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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