Oct 23 2009

A Culture of Science-Based Practice

The complementary and alternative (CAM) or integrative medicine phenomenon that has arisen over the last couple of decades primarily involves the creation of a separate subculture within medicine. The primary defining characteristic of the CAM subculture is a lack of dedication to a culture of science-based practice.

The strength of mainstream medicine, which should strive for the ideals of science-based medicine, is that it mostly does. There is a culture of ultimate respect for the scientific evidence. The application, of course, is imperfect – but the ideal is there. If you bring enough high quality evidence to bear, you can change the standard of care, how everyone else is practicing medicine.

Like freedom and democracy, science-based medicine is messy in all the ways that human cultures are messy, and it requires vigilance and constant self-examination. Right now the systems of quality control and self-correction within medicine are straining to keep up with the rapid advances in medical knowledge and technology. We are, in some ways, victims of our own success. The evidence-based medicine (EBM) movement is primarily about codifying strategies for keeping up with the exploding evidence.

While mainstream medicine is struggling to become more science-based, the parallel culture of CAM is searching for ways to undermine the scientific basis of medicine. Of course, no CAM proponent comes right out and says that. Instead they talk about broadening our concept of evidence, allowing “uncontrolled clinical observations” (i.e. anecdotes) to count as if it were high quality evidence, and respect for antiquity and “naturalness” as a substitute for quality evidence. They advocate pragmatic studies to assess their modalities because they are uncontrolled and rigorous controlled trials have a nasty habit of being negative.

In short, CAM proponents begin with their preferred modalities and then want to choose their evidence rather than have the evidence choose which modalities are legitimate.

I was recently asked if I thought that CAM research is of lower quality than mainstream medical research. I don’t know the answer to this question in any rigorous statistical way – but it occurred to me that the real problem is not with the quality of the research itself. There are good and bad studies, preliminary and definitive studies, in both mainstream medicine and CAM. The problem is with how the evidence is used.

Within medicine there is a culture of really listening to the evidence and changing practice accordingly. There are many examples of where this ideal was not met, where individuals and even institutions failed, but eventually the community self corrects. Within CAM, however, the dominant cultural attitude is that it’s all good. The purpose of scientific evidence is not to determine what works, but to prove that CAM modalities do work so that they can be increasingly promoted. Science in the CAM community is an annoying and tedious hoop they have to jump through to satisfy the eggheads and gain acceptance.

Take Senator Tom Harkin’s statements regarding the National Center for Complementary and Alternative Medicine that he created. He has characterized lack of acceptance of unscientific methods and practitioners as “discrimination”.  He was disappointed that NCCAM had not validated more CAM modalities – as if this were a failure of NCCAM, and he directed them to fix this “problem.” To him the purpose of NCCAM was not to discover what works, but to validate CAM.

So even when good studies are done within CAM, it doesn’t matter – they are not used to decide what works and how to practice. I have yet to see a single CAM modality rejected following high quality evidence for lack of efficacy. All such evidence creates is excuses and calls for less-rigorous research that can more easily be manipulated. There is no culture within CAM of real respect for science as the ultimate determinant of what works and how to practice.

The “healthcare freedom” laws that the CAM culture advocates and have successfully pushed through many states also reflects the desire for a double standard. Essentially these laws protect “alternative” practitioners from being held to a scientific standard of care.

I am covering this familiar ground again today in reaction to a recent study by Katherine Hunt and Edzard Ernst. They summarize in their abstract:

Methods: We obtained the codes of the following bodies: Association of Naturopathic Practitioners, Association of Traditional Chinese Medicine (UK), Ayurvedic Practitioners Association, British Acupuncture Council, Complementary and Natural Healthcare Council, European Herbal Practitioners Association, General Chiropractic Council, General Osteopathic Council, General Regulatory Council for Complementary Therapies, National Institute of Medical Herbalists, Register of Chinese Herbal Medicine, Society of Homeopaths, UK Healers, Unified Register of Herbal Practitioners. We then extracted the statements referring to EBP and compared this with what the respective codes of British doctors and nurses proscribed.

Results: Only the General Chiropractic Council, the General Osteopathic Council and the General Regulatory Council for Complementary Therapies oblige their members to adopt EBP.

Conclusions: This discloses double standards in UK health care which may compromise patient safety.

At least with the organizations named above, there is a lack of dedication to evidence-based practice in their codes of conduct. This, of course, is just one line of evidence and not definitive in and of itself, but it does reflect the broader observation based upon many lines of evidence that there is an inherent lack of respect of scientific evidence within the culture of CAM.

There is a parallel to be drawn with the creationist movement in the US. Creationists today talk about academic freedom, opposing dogma, fairness to those with alternate opinions, teaching the controversy, and including discussion of the strengths and weaknesses of scientific theories in the classroom. Taken in isolation and out of context, each of these points may seem legitimate. But we know what the ultimate purpose of all of this is – to promote a sectarian anti-scientific and overtly religious view of the origins of life at the expense of the quality of science education. The creationists are not fooling anyone with the slightest knowledge of recent history.

In the same way CAM proponents talk about health care freedom, scientific dogma, closed-mindedness, discrimination, respect for local cultures and nature, and broadening our concepts of science and evidence. But in reality this is all a cover, and at the core the CAM movement is all about creating a double standard to shield their preferred ideologically driven modalities from being held to a scientific standard.

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