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.

13 responses so far

13 thoughts on “A Culture of Science-Based Practice”

  1. crtopher says:

    How did “we” (you know who I mean!) get this guy Ernst! He’s the first ever Professor in CAM and he absolutely pans the stuff.

    Is he really a skeptic mole, a spy for the EBMers that has somehow infiltrated into the highest echelons of the Alternative Movement? He’s like the Benedict Arnold of the Evidence vs Scam Wars. I love him!

    Bravo Edzard!

  2. titmouse says:

    Here is my idea, the idea which is mine:

    We make a documentary called “NOT EXPELLED!” In the intro, a charismatic pro-science voice explains that the scientific method is not a means for accepting good ideas. Rather, science progresses by ruling-out or EXPELLING ideas that fail certain tests.

    The movie intro would be followed by a series of interviews with several proponents of integrative medicine explaining the challenges they’ve faced in their effort to get alternative therapies “integrated” with mainstream practice.

    In the editing room, we splice in commentary after each interview reviewing how the scientific community failed to do its job. Practices that should have been expelled were NOT EXPELLED!

    I envision lots of amusing WTF? moments and humerous extrapolations regarding the clown car of crazy that might become medicine if the evidential bar remains so low that Reiki is NOT EXPELLED!

    Riding on the back of the “Expelled!” brouhaha means free publicity and an immediate fan base. Some of us are crack interviewers because we do it all day long. Evan Bernstein knows something about production, eh? Maybe we could self-fund the project.

    All we’d need are a few amazing laughs and some help with promotion and distribution to make a little money. Oh, and to get the word out about quackademic medicine.

    Best to delete this post prior to setting up any interviews, LOL.

  3. daijiyobu says:

    Per: “there is an inherent lack of respect of scientific evidence within the culture of CAM […] the parallel culture of CAM is searching for ways to undermine the scientific basis of medicine.”

    And yet, sCAMsters have huge respect for the financial and political gain [ill-gotten] that occurs from misusing the ‘science’ label.

    NDs do this wildly, and overall, in my view, hugely abusively.

    I think the “way” is to:

    a) legislate it, and get it ‘.gov’:

    e.g., http://www.oregon.gov/OBNE/Aboutnaturopathy.shtml [notice the nonscience that is claimed to survive scientific scrutiny…absurd].

    b) publish it, and get it on paper [not, of course, in a peer-reviewed scientific area where it would FAIL, of course; just pubish it as science commercially]:

    e.g., there’s Chaitow’s 2008 ‘naturopathic textbook’ (ISBN 0443103909), available in part on books.google.com, INCREDIBLY under Elsevier’s “Health Sciences” imprint.

    To quote Ellen Ripley from “Aliens”:

    “did IQs suddenly drop sharply while I was away?”

    In other words, the “way” is to, as you’ve said before Dr. N., do an ‘end run around actual science’.


  4. eiskrystal says:

    It is highly amusing that under normal circumstances and with the slightest knowledge of the human body most CAM modalities become impossible and ludicrous.
    The question really is why, and how clearly delusional modalities have gone on so long under medicine and through government. Following a few money trails would i’m sure raise some very interesting questions.

    The government needs to be pushed and dragged kicking and screaming into giving us decent protection against this kind of stuff as it has wholely failed to do so.
    I should not be able to buy medicinces that have been proved to have no effect in a large drug store chain. That is a scam. Worse it is a scam given legitimacy by the governments poor label control and endorsement by said drug stores.

  5. Squillo says:

    Terrific post, and great comments. (I love titmouse’s “NOT EXPELLED” idea.)

  6. titmouse says:

    Why of course you do, Squillo, for it is clearly genius. And awesome likewise.

    But shh! Don’t let the alties get wise to our plan, else we’ll never get those interviews.

  7. artfulD says:

    “the scientific method is not a means for accepting good ideas. Rather, science progresses by ruling-out or EXPELLING ideas that fail certain tests.”


  8. artfulD says:

    Dropping the other shoe:

    The scientific method is rather one of open minded intelligence.

    And as someone else in the scientific arena has said it better:
    “Conformity to preconceptions—whether of fact, or of method—cannot be the route to scientific progress. Both causality, as a rationalizing concept, and sophisticated statistical technique, as a means of establishing relationships, must be stages in a more complete process of open-minded intelligence by which the solution of problems is achieved.”

    Cases in point: Hundreds Of Natural-selection Studies Could Be Wrong, Study Demonstrates

  9. HHC says:

    Iowa’s Senator Harkin is extremely interested in national healthcare? This is amusing because the U.S. Justice Department has been investigating for at least the past decade one of Iowa’s state facilities, Glenwood Resource Center formerly Glenwood State Hospital-School. There is staff on staff violence, staff on resident violence, resident on staff violence, and resident on resident violence. What are the clients of such a center learning? Does the Iowa Senator understand what a high level of quality care is all about with respect to his own state’s healthcare facilities?

  10. Joe says:

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

    However, that is only window-dressing for the first two organizations. The British chiro ass’n have famously failed to provide evidence supporting many of their claims. Less famously, on another forum http://www.skeptics.org.uk/forum/showthread.php?t=2452 I discovered that osteopaths outside the USA are just as quacky as chiros. Osteopaths really have no excuse since the DOs in America made the transition a long time ago and that should serve as a model.

    As for Ernst being a stealth skeptic, I think he is openly critical; but I think he is too accepting of CAM at times. For example, he still lists chondroitin and glucosamine for arthritis; yet a UK arthritis charity is tepid on them: “There is some promising evidence to suggest that the compound works. The evidence will be from more than one study. However there may also be some studies showing that it does not work. Therefore we are still uncertain whether compounds in this category work or not.” http://www.arc.org.uk/arthinfo/documents/6300.pdf

  11. Kimball Atwood says:

    “As for Ernst being a stealth skeptic, I think he is openly critical; but I think he is too accepting of CAM at times.”

    Dr. Ernst is an enigma; or, perhaps, he is simply evolving away from a previous attraction to “CAM” because, unlike most enthusiasts, he is intellectually honest and goes where the evidence takes him. See here, under “Prior Probability, Misleading Language, and Mr. Magoo,” for a discussion: http://www.sciencebasedmedicine.org/?p=55

  12. eiskrystal says:

    -But shh! Don’t let the alties get wise to our plan, else we’ll never get those interviews.-

    It’s ok, we will just pretend to be a different company and lie about our reasons for making the movie, then cut their interviews so they look even worse (where possible). We may want to cause a scene at one of the movie theatres by chucking out one of the alt meds that was in the film. For extra publicity.

    oh wait….

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