that most people don’t take it very seriously. They learn enough to get by (which isn’t much since you could do quite poorly on it and still get decent grades overall) and are generally happy with a cursory examination.

    I learned most of my EBM and study interpretation through reading SBM, RI, and this blog, as well as my background in post-grad research. But I just recently had some classmates beg me for a tutorial in EBM for our finals which we just had and it was clear there was not a deep understanding of it.

    Now this is quite fine, assuming that studies and consensus views are intellectually honest. If Cochrane actually said, “Studies on homeopathy are equivocal, with some showing minor benefits, but it is still total BS because we’d have to live in bizarroworld for it to possibly do anything” then I’d say the level of understanding your average medical student gets through the curriculum would be quite sufficient.

    Of course, many students go on and learn on their own and truly think about such things – those students tend to be my best friends over here at med school. But I also have good friends representative of the other side of the spectrum – those for which their science background is not quite as extensive and are having a hard enough time just keeping up with the flow of material and expected amount of knowledge learned to bother themselves with thinking in depth about such matters. One in particular comes from a very “new-agey” background and is hard pressed to give up some of her slightly woo-ish notions, but at least she listens when presented with evidence and changes her opinion accordingly.

    But many are blown away when I show them evidence about our CAM professor – I’d been lambasting him for some time and finally one of them looked him up and gasped; everything I’d been saying was spot on and suddenly the room was abuzz. These are the same students that had been to his lectures and listened to what he had to say and took it in (or ignored it) without much thought. But when I actually showed them the depth of his quackery and discussed some specifics and actually demonstrated his sleight-of-hand tactics they were shocked – so I would very much second Dr. Novella’s statement that most well credentialed physicians aren’t aware of what CAM actually is. This is because many intelligent and otherwise concientious med students also don’t know. Heck, most can’t even tell me what homeopathy or chiropractics actually are. They think they are “natural” (aka “wholesome” or “holistic”) or just physical therapy. They know nothing of the Law of Similars or the Theory of Subluxation. When I tell them, they are once again aghast.

    So yeah. Take med students who are busy trying to learn the real stuff, add in ignorance on the specifics of the modalities, sprinkle in some lack of rigor with the EBM modules, add a few years time and you get a credentialed physician who is a shruggie and doesn’t think (s)he needs to care much about homeopathy or acupuncture.

  58. chaos4zapon 20 Jun 2011 at 3:06 pm

    A college roommate of mine went to Drexel for medical school and he mentioned on a few occasions that Drexel med use to be called MCP Hahneman. Recognizing the name, I looked it up to see if there was a connection to our dear friend Samuel “father of homeopathy” Hahneman and sure enough…it was named after him. Apparently it started as The Homeopathic College of PA and was the first US Homeopathic College in the US (did they also offer degrees in finger painting and bread cutting?). Over the years, through mergers and acquisitions, it is now Drexel Med and seems to be a respectable evidence based med school. My point being, in a day and age when medical schools seem to be more and more content in promoting pre-scientific non-sense to humor the masses, there is at least one that seems to have done a complete 180 in the other direction. I’m sure this was more a result of the different entities running things and not just some natural evolution towards evidence and actual science but I still derive a bit of pleasure just knowing that Hahneman’s name got the ax.

  59. Mlemaon 21 Jun 2011 at 11:02 pm

    nobody wants “woo” in their science, but for those of you who like a little science with your “woo”:

    http://www.youtube.com/watch?v=l3EdUk8QXzc

    if this guy says “qi” (chi) is real, are YOU gonna argue with him?

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