Science-Based Medicine

Earlier today, Steve discussed a new report hot off the presses (metaphorically speaking, given that it’s been published online) from the Bravewell Collaborative. Naturally, given the importance of the issue, I couldn’t resist jumping in myself, but before you read the blather I have to lay down, you really should read what Steve wrote about it. It’s that good. (Also, he’s our fearless leader, and I wouldn’t want him to be…unhappy about my having muscled in on his usual day to post.) Have you read it? Good. Now we can begin…

One of the most common (and potent) strategies used by promoters of “complementary and alternative medicine” (CAM)–or, as its proponents like to call it these days, “integrative medicine” (IM)–to convince the public and physicians either to use it (or at least to remain a shruggie about it) is in essence an argumentum ad populum; i.e., an appeal to popularity. Specifically, CAM/IM apologists like to use the variant of argumentum ad populum known as the “bandwagon effect,” in which they try to persuade patients and physicians that they should get with the CAM/IM program because, in essence, everyone else is doing it and it’s sweeping the nation in much the same way New Coke did in the 1980s. (Admittedly, CAM/IM apologists are, unfortunately, much better at sales than Coca-Cola was.) Not coincidentally, this is one type of method of persuasion much favored by Madison Avenue when selling cars, clothing, music, movies, food, beer, and nearly every other product–like Coca-Cola. I say “not coincidentally” because what CAM proponents are doing, more than anything else, is selling a lifestyle, a brand, a belief system, and, of course, many, many products whose value reminds me, more than anything else, of the aforementioned New Coke. In using this appeal to popularity, CAM/IM proponents try to portray stodgy physicians (you know, like pretty much every one of us at this blog) who insist on plausibility, science, and evidence to support the use of drugs and treatments as hopelessly behind the times, dogmatic, out of touch, and in general no fun to be around at all, particularly at parties.
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This is yet another response to the recent “Integrative Medicine in America” report published by the Bravewell Collaborative. Drs. Novella and Gorski have already given that report its due, so I won’t repeat the background information. Inevitably, I’ll cover some of the same points, but I’ll also try to emphasize a few that stand out to me. Most of these have been discussed on SBM over the years, but bear repeating from time to time. Let’s begin with:

If it Ducks like a Quack…

Misleading language is the sine qua non of ‘integrative medicine’ (IM) and its various synonyms. The term itself is a euphemism, intended to distract the reader from first noticing the quackery that is its distinguishing characteristic. As previously explained, Bravewell darlings Andrew Weil and Ralph Snyderman, quack pitchmen extraordinaires, recognized nearly 10 years ago that if you really want to sell the product, you should dress it up in ways that appeal to a broad market.

Let’s see how this is done in the latest report. Here is the very first sentence:

The impetus for developing and implementing integrative medicine strategies is rooted in the desire to improve patient care.

Who would disagree with improving patient care? (Try not to notice the begged question). Here’s the next paragraph (emphasis added): Continue Reading »

Being on the West Coast places me (and Harriet?) at disadvantage in responding to recent developments, as I find out about them later in the day, if that day. (Retirement doesn’t help.)

First I had some comments on the WSJ article on “CAM,” the NCCAM by Steve Salerno and the response by the pseudoscince leadership. The 4-author response revealed political tactics used by quacks and sectarian medicine advocates to answer with straw man points and especially to ignore what they cannot answer.

In their response to Salerno’s article they accused him of being unqualified to object to “CAM” because he was only a reporter. Fact was that most of his points were from my writings, which Slerno frankly acknowledged. The several rebutting authors never mentioned my name. Of course not. (That it was lost in the SBM analyses is understandable.)

And that is the frank dishonesty we are dealing with when we face off with these characters, who now have the ears and eyes of the Institute of Medicine, academic deans and professors, and government. They are smiling as they read this.
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The Bravewell Collabortive is a private organization whose stated mission is to, “accelerate the adoption of integrative medicine within the health care system.” They are well-funded, and they have successfully used their money to advance their mission. They also now appear to be an effective propaganda machine, producing what they are calling a “landmark report” on the use of integrative medicine in the US. The report is indeed revealing, but perhaps not in the way Bravewell intends.

The report is simply a survey of 29 integrative centers in the US. Before presenting the major findings the report defines “integrative medicine:”

“an approach to care that puts the patient at the center and addresses the full range of physical, emotional, mental, social, spiritual, and environmental influences that affect a person’s health. Employing a personalized strategy that considers the patient’s unique conditions, needs, and circumstances, it uses the most appropriate interventions from an array of scientific disciplines to heal illness and disease and help people regain and maintain optimum health.”

This is the standard marketing propaganda, which we have dissected many times before (so one more time won’t hurt). It is important to note that this is not a legitimate philosophy or approach to medicine, but pure marketing hype with the purpose of rebranding medical pseudoscience and quackery.  There is a growing list of terms used for this rebranding – first “alternative” or “holistic” then “complementary” now “integrative”, “personalized”, and “patient-centered.” It’s the same nonsense, only the labels have evolved (market-tested, if you will).

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I’m not here to convince people that we are right, although it would be nice if it turned out that way. I’m here to tell the truth and let readers decide for themselves.”

— Kimball Atwood, Science Based Medicine, Bravewell Bimbo Eruptions

I had been too inarticulate to formulate what is essentially my approach to this blog: to tell the truth. That would appear to be simple enough. Of course it gets down to what constitutes the truth, and whether you can handle the truth.

What is truth, small ’t’? Truth with a big ’T’ is provided by belief systems that originate in a personal epiphany and you suddenly understand the meaning of life, the universe and everything. Or conjure up reiki or chiropractic. I suspect I was either born without the part of the brain that allows me to appreciate the mystical/spiritual aspects of human existence, or perhaps it was my upbringing. Probably a bit of both, although having raised two kids in the eternal nurture/nature debate has swayed me heavily towards the nature side of the fence. I bet I was born that way. But I am totally tone deaf to issues of spirituality and the surrounding issues of big ’T’ Truths, so I am going to stick to the little ’t’ truths. Continue Reading »

The quest of advocates of unscientific medicine, the so-called “complementary and alternative medicine” (CAM) movement is to convince policy makers, patients, and physicians that it does not deserve the rubric of “alternative,” that it is in fact mainstream. Indeed, that is the very reason why “alternative” medicine morphed into CAM in order to soften the “alternative” label. Increasingly, however, advocates of such highly implausible medical practices appear no longer to like CAM as term for their dubious practicies, because it still uses the word “alternative.” That is, of course, because they recognize that labeling something as “alternative” in relationship to scientific medicine automatically implies inferiority, and CAM advocates are nothing if not full of hubris. Such a term conflicts with their desire to “go mainstream,” and they most definitely do want to go mainstream, but they want to do it on their own terms, without all that pesky mucking about with science, evidence, and rigorous clinical trials. Consequently, they increasingly use a new term, a shiny term, a term free of that pesky “alternative” label. Now they want to “integrate” their unscientific placebo-based practice with real, scientific medicine. Thus was born the term “integrative” medicine (IM, an abbreviation that is the same as that for internal medicine, an identity that I don’t consider coincidence).

One of the biggest complaints we at SBM (or at least I at SBM) have about the attitude of practitioners of scientific medicine towards CAM/IM is that most of them do not see it as a major problem. Dr. Jones characterized this attitude as the “shruggie” attitude, and it’s a perfect term. Equally perfect is her analogy as to why “integrating” pseudoscience with medical science is not a good idea. I myself have lamented the infiltration of pseudoscience and outright quackery into medical academia and the role that the National Center for Complementary and Alternative Medicine (NCCAM) has played in promoting that infiltration. In addition, wealthy patrons of CAM/IM such as Donna Karan and the Bravewell Collaborative have been generous spreading their money around. In this increasingly cash-strapped health care environment, hospitals know on which side their bread is buttered and see the “integration” of woo into their service portfolio as a means of beefing up the bottom line with cash on the barrelhead transactions that require no mucking about with nasty insurance forms. In fact, services such as reiki, homeopathy, acupuncture, and others often require no forms other than credit card receipts for the patient to sign.
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A couple of weeks ago, in a review of the Mayo Clinic Book of Home Remedies, Harriet Hall expressed relief that she hadn’t found any “questionable recommendations for complementary & alternative medicine (CAM) treatments” in that book:

Since “quackademic” medicine is infiltrating our best institutions and organizations, I wasn’t sure I could trust even the prestigious Mayo Clinic.

The Home Remedies book may be free of woo, but Dr. Hall was right to wonder if she could trust the Mayo Clinic. About a year ago I was asked to comment on an article in the American Journal of Hematology (AJH), in which investigators from the Mayo Clinic reported that among a cohort of lymphoma patients who were “CAM” users,

There was a general lack of knowledge about forms of CAM, and about potential risks associated with specific types of CAM…

This suggests the need to improve access to evidence-based information regarding CAM to all patients with lymphoma.

No surprise, that, but I couldn’t help calling attention to the paradox of one hand of the Mayo Clinic having issued that report even as the other was contributing to such ignorance:

The Mayo Clinic Book of Alternative Medicine details dozens of natural therapies that have worked safely for many patients in treating 20 top health issues. You may be surprised that Mayo Clinic now urges you and your doctor to consider yoga, garlic, acupuncture, dietary supplements and other natural therapies. Yet the record is clear. Many of these alternative therapies can help you achieve reduced arthritis pain, healthier coronary arteries, improved diabetes management, better memory function and more.

Nor could such a paradox be explained by the right hand not having known what the left was doing: Brent Bauer, MD, the Director of the Mayo Clinic Complementary and Integrative Medicine Program, is both the medical editor of the Book of Alternative Medicine (MCBAM) and a co-author of the article in the AJH.

As chance would have it, I had picked up a copy of the latest (2011) edition of the MCBAM only a couple of days before Dr. Hall’s post. Does it live up to its promises? Do its “straight answers from the world’s leading medical experts” respond to “the need to improve access to evidence-based information regarding CAM?” Let’s find out. In some cases I’ll state the implied questions and provide the straight answers.

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One thing about blogging once a week or so compared to my other blogging gig, which is usually close to every day, occasionally more often, is that I really can’t cover everything I want to cover for this blog. Even more so than at my not-so-super-secret other blogging gig, I have to pass on topics that could be fodder for what could be excellent to even awesome posts—or, self-congratulating hyperbole aside, at least reasonably interesting to the readers of this blog. When that happens, I can only hope that one of my co-bloggers picks up on it and gives the subject matter the treatment it cries out for. Or, sometimes, such subject matter just has to be dealth with elsewhere by me—or not at all. Even a hypercaffeinated blogger like myself has limits.

Sometimes, however, I actually get a second chance. In other words, I get a chance to revisit a topic that I passed by. Usually, this happens when something new happens that gives me an excuse to revisit the topic. So it was last of week, when I was perusing the New York Times by an oncology nurse named Theresa Brown. Her article was titled, appropriately enough, Hospitals Aren’t Hotels. It will become very apparent very quickly why in a moment. But first, let’s sample Brown’s article a bit, because it brings up an issue that is very pertinent to science-based medicine:
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NB: I posted this on Health Care Renewal a couple of days ago, figuring that Dr. Gorski’s post would suffice for the SBM readership (he and I had discussed the topic while at TAM8 last week). But Managing Editor Gorski has asked me to repost it here, which I’m happy to do. I am especially pleased to demonstrate that I am capable of writing a shorter post than is Dr. Gorski.

…

On July 7, President Obama appointed Dr. Donald Berwick as Administrator of the Centers for Medicare and Medicaid Services (CMS). Dr. Berwick, a pediatrician, is well known as the CEO of the non-profit Institute for Healthcare Improvement (IHI), which “exists to close the enormous gap between the health care we have and the health care we should have — a gap so large in the US that the Institute of Medicine (IOM) in 2001 called it a ‘quality chasm’.” Dr. Berwick was one of the authors of that IOM report. His IHI has been a major player in the patient safety movement, most notably with its “100,000 Lives Campaign” and, more recently, its “5 Million Lives Campaign.”

Berwick’s CMS gig is a “recess appointment”: it was made during the Senate’s July 4th recess period, without a formal confirmation hearing—although such a hearing must take place before the end of this Senate term, if he is to remain in the position. A recent story suggested that Obama had made the recess appointment in order to avoid a reprise of “last year’s divisive health care debate.” The president had originally nominated Berwick for the position in April, and Republicans have opposed “Berwick’s views on rationing of care,” claiming that he “would deny needed care based on cost.”

A “Patient-Centered Extremist”

If there is a problem with the appointment, it is likely to be roughly the opposite of what Republicans might suppose: Dr. Berwick is a self-described “Patient-Centered Extremist.” He favors letting patients have the last word in decisions about their care even if that means, for example, choosing to have unnecessary and expensive hi-tech studies. In an article for Health Affairs published about a year ago, he explicitly argued against the “professionally dominant view of quality of health care”:

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If there’s one thing that purveyors of pseudoscientific medical modalities crave, probably above all else, it’s legitimacy. They want to be taken seriously as Real Scientists. Of course, my usual reaction to this desire is to point out that anyone can be take seriously as a real scientist if he is able to do science and that science actually shows that there is something to his claims. In other words, do his hypotheses make testable predictions, and does testing these predictions fail to falsify his hypotheses? That’s what it takes, but advocates of so-called “complementary and alternative medicine” (CAM) or “integrative medicine” (IM, or, as I like to refer to it: “integrating” quackery with scientific medicine) want their woo to be considered science without actually doing the hard work of science.

There are several strategies that pseudoscientists use to give their beliefs the appearance of science, a patina of “science-y” camouflage, if you will. One, of course, is the cooptation and corruption of the language of science, which has been a frequent topic on this blog, particularly in posts written by Drs. Atwood and Sampson. Another is to produce journals that appear to be science, but are anything but. I’ve discussed one example, the Journal of American Physicians and Surgeons and Medical Acupuncture, but others include Homeopathy, the Journal of Alternative and Complementary Medicine, and Medical Hypotheses, which recently was forced to retract a horrible paper by arch-HIV/AIDS denialist Peter Duesberg. What’s worse is that some of these journals are even published by what are considered major publishers, such as Mary Ann Liebert, Inc., and Elsevier.

There is, however, a third strategy. How do scientists communicate their findings to other scientists, as well as meeting and mingling with other scientists? Why, they hold scientific meetings, of course! These meetings can be small or even as large as the American Association for Cancer Research meeting, which is attended by around 15,000 cancer researchers each year. So, too, do cranks hold meetings. These meetings often have all the trappings of scientific meetings, with plenary sessions, smaller parallel sessions, poster sesssions, and an exhibition hall, complete with exhibits by sponsoring companies. Sometimes these meetings can even appear so much like the real thing that they take in legitimate researchers and legitimate universities. Here, I present two examples of such conferences.
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