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A surprising article about “integrative” medicine in The New England Journal of Medicine vs. “patient-centered” care

The New England Journal of Medicine (NEJM) is published on Thursdays. I mention this because this is one of the rare times where my owning Mondays on this blog tends to be a rather large advantage. Fridays are rotated between two or three different bloggers, and, as awesome as they are as writers, bloggers, and friends, they don’t possess the rabbit-like speed (and attention span) that I do that would allow me to see an article published in the NEJM on Thursday and get a post written about it by early Friday morning. This is, of course, a skill I have honed in my not-so-super-secret other blogging identity; so if I owned the Friday slot I could pull it off. However, the Monday slot is good enough because I’ll almost always have first crack at juicy studies and articles published in the NEJM before my fellow SBM partners in crime, unless Steve Novella managed to crank something out for his own personal blog on Friday, curse him.

My desire to be the firstest with the mostest when it comes to blogging about new articles notwithstanding, as I perused the table of contents of the NEJM this week, I was shocked to see an article that made me wonder whether the editors at NEJM might just be starting to “get it”—just a little bit—regarding “integrative” medicine. As our very own Mark Crislip put it a little more than a week ago:

If you integrate fantasy with reality, you do not instantiate reality. If you mix cow pie with apple pie, it does not make the cow pie taste better; it makes the apple pie worse.

Lately, though, I’ve been more fond of a version that doesn’t use fancy words like “instantiate”:

If you integrate fantasy with reality, you don’t make the fantasy more real. You temporarily make your reality seem more fantasy-based, but reality always wins out in the end.

The part about the cow pie needs no change, although I think ice cream works a bit better than apple pie. Your mileage may vary. Feel free to make up your own metaphor inspired by Mark’s.

In any case, in the Perspective section, I saw three articles about “patient-centered” care:

As I and several of my fellow SBM bloggers have pointed out, the whole concept of “patient-centered” care, as worthy as it is in theory, is all too often in practice co-opted by promoters of unscientific, pseusocientific, and faith-based health care modalities to justify quackery. That’s why the fourth article on the list surprised me:

What’s the Alternative? The Worldwide Web of Integrative Medicine by Ranjana Srivastava, F.R.A.C.P.

When I saw this title, I was rather expecting apologetics about “integrative” medicine. What I got instead was an article that would have been appropriate right here on this very blog, a post about a woman who had fallen prey to a dubious test promoted at an “integrative” health fair and the devastating results of that test. That’s why I was suprised.

After all, let’s look at the record of the NEJM over the last couple of years. What is still considered to be one of the best medical journals in the world, if not the best, appears to be the victim of a conscious effort on the behalf of its editors to dethrone itself as king of medical journals through its increasing acceptance of the spin placed on medical science by those who would integrate fantasy with reality in medicine in the hope of improving medicine. Unfortunately for them reality has a way of always winning out in the end, just as the cow pie wins out in Mark’s metaphor.

For me, the first sign of major trouble appeared back in the summer of 2010, when the NEJM published what was on the surface an unremarkable study that found that tai chi appeared to have a beneficial effect on symptoms in patients with fibromyalgia. Indeed, I remember it well because its publication coincided with my trip to Chicago to give an invited talk to the Chicago Skeptics, the Women Thinking Free Foundation, and CFI-Chicago. (Hey, come to think of it, it’s been a long time since then. Maybe the skeptical crew would want to invite me out again to give a talk. But I digress…) In any case, part of what was so annoying about the article is that, as I put it, the NEJM completely and uncritically let the authors spin their results in—shall we say?—an “alternative” frame. As I pointed out at the time, let’s say that tai chi is the greatest thing since sliced bread and that it alleviates fibromyalgia pain and stiffness better than anything we’ve yet come up with. Let’s assume all of those things are true, just for the moment: what thought comes to mind to you? I know what thought comes to mind to me. What on earth is “alternative” or “complementary” about such a finding? In reality, such findings would simply indicate that certain forms of low-impact exercise could help fibromyalgia symptoms, which is not anything particularly surprising at all, given what we already know about fibromyalgia. In the interim, this NEJM article has been touted far and wide by apologists for “complementary and alternative medicine” (CAM), or, as they prefer to call it these days, “integrative medicine.”

Around about the same time, the NEJM published an even more credulous article about acupuncture in its Clinical Therapeutics section. As I described at the time, it was a clinical vignette, a little case presentation if you will, by Dr. Brian M. Berman, who has managed in a brief period of time to become the foremost popularizer of acupuncture in academic medical centers. In this vignette, the acupuncture was presented as a perfectly fine alternative for low back pain, and, as both Mark Crislip and I described, Berman did some pretty creative spinning to make it seem as though evidence favored acupuncture.

Since then, there have been other examples of the once-venerable NEJM falling for what can best be described as utter nonsense. In fact, even when publishing what could be a scientifically interesting and medically useful paper on placebo effects, its editors allowed the authors, led by Ted Kaptchuk, to spin the results in a way to imply that patients can have symptomatic relief without actual reversal of the underlying physiologic derangement that caused their symptoms in the first place and that that’s OK. In this case, the disease was asthma, and the paper published showed that placebo acupuncture resulted in asthma patients feeling better but didn’t reverse the airway constriction that led patients to feel short of breath in the first place. Peter Lipson quite properly described this as “folly,” but it’s worse than that. The NEJM doubled down and published an accompanying editorial by Daniel Moerman, who is about as postmodernist as it gets and all about “meaning” in the doctor-patient interaction. I’m going to quote the same passage from his editorial now that I quoted then, in which Moerman makes an explicit plea for placebo medicine based on the concept of patient-centered care:

The authors conclude that the patient reports were “unreliable,” since they reported improvement when there was none — that is, the subjective experiences were simply wrong because they ignored the objective facts as measured by FEV1. But is this the right interpretation? It is the subjective symptoms that brought these patients to medical care in the first place. They came because they were wheezing and felt suffocated, not because they had a reduced FEV1. The fact that they felt improved even when their FEV1 had not increased begs the question, What is the more important outcome in medicine: the objective or the subjective, the doctor’s or the patient’s perception? This distinction is important, since it should direct us as to when patient-centered versus doctor-directed care should take place.

For subjective and functional conditions — for example, migraine, schizophrenia, back pain, depression, asthma, post-traumatic stress disorder, neurologic disorders such as Parkinson’s disease, inflammatory bowel disease and many other autoimmune disorders, any condition defined by symptoms, and anything idiopathic — a patient-centered approach requires that patient-preferred outcomes trump the judgment of the physician. Under these conditions, inert pills can be as useful as “real” ones; two inert pills can work better than one; colorful inert pills can work better than plain ones; and injections can work better than pills.

Which brings us to today, skipping over the recent incident where the NEJM apparently has decided that accepting dubious advertisements is acceptable. The article about the cancer quack begins with a patient who out of curiosity wanders into an “integrative” health exhibition, and this is what happens:

Out of curiosity, an impressionable woman in her 30s attends an integrative medicine exhibition; having recently had a child, she’s been sleep-deprived and wants to investigate natural remedies. At the seminar, she wins a door prize — a blood test that promises to diagnose cancer. She was considering getting a blood test anyway and seizes this opportunity for a more comprehensive workup. After all, you can’t be too careful about avoiding cancer.

Weeks later, she receives a call from an apologetic but alarmed stranger telling her she has advanced cancer.

“How do you know?” she gasps.

“Your blood test is positive for circulating tumor cells.”

“What does that mean?” she cries.

He sends her a three-page report and tells her to seek immediate help. She spends a nail-biting week awaiting an appointment with the recommended integrative health expert.

Glancing at the report, the expert declares, “You have advanced non-small-cell lung cancer. You need treatment now.” The woman is petrified: Has her teenage smoking habit come back to haunt her?

“Are you sure?” she asks.

“Absolutely. There are circulating tumor cells in your blood.”

Tears streaming down her face, the woman asks, “What now?”

Ten years ago, it was whole body scans, which, while not really advertised as “integrative” or “alternative” produced the same sorts of results: Terrified people who thought they had a horrible disease based on an “incidentaloma.” The end results were frequently multiple additional imaging tests, with the concomitant unnecessary doses of radiation, invasive procedures, and even surgeries to try to determine whether these incidentalomas were actually cancer or anything else to worry about. Because the prevalence of abnormalities on such scans is so high, the fraction of these “false alarms” was (and remains) very high. The result is that such highly sensitive tests indiscriminately applied to a population in which the likelihood of the disease being sought is low are far more likely to cause harm through false alarms that result in further tests than they are to save lives through early detection. Sure, there will be the occasional “save,” in which a potentially deadly tumor is discovered at a very small size and resected. Certainly that is what the whole body scanning businesses that sprouted up a decade ago and have now (thankfully) mostly gone away would tout in their advertisements. What they wouldn’t tell you is the cost, how many were harmed or how many were sent off on wild goose chases compared to the rare person who might have been saved by such a pickup.

After hearing the recommendation of the “integrative practitioner” that she undergo a 12-week course of intravenous vitamin C, at a cost of $6,000, the patient decided to seek out an oncologist. As I’ve pointed out time and time again, vitamin C has pretty much failed as a potential treatment for cancer, its advocacy by a Nobel Laureate notwithstanding. Basically, it requires incredibly high doses of vitamin C. There might be a very modest antitumor effect at incredibly high doses, but it’s such a long run for a short slide that it doesn’t really make sense to use, particularly given that there is evidence that vitamin C at high concentrations can interfere with convention chemotherapy treatments.

But let’s get back to the “diagnosis.” A decade ago, it was full body scans. Apparently today it’s “circulating tumor cells.” (And, of course, thermography is forever.) Remember how extensively I’ve written about how earlier detection is not always better? Overdiagnosis, detection bias that favors less aggressive cancers among screening-detected cancers, stage migration (the “Will Rogers effect”), and a number of other confounders make it difficult to determine just when and how often to use good screening tests for which we have data from very large population-based studies and clinical trials, like mammography. There remains controversy to this day regarding when and how to screen for breast cancer and even whether to screen for prostate cancer. In the meantime, trying to screen for lung cancer using CT scans has largely been a failure.

So here we have a quack—yes, a quack—looking for circulating tumor cells (CTC) in the blood of a young woman in whom there is no strong reason to suspect cancer other than a distant smoking history. Who knows if the test is valid? That is, of course, the first thing I would question, given where the company was promoting its wares and what the “integrative” practitioner recommended. But let’s for the moment assume that there were circulating tumor cells in a woman with no known tumor? Do we know what to do with such things? No! We have no idea. Measuring circulating tumor cells in the blood is a hot area of research right now, which is no doubt why “integrative” practitioners are apparently offering such tests, to capitalize on the interest. In any case, the research that is going on is primarily focused on using CTCs as prognostic markers in patients diagnosed with cancer and for following response to therapy, and, even in those situations, they have not been validated to the point where they have become standard of care. Measuring CTCs is still, at best, experimental, and there is as yet no good evidence that they will be useful as screening tools in populations not at high risk. Scientists still argue over the proper cutoff points for patients with cancer; they have no idea what to use as a cutoff measurement in healthy patients. As Max Wicha put it, not all detected cells are bad and not all bad cells are detected.

The rest of the story goes something like this. A skeptical friend of the woman suggested that she should have a scan, and she had a cousin of hers, who happened to be a physician, order a chest X-ray and CT scan (which is another excellent example of why physicians should not treat family members), which revealed “two tiny nodules, 2 mm each in diameter.” On the radiology report were those waffle words that clinicians dread reading, “Clinical correlation is recommended in the context of a smoking history” (which is another reason physicians should not order tests whose results they won’t know what to do with). After trying to get in to see a thoracic surgeon, the patient is referred to an oncologist’s office, that of Dr. Srivastava, the author of the paper. This is what happens next, as described by Dr. Srivastava. I’ll quote as liberally from the article as I think I can and still be in the bounds of fair use, because, oddly enough, even though the three articles on patient-centered care are free for the download on the NEJM site, this article on cancer quackery is not. I wonder why. In any case, on with the story:

“There’s no evidence of cancer,” I reply, seeking to reassure her.

Instead, her tone sharpens: “But I have circulating tumor cells! How can you say that?”

Incredulous, I try to explain too many things. The blood test is a long way from being validated for clinical use. It was unscrupulous even to offer it. Does it make sense to her that it was sent to an unheard-of overseas laboratory for processing? Why did no one recommend that she see an oncologist?

Rolling her eyes, she counters, “I’ve heard that I need a PET scan. And if the spots light up, this test will have been my lifesaver.”

She is right on one count: the surgeon she sees orders a PET scan, saying he needs to be sure. She loses sleep over the results — the surgeon’s appointment is 2 weeks away, and she wants to schedule the operation. Feeling sympathetic, I tell her the PET scan was clear and the two small nodules seen on the first CT have disappeared; the radiologist thinks they were probably transient foci of inflammation.

But any relief the woman feels is ephemeral. “So what does that mean?” she asks. “The PET scan is faulty?”

“There is no cancer,” I reiterate.

“But someone has seen cancer cells,” she insists.

“That was not a validated test — not something we currently use to diagnose cancer,” I protest.

Dr. Srivastava goes around and around with the patient, trying to reassure her that she does not have cancer. She largely fails. The patient insists on being followed by her because she thinks she has a tiny cancer somewhere that’s just waiting to blossom, leading Dr. Srivastava to lament, quite appropriately, “How does one ‘disprove’ a serious diagnosis once its specter has been raised by an unqualified ‘expert’?” How indeed? I’ve had the same sort of problem with women who come in with thermograms convinced that they have breast cancer and wanting a double mastectomy. Fortunately, this is not common, at least not in my practice. Very fortunately.

Dr. Srivastava then hits the nail on the head:

At one time, the worst offense one encountered was someone prescribing a few herbs to a desperate patient who’d exhausted all other means of treatment. The usual thinking was, “At this stage, it can’t do any harm.” But insidiously and alarmingly, “alternative medicine” has crept from offering last-ditch treatments to making diagnoses. As the cancer armamentarium has expanded with targeted therapies, unscrupulous practitioners of alternative therapy have devised competing offers that sound at least as impressive to the average patient, who is often marginally health-literate and eager to embrace the promise of a cure without toxicity. But the radical, completely unregulated, and often dangerous options on offer can and do cause harm.

After describing the sorts of quack treatments she’s seen her patients use, Dr. Srivastava then drives to the heart of the matter when she points out:

The practitioners never write directly to oncologists and refuse to be accountable for their actions. Unauthorized to order tests, they tell patients, “Ask your doctor to do these bloods,” or “You need to have a scan to see whether the microwaves are working.”

Alternative therapies need meet no burden of proof except a patient’s gullibility. One never hears of alternative therapies that failed: the patient merely waited too long to try them. For every patient who openly discusses such treatments, there must be many who assume the treatments aren’t worth mentioning to “traditional” oncologists. After all, to make integrative health the multibillion-dollar industry it is, people must be supporting it; those people are our patients.

Physicians would be naive to ignore the elephant in the room. Integrative medicine comes in many forms — some useful, but many dangerous. It also comes at tremendous personal and societal cost. The initial expenditure may come from patients’ pockets, but often the health care system eventually inherits the problem. Although there’s probably no way of calculating the psychological cost, for many it is high and unending.

Indeed. Maybe I’ll send Dr. Srivastava an invitation to write a post or two for SBM. She sounds like my kind of doc.

All of this brings us back to “patient-centered” care and how it relates to the article about the cancer quack. Indeed, I wonder whether the NEJM editors are actually starting to “get it” by tacking Dr. Srivastava’s article on to the end of the NEJM Perspectives section. Think back to Dr. Moerman’s definition of “patient-centered care.” Now look at what we are told in the first article, by Ruben and Tinetti:

Perhaps the most important barrier to goal-oriented care is that medicine is deeply rooted in a disease-outcome–based paradigm. Rather than asking what patients want, the culture has valued managing each disease as well as possible according to guidelines and population goals.

Ultimately, good medicine is about doing right for the patient. For patients with multiple chronic diseases, severe disability, or limited life expectancy, any accounting of how well we’re succeeding in providing care must above all consider patients’ preferred outcomes.

Dr. Bardes writes in the third article:

“Patient-centered medicine” is the newest salvo in these ancient debates. As a form of practice, it seeks to focus medical attention on the individual patient’s needs and concerns, rather than the doctor’s. As a rhetorical slogan, it stakes a position in contrast to which everything else is both doctor-centered and suspect on ethical, economic, organizational, and metaphoric grounds.

But what does that mean? Ruben and Tinetti discuss prioritizing patients’ desired outcomes and helping them to achieve these outcomes, as long as they are possible. Dr. Bardes likens the relationship between doctor and patient as one of equals, like two binary stars orbiting a common center of gravity, a double helix, whose strands circle each other, or even the caduceus, with two serpents intertwined. I have to hand it to Dr. Bardes, he’s a poetic guy, but he goes too far. While patient and physician might be equals as human beings, in terms of medical knowledge they are not. If they were, then the patient arguably would not need the physician and would be able to handle his health problems himself. A better way of looking at it would be that the physician is the expert consultant, whose skill and knowledge the patient requests, while the patient is free to accept or refuse the physician’s advice. This is not the same as the old paternalistic model, where the doctor ordered and the patient acquiesced, because the patient is actively involved in seeking advice and can reject that advice. In other words, the relationship is more equal, but not exactly equal.

Now let’s think of what extreme patient-centered care would mean in the case of the woman described by Dr. Srivastava. This woman wanted more tests either to prove she didn’t have cancer or to remove the tiny 2 mm masses that were suspected to be cancer. That was her greatest concern, and medicine could address that quite easily by doing what the patient wanted; i.e., either operating on her or otherwise treating her. As it is, Dr. Srivastava could very easily have simply taken the patient on as a regular and seen her periodically, ordering tests every so often to assuage her fears. That would have been less potentially harmful than doing additional tests or even surgery. A physician could (and some do) build up lucrative practices of just such “worried well.” Would that be patient-centered care? It would certainly be giving the patient what she wants and placing the patient’s desires over that of the physician’s.

Certainly many “integrative” practitioners have wholeheartedly embraced the concept of patient-centered care. However, they have done so more out of a desire to be able to justify placebo medicine. If it makes the patient feel better, it must be better, you know, just like the sham acupuncture that made the asthma patients feel better without reversing their underlying airway constriction. Those patients felt great and probably would continue to feel great until they turned blue. “Patient-centered care” is easy when it devolves into giving the patient what she wants without consideration of science. Real patient-centered care is hard and must contend with situations where what the patient wants is unrealistic or impossible.

Certainly a better model is the one described by Barry and Edgman-Levitan, which calls for shared decision-making:

For some decisions, there is one clearly superior path, and patient preferences play little or no role — a fractured hip needs repair, acute appendicitis necessitates surgery, and bacterial meningitis requires antibiotics. For most medical decisions, however, more than one reasonable path forward exists (including the option of doing nothing, when appropriate), and different paths entail different combinations of possible therapeutic effects and side effects. Decisions about therapy for early-stage breast cancer or prostate cancer, lipid-lowering medication for the primary prevention of coronary heart disease, and genetic and cancer screening tests are good examples. In such cases, patient involvement in decision making adds substantial value.

This is probably true, but it depends upon the patient being provided with scientifically valid information to help guide their part of the shared decision-making process. I’ve frequently referred to a concept that I like to call “misinformed consent.” Basically, that’s how practitioners of unscientific nonsense will exaggerate the benefits and minimize the risks of their recommendations, all the while exaggerating the harms and minimizing the benefits of conventional therapies. A particularly apt example is the antivaccine movement, which tries to convince people that vaccines don’t work and are very dangerous. CAM practitioners do the same thing in their vision of “patient-centered care,” but informed consent is not optional, and without informed consent patient-centered care cannot work.

I wonder whether the editors realized that they just might be making a statement when they juxtaposed Dr. Srivastava’s article about what happens when “integrative” care runs rampant with three articles describing the very “patient-centered” care that such practitioners take advantage of. It’s not possible to have real patient-centered care without real informed consent, and “integrative medicine” relies on misinformed consent.

Posted in: Cancer, Medical Academia, Medical Ethics

Leave a Comment (121) ↓

121 thoughts on “A surprising article about “integrative” medicine in The New England Journal of Medicine vs. “patient-centered” care

  1. papertrail says:

    Yay! I was looking for someone to post the rest of that article after seeing just the headline and intro paragraph. Thanks! Really, that article should be made public, and it would be great if you can get the author to write a piece for SBM. I enjoyed your commentary too, as usual.

  2. papertrail says:

    Oh, yeah, and I realize you didn’t post the whole rest of the article (fair use issues), but glad you gave us enough to get the idea.

  3. DW says:

    “The initial expenditure may come from patients’ pockets, but often the health care system eventually inherits the problem. Although there’s probably no way of calculating the psychological cost, for many it is high and unending.”

    A very important point. The money spiraling down the drain of “integrative” medicine is astounding. First the patient spends megabucks on pointless crap. Then the actual disease progresses, past a point where conventional treatment might have been curative, and the big bad traditional health care system spends even more (exponentially more) trying to mop up the mess. (Yes, I am once again talking about my father, who spent thousands on wacky remedies; then Medicaid spent a couple hundred thousand taking care of him after he was incapacitated by strokes that probably didn’t need to happen if he’d taken the meds prescribed by the cardiologist.)

  4. weing says:

    Best line: “Alternative therapies need meet no burden of proof except a patient’s gullibility. “

  5. DevoutCatalyst says:

    Patient centered care should mean being treated like an adult, by an adult. I feel these integrators are adults based on chronology only, they do not display the richness of human maturity. When I was young and excitedly brought in some ‘fossilized vertebrae’ I had found, the geologist didn’t engage my fantasy — he told me it was just some chert. If I have a boneheaded idea about my health care, the doctor had better provide me with reality as best we know it, and not waste my time with some cloying integrator buddy of his who wants to hump my leg in support of his mystical healer fantasy. It is the commitment to “utter honestly” that Richard Feynman spoke of, and not the misleading fluff of pseudoscience, which is the standard of care people deserve.

  6. Kausik Datta says:

    David, when I shared this article with you and others on Facebook, I was very surprised to have been told that it was actually behind a paywall (which I didn’t realize, having accessed it via the university library system). I am glad that you discussed it in such detail. I am not yet free of my doubts about a possible policy change at the NEJM, though.

    One quibble: Dr. Ranjana Srivastava is not a ‘he’, but a ‘she’ (I could have told you that, hehe! :D She’s Indian by origin). She is currently based in Australia, having trained in the UK and US. She writes at a lot of places, including NEJM and Lancet. Many of her writings are available as PDFs on her website, although not – unfortunately – this NEJM article, yet.

  7. rork says:

    The link for the Wicha quote is a great article (I expect as much from the director of the finest cancer center around), but I might give Dan Hayes, the other author, some credit too.

    Thankyou for a fine article and pointer to Srivastava story.

  8. I hope that the actual journal article made a detailed record of this incident.(name of testing company, alt med practitioner etc) I’ve heard a lot of anecdotal evidence about situations like the one in Dr. Srivastava’s article. Many of these stories tell about incredible financial losses. When I ask the people telling the story if they reported it to an authority of any kind or made a verifiable record of the treatments they always say no. The details of the con get lost in obscurity.

    I wonder if this was a fake testing company like the one with the lady who analyzed hairs for Dr. Nick Gonzales.

    Wasn’t The Quackwatch guy being sued by one of these companies?

    maybe it was a real test just inappropriate.

    Thanks for subscribing to the NEJM!

  9. benbouajili says:

    I agree with DevoutCatalyst. I found it disturbing recently to learn that some physicians might feign an acceptance of “integrative medicine” to not drive away patients and in the name of patient-centered care. For example, if a patient persists in complaints despite conventional treatment and wants to see a naturopath, a physician might pretend to think it is a good idea and thereby ensure that the patient sees someone that he knows is “harmless.” The fear is that by rejecting the idea of seeing an alternative medicine provider, the physician might drive the patient further down the path of woo.

    I think this is unethical, and it treats patients like adolescents rather than adults. It is condescending. However, I think discussing the straightforward facts is difficult, as illustrated in the NEJM article.

    What is the best way of avoiding going around and around with a patient who has been affected by the deceit of alt med practioners? Is there a best way to handle the situation? We have actually been discussing using this scenario as part of a standardized patient exercise in GME.

  10. Dr. Srivastava sounds like an SBM-activist in the making! Thanks for giving us a look at these excerpts, Dr. Gorski!

    Also, your hyper-productivity both astounds me and cracks me up! :D It takes me, like, an hour to write a blog comment.

  11. MerColOzcopy says:

    It’s sort of ironic that the 5 ads…right now…on SBM home Page are:

    3-Minute Chakra Test
    Noumena Nathuropathic
    What is Acupuncture?
    Do you have Fibromyalgia?
    Ready to Heal Yourself?

  12. annappaa says:

    It’s not possible to have real patient-centered care without real informed consent, and “integrative medicine” relies on misinformed consent.

    YES, thank you! That’s how I’ve been thinking of it, but it’s nice to see it articulated so succinctly!

  13. “The practitioners never write directly to oncologists and refuse to be accountable for their actions. Unauthorized to order tests, they tell patients, “Ask your doctor to do these bloods,” or “You need to have a scan to see whether the microwaves are working.”

    Did Dr. Srivastava list any of the specific alt med practitioners that her stories were based on? It seems like her patients would have told her if she had asked.

    I need something to google yo!

    links would be super cool.

  14. Quill says:

    Definitely a fine article and I certainly hope these other published articles are a sign that NEJM is starting to “get it.”

    One thing in Dr. Gorski’s post struck me as very funny: “While patient and physician might be equals as human beings, in terms of medical knowledge they are not.”

    Might be equal as human beings? How would they not be? lol Or have you met my third cousin Gus who most suspect is at least one-fourth preening rooster?

  15. David Gorski says:

    Dr. Srivastava did not mention the specific company offering the test or even hints that would allow one to make educated guesses. She didn’t even mention which “integrative exhibition” her patient had attended. Obviously, it must have been in Australia and probably in the Melbourne area, given that that’s where Dr. Srivastava practices.

  16. pmoran says:

    Dr Srivastava is using the term “integrative” medicine incorrectly, perhaps prompted to do so by the patient and some of the entities that she encountered.

    Even “complementary” medical practitioners would, or should, disown this kind of medical practice, since that term also implies that normal conventional medical procedures are (also) being followed.

    This is a different thing — health fraud, pure and simple. It is wrong to imply that that integrative medicine will necessarily lead to this kind of thing.

    On the other hand, we should be alert to ensure that those who justify themselves with these terms actually practice what they preach.

  17. Mark Crislip says:

    I do have a love for unusual or archaic words and like the parallel construction that the word pie provides.

  18. Ken Hamer says:

    ” If it makes the patient feel better, it must be better, you know, just like the sham acupuncture that made the asthma patients feel better without reversing their underlying airway constriction.”

    So with enough Demerol, you can cure pretty much any illness or injury?

    sCAM at its finest.

  19. Mark P says:

    This is a different thing — health fraud, pure and simple. It is wrong to imply that that integrative medicine will necessarily lead to this kind of thing.

    Ah, the old “no true Scotsman” fallacy gets another run! http://en.wikipedia.org/wiki/No_true_scotsman

    Inasmuch as “integrative” actually is code for complementary or alternative, it does lead to this sort of thing all the time. OK, sometimes one’s chakras are misaligned, or the chi is blocked, or there is a subluxation etc. But the essentials are the same.

  20. MerColOzcopy says:

    Supplements don’t work? How about 22 different ones recommended by Dr. Oz. Working miracles for this guy!!!
    http://www.youtube.com/watch?v=V33Y5rqj4_g Minute 3
    http://www.youtube.com/watch?v=eHa06Ikqadw&feature=related

  21. pmoran says:

    Inasmuch as “integrative” actually is code for complementary or alternative, it does lead to this sort of thing all the time.

    I defy you to find an example where a self-designated “integrative” medical practitioners has done anything comparable. It makes no sense that, having developed such a concept so as to make their activities more palatable to the mainstream, they would then go and shoot their foot off.

  22. sarah007 says:

    David it’s a nice idea but it does depend on which side the fantasy is. For example being told that having a swine flu jab or that even swine flu is pandemic consitutes a fantasy, avoiding your doctor at all costs on this one is a must.

    If I have arthritis being told that pain relief or joint replacement or steroid injections is all we can do is a fantasy, along with stents ie we can fix it.

    The idea of integrative is nonsense and that I would agree with wholeheartedly.

  23. sarah007 says:

    Like the post mercolozopy, funny how no one really acknowledged it?

  24. I defy you to find an example where a self-designated “integrative” medical practitioners has done anything comparable. It makes no sense that, having developed such a concept so as to make their activities more palatable to the mainstream, they would then go and shoot their foot off.

    Peter,

    Please look here for the reference to the ACAM (American College for Advancement in Medicine), which calls itself the “voice of integrative medicine.” Look at the various links to other discussions of “chelation therapy.” I’m sure you’ve seen them before.

  25. “Dr. Srivastava did not mention the specific company offering the test or even hints that would allow one to make educated guesses. She didn’t even mention which “integrative exhibition” her patient had attended.”

    bummer.

  26. David Gorski says:

    This is a different thing — health fraud, pure and simple. It is wrong to imply that that integrative medicine will necessarily lead to this kind of thing.

    No, Peter, it is not wrong, and, whatever Dr. Srivastava’s intent, I at least am not implying that integrative medicine will lead to this kind of thing. I’m outright asserting it. It’s not as if we here at SBM haven’t provided numerous examples over the course of the four years this blog has been in existence. Need I mention the Cancer Treatment Centers of America and “naturopathic oncology” yet again, in addition to Kimball’s example?

  27. David Gorski says:

    I defy you to find an example where a self-designated “integrative” medical practitioners has done anything comparable.

    Dr. Rashid Buttar, who is president of the North Carolina Integrative Medical Society. He is also a cancer and autism quack. Dr. Buttar has done much worse than what is described in Dr. Srivastava’s article.

    http://www.sciencebasedmedicine.org/index.php/the-north-carolina-board-of-medical-examiners-dr-rashid-buttar-and-protecting-the-public-from-practitioners-of-non-science-based-medicine/

    http://www.sciencebasedmedicine.org/index.php/pitfalls-in-regulating-physicians-part-1/

    I’ll be happy to provide more examples, if that’s not enough.

  28. Scott says:

    Dr. Srivastava did not mention the specific company offering the test or even hints that would allow one to make educated guesses. She didn’t even mention which “integrative exhibition” her patient had attended.

    I would have expected that she couldn’t mention such details due to privacy concerns. OTOH, I also would have expected you to mention that, if such was indeed the standard. Where does the line lie on that sort of thing?

  29. David and Kimball,

    Reality be damned; obviously those aren’t true Scotsmen.

  30. papertrail says:

    MerColOzcopyon said:
    “You guys are getting your ass kick here!!!” http://www.care2.com/greenliving/chiropractors-naturopaths-are-they-dangerous.html

    That article is by Mercola=huge red flag. A quick Googling shows that the judge wasn’t ruling on the efficacy or safety of chiropractory nor on the right of the defendants to heavilyt criticize it, but rather the judge ruled that the defendants (AMA and others) didn’t have a right to to launch what the judge thought was an all-out boycott against chiropractory. The defendents had already ceased the purported boycott activities years before, but the judge wanted them to acknowledge that licensed chiropractory has a right to exist – even if screwy (my words, not the judge’s). No monetary penalty was issued against the defendants.

    RE: the SBM ads, sites have no control over the ads that Google chooses to run; it’s based on keywords.

  31. pmoran says:

    David and Kimball, yes, Buttar does strain my point that integrative medicine is a more benign form of CAM that recruits mainly relatively safe psychological therapeutic influences including placebo treatments, and that may be able to help a few patients with existential problems that the major religions previously took upon themselves.

    Yet even he states on his web site “The therapies that patients will receive will compliment the care they receive from their primary care physicians and will not replace those treatments.”

    The care that Dr. S’s patient received is NOT “comparable” to that. There is even a strong hint of knowing deception (i.e. fraud) in that case, whereas I have little doubt that Buttar believes in his chelation, just as many other mainstream doctors once believed strongly in mammary artery ligation, and arthroscopy for knee osteoarthritis.

    Our difficulty in convincing the Buttars and like medicos of the error of their assumptions highlights the absurdity of the view that we can somehow educate the general public around to our way of thinking about the medical sciences. We may be able to increase public trust in us in various ways, most notably by coming up with better answers to their medical problems, but we will never be able intellectually immunize them against rogue medical science, in my view.

    So I am considering a fall-back position that contains strategies to deal with the main dangers from CAM. I can’t see any strategy towards anything realistic in the “tar it all with the same brush”, “our way or no way” approach manifested in the sceptical side of most skeptical discussion.

    That has the potential to confront patients with the same extremely dangerous either/or choice that the worst elements of CAM create with their extreme hostility towards mainstream medicine. Even chelation is less dangerous than that.

  32. Harriet Hall says:

    @pmoran,

    You seem to think that it’s OK to accept the less harmful bits of CAM just because you don’t want to alienate patients who might then go on to the more harmful bits. Is there a logical fallacy called the argument from fear? I maintain that we should be able to find ways to inform patients without alienating them and to accept their use of CAM without having to censor our reasons for not using it.

    “Our way or no way”? You keep hearing that, but it’s a distortion of what we are actually saying.

    As for tarring it all with the same brush, is there some CAM that you think doesn’t deserve any tar at all?

  33. DW says:

    “and that may be able to help a few patients with existential problems that the major religions previously took upon themselves”

    Previously? Last time I checked, the major religions haven’t stopped taking them on …

  34. pmoran says:

    DW:“and that may be able to help a few patients with existential problems that the major religions previously took upon themselves”

    Previously? Last time I checked, the major religions haven’t stopped taking them on

    Quite true, of course, but they are known to have fewer adherents, and people are seeking meaning for their lives in other ways.

  35. papertrail says:

    pmoran said: “I have little doubt that Buttar believes in his chelation”

    Why do you say this? He looks like a genuine scammer to me.

  36. papertrail says:

    “integrative medicine is a more benign form of CAM that recruits mainly relatively safe psychological therapeutic influences including placebo treatments,…”

    It’s more insidious than the obvious fraudulent scams to integrate nonsense into a medical system that needs more, not less, effective treatments. Placebo is a low bar for treatment efficacy. Isn’t the point of controlled study to see if a treatment significantly EXCEEDS the placebo effect? I, for one, resent this deviation from science, reason, reality that we see with integrated medicine. It’s costly, misleading, and it erodes critical thinking abilities. I see a lot of doctors going along with patients who want to try x,y, or z “alternative” methods. I don’t know if they just don’t want to argue, or if they themselves believe it might work, or they don’t want to be the bad guy taking away hope, or if they don’t want to be blamed if the patient’s condition worsens. I, for one, would appreciate if a doctor told me honestly if something has known efficacy or not. I find it a bit frightening to see real doctors and institutions lowering their standards of evidence. Heck, I jumped down my dentist’s throat for recommending Zicam to me for a cold. “I believe you; I believe you,” he said.

  37. lizditz says:

    PMoran, I see you are a retired general surgeon in Australia. You may not be aware of the extent to which CAM or integrative medicine (CAM/I) has invaded the treatment of autism in childhood. (Note: autism is a life-long condition; it seems that parents of children with autism, rather than autistic adults, are the major consumers of CAM/I.

    I have been following listserv discussions of CAM/I for autism for over 7 years. The sorts of testing and “treatment” routinely suffered by autistic children makes what happened to Dr. Srivastava’s patient look like a cakewalk. Yes, the patient was frightened, but did she have unnecessary invasive procedures, years of potentially dangerous (and useless) medications, rounds of intravenous treatments, diet restrictions, and more?

  38. I have little doubt that Buttar believes in his chelation…

    Peter,

    Whether or not he believes in his chelation is irrelevant. He and many other ACAM members are dangerous quacks. Please read the entire chelation article that I linked previously, and look at some of the websites of the “community chelation sites.”

    The best ‘fallback’ position, in my opinion, is to return to the stance of modern medicine prior to its recent capitulation to pseudomedicine: call quacks what they are, loudly and clearly, so that they will once again be marginalized.

  39. David Gorski says:

    Yet even he states on his web site “The therapies that patients will receive will compliment the care they receive from their primary care physicians and will not replace those treatments.”

    Of course he does. That’s nothing more than a common variant of the Quack Miranda Warning. Its only purpose is to attempt to protect Dr. Buttar from liability.

    Are you really that naive? I mean, really.

  40. David Gorski says:

    I have been following listserv discussions of CAM/I for autism for over 7 years. The sorts of testing and “treatment” routinely suffered by autistic children makes what happened to Dr. Srivastava’s patient look like a cakewalk. Yes, the patient was frightened, but did she have unnecessary invasive procedures, years of potentially dangerous (and useless) medications, rounds of intravenous treatments, diet restrictions, and more?

    Indeed. For instance, there’s the Rimland Center for Integrative Medicine, which advertises hyperbaric oxygen chambers, woo diets, antivaccine views, and “biomedical” quackery.

  41. David Gorski says:

    So I am considering a fall-back position that contains strategies to deal with the main dangers from CAM. I can’t see any strategy towards anything realistic in the “tar it all with the same brush”, “our way or no way” approach manifested in the sceptical side of most skeptical discussion.

    Straw man much, Peter?

  42. pmoran says:

    The calling of logical fallacies is getting close to a substitution for factual debate.

    David and Harriet, the “tar it all with the same brush” is a necessary consequence of the prevalent skeptical orthodoxy that softness towards any area of CAM will encourage its crazy depths.

    The “our way or no way” is a necessary and logical consequence of the principles of EBM/SBM often espoused here, those allowing for no leeway between methods that “work” and methods that “don’t work”.

    So how can you claim that I am constructing a “straw man” with these phrases? What enables you to say, “we are not like that at all”? Or am I to regard it as a generous concession towards CAM if you occasionally and very privately show leniency towards CAM when under patient pressure to do so?

    If this truly IS a straw man, then you do need put opposing sentiments on show somehow, in the interest of public perceptions and all that. (To be fair, Harriet does in some ways.)

    So that it is clear, I take very seriously the responsibility that the public has placed upon the medical profession and its institutions to sort out what is true and not true in what would otherwise be, and indeed once was, medical chaos.

    So there is no question, Harriet, of me ever “accepting” homeopathy or like methods as having equal status within conventional medical care. Fortunately there would already be few members of the public who do not know that these methods lack some of the certainties that can be attached to conventional methods. We reinforce that perception by having special names for them such as “CAM”. If they were to be more passively tolerated in some settings, they should always be held at some distance (intellectually) from routine medical care.

    Medical interactions can be very complex. Many aspects don’t in the least fit in with the physicochemical model upon which most mainstream therapeutics is based. We heap scorn on CAM practitioners when they say this, but it is actually a context-dependent component of medical truth, as is the inevitability that within the often frantic, over-stressed, complex machinations of conventional medical systems some patients will not get treated with the humanity and sensitivity that sick individuals deserve or need. That is another matter of fact.

    So what then, if some doctors should want to (reasonably safely) specialize in those aspects of medical care, and try to help our most difficult and needy patients, in any way that seems to be helpful including the use of symbolic diagnoses and treatments? I don’t feel wholly comfortable that this should be needed either, but I have to stop short of the standard attitude of total condemnation. (Please don’t bother claiming that that is another straw man — it is a matter of fact and strongly evidenced here by attitudes and misunderstandings of integrative medicine as it is intended by most of its proponents. )

  43. Harriet Hall says:

    @pmoran,

    I reject false claims and physicians offering treatment based on false claims; I don’t reject the rights of patients to choose treatments based on false claims by others. But I do think they have the right to be given accurate information, and who is going to do that if we don’t?

    “Many aspects don’t in the least fit in with the physicochemical model upon which most mainstream therapeutics is based”

    Good medicine follows the biopsychosocial model and considers every aspect of patient care including psychological factors, human interactions, caring, etc.

    “within the often frantic, over-stressed, complex machinations of conventional medical systems some patients will not get treated with the humanity and sensitivity that sick individuals deserve or need”

    That is true, but that’s a reason to improve our humanity and sensitivity, not to abdicate and let CAM pick up the slack.

    “if some doctors should want to (reasonably safely) specialize in those aspects of medical care, and try to help our most difficult and needy patients, in any way that seems to be helpful including the use of symbolic diagnoses and treatments?”

    If they can do this without lying, fine. The problem I have with CAM and integrative medicine is that they misrepresent the truth about the treatments they offer; they make truth claims not supported by evidence. Symbolic? There’s a difference between suggesting “you could think of this as an imbalance of yin and yang” and claiming “this needle will balance your qi.”

  44. David Gorski says:

    The calling of logical fallacies is getting close to a substitution for factual debate.

    “Factual debate”? I certainly don’t recall seeing you contributing your own facts very often. More specifically, I don’t see you citing much in the way of studies, science, or anything other than your beliefs and anecdotes. In fact, argument by assertion sans studies and evidence seems to be your modus operandi. We here on SBM analyze studies and cite evidence. You complain about how mean and close-minded you think some of us are, apparently especially me. And, no, your touting your alleged scientific/skeptical credentials doesn’t deflect criticism. Not accepting homeopathy as scientifically valid is an exceedingly low bar for a skeptic to meet, and you are no skeptic any more. You were at one time. I remember when you were, back in the day on misc.health.alternative, when you helped inspire me to become a lot more active in combatting quackery and antivaccine nonsense. You were awesome. You inspired me. But not anymore. It saddens me to think back on those days. It really does.

    In any case, one notes how you sidestepped the issue of Dr. Rashid Buttar. In fact, you came damned close to outright defending a complete quack, even going so far as to point out his disclaimer on his website, not realizing that it’s nothing more than a quack Miranda warning. I point out that you just cited a quack Miranda warning, and you try to act as though the topic never came up, preferring instead to wax indignant about straw men.

    In any case, Harriet, as she usually does, nails it. The problem with so-called “integrative” medicine is that it requires misrepresenting science to patients.

    We reinforce that perception by having special names for them such as “CAM”. If they were to be more passively tolerated in some settings, they should always be held at some distance (intellectually) from routine medical care.

    Nonsense. You have it exactly backwards. CAM and “integrative medicine” are passively tolerated more and more. The result is not what you think it should be. That’s the problem. The more CAM and IM have become tolerated, the less distance quackery is held intellectually from routine medical care. In fact, that’s the entire point of CAM practitioners wanting to “integrate” alternative medicine into real medicine.

  45. pmoran says:

    My remarks stand. Harriet at least seems prepared to respond according to the details of the medical claim and according to cost/benefit/risk potential, which is mainly all I am suggesting.

    It is not a “lie” to say that homeopathy seems to help some people with subjective symptoms, in fact that “fact”, David, is supported by so much evidence that it is the whole reason that we have to perform double-blind placebo controlled studies when trying to find out which treatments possess intrinsic efficacy.

    I disagreed that the Buttar quote is a quack “Miranda warning” but couldn’t be bothered responding to the attempt to discredit me with an go at an “all Scotsman are dangerous” fallacy.

    It is probable that some scammers and know-nothings will try and exploit the integrative medical label, but for credibility purposes with their wiser clients, not because it offers any protection against the law if they injure people with quack treatments. It doesn’t, that I can see.

  46. David Gorski says:

    It is not a “lie” to say that homeopathy seems to help some people with subjective symptoms, in fact that “fact”, David, is supported by so much evidence that it is the whole reason that we have to perform double-blind placebo controlled studies when trying to find out which treatments possess intrinsic efficacy.

    Then surely you could cite a few studies, Peter. If there is so much evidence supporting your point of view, it shouldn’t be too hard for you to throw me a bone and provide me with a few studies, would it?

  47. Harriet Hall says:

    @pmoran,

    “It is not a “lie” to say that homeopathy seems to help some people with subjective symptoms.”

    No, but that’s not what they tell their patients. They tell them it is an effective treatment for specific diseases. And some even claim it can replace vaccines!

  48. DW says:

    “… softness towards any area of CAM will encourage its crazy depths.”

    That is plainly true.

    “allowing for no leeway between methods that ‘work’ and methods that ‘don’t work’.”

    How much leeway should there be between methods that work and methods that don’t work? “None” seems about right to me.

  49. nybgrus says:

    If they were to be more passively tolerated in some settings, they should always be held at some distance (intellectually) from routine medical care….So what then, if some doctors should want to (reasonably safely) specialize in those aspects of medical care, and try to help our most difficult and needy patients, in any way that seems to be helpful including the use of symbolic diagnoses and treatments?

    You are very, very far removed from reality here Peter. Perhaps you should go an audit a few of the CAM and IM lectures offered at your local medical school.

    Or perhaps you would be willing to continue defending the concept of IM after hearing my professor – the head of the IM department at my medical school – lecture about how good and bad thoughts and heal and cause cancer? Or how he thinks there is genuine intrinsic value to Reiki beyond placebo and non-specific patient/practitioner effects? Or perhaps you would like to attend his weekend workshop where he sells you the credentials to give your patients a saliva test for $300 to determine how well their nutraceutical anti-aging regimen is working?

    Or perhaps you’d be interested to discuss levels of evidence with the PharmD lecturer on CAM at my medical school. The same one that cites a Cochrane and NaturalStandard review of glucosamine and says we should recommend that to OA patients, but when citing nearly identical reviews from the same two sources regarding feverfew for migraine says we shouldn’t recommend that to patients. I asked her how, based on evidence that is 98% identical, we can recommend one but not the other. She had no answer. She went on to say that some things just can’t be “reduced” and that “science has tried but failed” to separate out these mystical synergistic attributes to “holistic herbals.” And closed the lecture by citing that asinine “study” on the necessity for an RCT to demonstrate we need parachutes when skydiving. The point of which being that, sometimes, we just don’t need no stinkin’ evidence – not when it comes to our “holistic herbs.”

    Or perhaps you would like to meet some of my undergrad professors in medical anthropology who literally yelled at students (myself included) that “Western medicine” is evil and very rarely gets things right, that “Eastern medicine” is tried and true over millennia and is the only true healing modality out there.

    I guess my point here is, that your conclusions are logical and valid… but your assumptions on which they are based are false. People are NOT learning CAM/IM in the manner you seem to think they are. They are being taught as true and useful healing modalities. Not from a “placebo and non-specific, when patients are desperate and SBM has run out of options” perspective. No, sir. From a “these are equally valid and often superior modalities that will, in and of themselves, improve the quality of medical care delivered by including them in the SBM armementarium” perspective. And, of course, in order to maintain that veneer of genuine intrinsic utility, poor critical thinking and logical fallacy is taught outright as part and parcel, with heavy appeals to the naturalistic fallacy and the argument of ancient knowledge.

    So before you go on again about how wonderful placebo effects are and how we can scientifically integrate it into our practice (damned be the ethics of lying to patients), take a second to realize that is not what is being taught in CAM/IM classes and lectures. And the more and more they are “integrated” and have their own departments and heads, the more and more the genuine woo starts coming through. It’s not just a conflation of pharmacognosy with CAM – it is a genuine belief in ideas as ridiculous as energy healing being taught credulously. The more imprimatur of legitimacy these charlatains gain, the more bold they are becoming in asserting BS as fact and teaching that, in certain cases (as determined by them, of course), it is just fine to suspend the rules of EBM because “science just can’t reduce that.”

    This has been documented extensively here, and I have personally experienced it – both in the US and Australia – throughout my education.

    And I have to close by addressing this bit of tripe:

    Many aspects don’t in the least fit in with the physicochemical model upon which most mainstream therapeutics is based. We heap scorn on CAM practitioners when they say this, but it is actually a context-dependent component of medical truth, as is the inevitability that within the often frantic, over-stressed, complex machinations of conventional medical systems some patients will not get treated with the humanity and sensitivity that sick individuals deserve or need. That is another matter of fact.

    First off, we are all taught the biopsychosocial model. There is no such thing as the “physiochemical model” however much the sCAMsters would love to have everyone believe that.

    Secondly, I cannot begin to describe to you how much it is hammered into us that medicine is vastly context dependent, that patient-practitioner interaction and rapport is vital, and that we are frantic and over worked and as such we need to work even harder and change systems in order to make sure that everyone gets treated with the humanity and sensitivity that people need. You want to know how seriously that is taken? I had a mate FAIL an assessment because he laughed while breaking bad news. To a standardized patient.

    It is a matter of fact – and we are being taught about it and how to combat it. Systems are changing to better address it. But the notion that we need to somehow add in CAM to address it is absolutely inane. I mean really – the problem is we are over worked and have too much to do, so lets add more things to learn and practice and take up time?? Nevermind that those things are BS and only designed to take up time anyways.

    I’m sorry Peter, but you really are off the reservation on this one. You are arguing a straw man – but one that is fundamental to your very understanding of the issue.

  50. pmoran says:

    Me: It is not a “lie” to say that homeopathy seems to help some people with subjective symptoms, in fact that “fact”, David, is supported by so much evidence that it is the whole reason that we have to perform double-blind placebo controlled studies when trying to find out which treatments possess intrinsic efficacy.

    David:Then surely you could cite a few studies, Peter. If there is so much evidence supporting your point of view, it shouldn’t be too hard for you to throw me a bone and provide me with a few studies, would it?

    I obviously have in mind the innumerable studies involving dozens of unlikely treatment methods that enable us to now predict that anything at all offered as a potentially active medical treatment is bound to elicit “positive” results in non-blinded RCTs of subjective and psychosomatic complaints.

    As I said, this is why we now insist upon blinding, also why the physicochemical therapeutic model (that relying upon direct physical or chemical physiological influences, Nybgrus) favoured by EBM/SBM generally refuses to take any notice whatsoever of what non-blinded studies show.

    That is the correct approach for many medical questions, but it might be going a tad too far when considering the interests of some patients under conditions that are very likely to apply right here and now, and that they constantly try to tell us about, and that some skeptics respond to in the most alienating fashion possible.

    All that “negative” results in blinded studies enable us to say is that those treatments lack intrinsic medical activity. It does not say the patient is not truly feeling better for for other reasons, as is also allowed by the “biopsychosocial model” of medical practice that Nygbrus and his fellow medical students are now being encouraged to practice.

  51. Harriet Hall says:

    @pmoran,

    I’m having difficulty following your reasoning.
    “anything at all offered as a potentially active medical treatment is bound to elicit “positive” results in non-blinded RCTs of subjective and psychosomatic complaints.” and placebos elicit a certain percentage of positive results when used as controls in blinded studies. So should we listen to what these patients “constantly try to tell us about” and feel free to offer them all kinds of CAM as well as sugar pill placebos with the claim that “these seem to help people with subjective symptoms”?

    If RCTs are “the correct approach for many medical questions,” when are they not the correct approach and how do you know that they are not?

    If you are willing to go by the patient’s statement that he truly feels better, doesn’t that mean it’s just as logical to give him a sugar pill?

  52. nybgrus says:

    also why the physicochemical therapeutic model (that relying upon direct physical or chemical physiological influences, Nybgrus) favoured by EBM/SBM generally refuses to take any notice whatsoever of what non-blinded studies show.

    I have many friends in medical school. And not just mine. Not a single one of them is taught anything outside the biospychosocial model. Everything we do is framed in the context of it. Give a drug? Discuss options which take into account the patient – can they afford it? Are the side effects tolerable? Can you convince them and help them to do diet and lifestyle changes that will accomplish the same goal? Do they just need someone to talk to and that’s why they are asking for a drug?

    And I am not kidding about the last one. It is an explicit point in the diagnostic routine I am taught – “What is the patient trying to tell me?” Are they asking for a narcotic or benzo because they are depressed and could use some talk therapy? Then talk to them!

    So I cannot even begin to imagine how you think that “EBM/SBM generally refuses to take any notice whatsoever of what non-blinded studies show” because I am constantly reminded of it in my learning and by all my attendings when seeing patients, with no sCAMs needed to facilitate that.

  53. David Gorski says:

    I obviously have in mind the innumerable studies involving dozens of unlikely treatment methods that enable us to now predict that anything at all offered as a potentially active medical treatment is bound to elicit “positive” results in non-blinded RCTs of subjective and psychosomatic complaints.

    Then throw me a bone and list a couple, if these studies are so “innumerable.” Then explain how they support the use of implausible methods, which is what you seem to be arguing. I don’t think I’m asking for much at all. In fact, I’m amazing myself right now at how low a bar I’m setting right now. I’m usually much more of a pain in the posterior. I must be getting soft in my old age.

  54. David Gorski says:

    If you are willing to go by the patient’s statement that he truly feels better, doesn’t that mean it’s just as logical to give him a sugar pill?

    Well, yes, that does appear to me to be exactly what Peter is arguing (or has been arguing over the last couple of years). At least, when you strip away all the verbiage and contortions, I really do think that that’s what Peter’s thesis boils down to, advocating placebo medicine. In that case, I really do share your question: When are RCTs not an appropriate means for judging the efficacy of an intervention, particularly for diseases or conditions with a large subjective component? And if a treatment does no better than placebo, why would it be ethical to use it? After all, if drug companies tried to market products that were no better than placebo, they’d be rightly condemned (look at all the controversy right now over antidepressants, where some evidence suggests that for mild depression they aren’t any better than placebo), but when CAM practitioners do it they’re excused or even defended?

  55. marilynmann says:

    Some practitioners of integrative medicine may try to coopt the concept of patient-centered medicine, but then some of them try to use the language of quantum physics . . . That does not make either patient-centered medicine or physics less valid, in my opinion.

  56. pmoran says:

    Harriet:If RCTs are “the correct approach for many medical questions,” when are they not the correct approach and how do you know that they are not?

    David: When are RCTs not an appropriate means for judging the efficacy of an intervention, particularly for diseases or conditions with a large subjective component?

    Harriet, you yet again, and despite my previous protests extracted a phrase of mine and gave it a wholly different context and meaning. Then David responded to your misrepresentation. I have simmered down now and will try to clarify.

    As my use of the words “blinded”, and “non-blinded” (completely ignored in the above) should have suggested, I was talking about precisely what those different kinds of studies allow us to conclude.

    Approaching the point from a different direction, we all agree that one of our objectives and obligations is to provide truthful information to the public about what various medical approaches can “do”.

    So this question arises : “what should we say to the public when medical programs centred around acupuncture, or homeopathy or other CAM methods produce substantial effect sizes for subjective relief of symptoms in non-blinded studies?.” ( i.e. those studies that David is disingenuously pretending he has never heard of. If anyone truly doesn’t know what I am talking about, examine the studies involved in the Hrobjartsson meta-analyses, or any study on acupuncture that includes a no treatment group or the NEJM article on acupuncture for asthma recently discussed here. The briefest of Google searches yields this, showing how sham methods and other placebos can often produce clinically significant effect sizes using standard measurement instruments http://content.karger.com/produktedb/produkte.asp?typ=fulltext&file=000320374 . Hence my assertion that any treatment at all can “seem” to work given the right conditions. )

    The classical skeptical interpretation of the relevant body of evidence remains the bald “it (i.e. the treatment method) doesn’t work”. That is justifiable in the strict scientific sense, being a semantically true statement in the strict sense of the words whenever double-blind studies show that a method works no better than a sham version that we believe lacks any intrinsic medical activity. (That is not always entirely clear, but we’ll shelve that for now).

    Yet all we truly know is that “it” does not work better than sham, which often involves a trivial change such as inserting acupuncture needles in a slightly different place. That kind of sham has implications for theories as to “how” it might work or not work, but it doesn’t provide an entirely clear answer to the more general and open question of “whether it will work for me” ” i.e. the one that concerns most patients.

    So we do need to ask ourselves whether the classical approach is concealing information that some patients might find significant. Most people are exceptionally sensitive to testimonial, and not too concerned about the obvious flaws in those, so why would they not find such studies of interest for their personal purposes, especially when there is nothing better on offer or the only alternaitive is an unnecessarily powerful and side-effect prone pharmaceutical ?

    We are entitled, indeed obliged, to state that we think these methods work through placebo and other non-specific influences, but not to infer “this treatment program cannot possibly benefit you” when subjective and psychosomatic conditions are involved.. (Of course this will probably also now be labelled as one of the straw men that I am surely now renowned for. I maintain that it is either explicitly stated or a clear implication of at least 90% of the utterances on these pages. )

    Can we justify such a paternalistic and authoritarian approach? Is it even ethical to also wish to undermine such treatments at every opportunity, beyond stating the simple truth that any benefits are likely to be due to placebo and non-specific influences, and making sure that the limitations of those are clearly understood?

  57. Harriet Hall says:

    @pmoran,

    I think your distinction is irrelevant. Both unblinded and blinded studies can lead to false conclusions of effectiveness, especially when the blinding is suboptimal and the research design is faulty in other ways.

    “stating the simple truth that any benefits are likely to be due to placebo and non-specific influences, and making sure that the limitations of those are clearly understood?”

    Isn’t that what I’ve been advocating all along?

    I don’t say “this treatment program cannot possibly benefit you,” but if the benefits are due only to placebo, I question the ultimate value of providing them in a way that misleads patients.

    When we say a treatment “doesn’t work,” we are really saying that there is no evidence that it works better than placebo. Perhaps we need to be more careful about out language.

    If you are advocating something other than the deliberate use of placebos, I can’t see the difference.

  58. papertrail says:

    @nybgrus …”So before you go on again about how wonderful placebo effects are and how we can scientifically integrate it into our practice (damned be the ethics of lying to patients), take a second to realize that is not what is being taught in CAM/IM classes and lectures.”

    Your post is very disturbing! and enlightening for a layperson to get such a detailed glimpse of how medical schools are integrating nonsense and nonsensical instructors into their curriculum. I heard the same kind of thing from a retired doctor a few years ago. What will it take to stop this downward spiral?

    How did we get to the point where so many people, including friends of mine and family, announce that they don’t care if something is a placebo as long as it works? I sputter when I try to respond to them. I do believe placebos “work”, of course they do; we all know that if you believe something is helping you then you feel better. For one thing, it’s a relief to believe something is helping, and we all know that stress and being overly focused on a symptom can exacerbate it. But, I think that most of the time, placebo-based improvement in symptoms are a result of misattributing normal waxing and waning, resolution of pain, and the success of other treatments to the fake treatment.

    Fine, if someone wants to try fake medicine, that’s their problem, but should medical institutions pretend the emperor is wearing clothes? I’m pretty sure these same patients who claim placebos are fine would be pretty pissed off if they found out that a surgery they endured at a reputable hospital and paid thousands for was known to perform no better than a placebo.

  59. pmoran says:

    If you are advocating something other than the deliberate use of placebos, I can’t see the difference.

    Oh, come on! There is no one here who does not allow that placebos may have a place under some circumstances. Those who don’t are self-deceiving fools — or anaesthetists or infectious diseases consultants where the question will indeed hardly ever arise.

    What we are against is the systematic incorporation of placebo medicines into the mainstream. We have limited right to condemn them outisde that province, so long as the claims being made are consistent with placebo potential and well-meant. This is how medicine always was, and always will be to some extent until science delivers totally safe and effective asnwers to all medical problems. We are about half-way there.

    I just want us to understand our own science a bit better, and to understand CAM better, and to understand our patiients better.

    I remind you that this discussion began because pf inapproprate use of the term “integrative medicine” by Dr S. I still feel that deserved a comment, in fairness to the general run of those subscribing to that appellation. If this is to become a propaganda website, let’s call it something else.

  60. weing says:

    @pmoran,

    Let’s take the example of the patient with asthma who experiences subjective improvement with acupuncture but, as the study showed, no objective improvement in spirometry testing. If this patient decides to go camping far into the wilderness with a friend who has acupuncture needles with him instead of bringing along his inhaler for any asthmatic attack. How would you advise him? With a saying of the prophet? “Trust in God, but tie your camel first.”

  61. Harriet Hall says:

    @pmoran,
    “Oh, come on! There is no one here who does not allow that placebos may have a place under some circumstances.”

    I think the time has come for you to specify what you think the place of placebos is and under what circumstances.

  62. papertrail says:

    “I think the time has come for you to specify what you think the place of placebos is and under what circumstances.”

    That’s what I was wondering. Some examples please.

  63. nybgrus says:

    I don’t have much time to respond and I am on my phone, do this will be brief. But do take note that peter never once address the fact that so-called integrative medicine professors are NOT advocating the judicious use of well meaning placebo responses in specific circumstances. They are teaching that these interventions have actual and distinct effects BEYOND placebo. They are teaching that energy medicine is legitimate BEYOND placebo. They are teaching that science cannot”reduce” (in quotes since they use it as a pejorative) the effects of natural herbals to a single our few ingredients that elicit an effect, but that there is some sort odd mystical synergy that occurs from the “natural” version that would magically be lost if the individual molecular components were replicated in a lab. And they do all of this whilst flashing study tithes and journals, which, when I looked them up (which I can sure you nearly no one else did) were either very poor, did not actually sorry the thesis they were making, or were actually REDACTED.

    So once again peter, get off your placebo hobby horse and address the fact that no matter how much you say it, the version of IM you are talking about is not what is being taught.

  64. papertrail says:

    What nybgrus said.

  65. papertrail says:

    And, once confronted that these treatments are nothing more than the placebo effect, that’s when you start hearing the defense that placebos work, and so this mind-body medicine claim has to be addressed.

  66. nybgrus says:

    I still don’t have terribly much time but at least I am on a computer now. My previous post was riddled with autocorrect erros, but hopefully it was still understandable. If not, please let me know and I will take some time later today to correct it.

    @papertrail:

    Your post is very disturbing! and enlightening for a layperson to get such a detailed glimpse of how medical schools are integrating nonsense and nonsensical instructors into their curriculum. I heard the same kind of thing from a retired doctor a few years ago. What will it take to stop this downward spiral?

    It is disturbing. And exactly the point that is consistently referred to here and that I have been discussing. The detailed, nuanced, and indeed interesting finer points of the applicability of placebo do not enter the equation – the premise has not yet been addressed.

    As I said, if what was taught by the head of IM at my medical school was the judicious use of placebo and non-specific effects from patient-practitioner interaction that would be one thing, and we would be having a wholly different discussion. It is not the case however. As I said, he is specifically teaching that these CAM modalities have effect BEYOND placebo. That thought can literally cause and cure cancer.

    So any discussion about the applicability of placebo effects and responses in cases of highly subjective and suggestible outcomes is entirely moot. Yet Peter keeps dragging the conversation down that road. It is an interesting and worthwhile discussion. I disagree with Peter on a number of things, but I do not think he is completely off base. But, as I will continue to stress, the conversation hasn’t even made it to that point yet. The notion of how IM is actually taught and practiced needs to be addressed, and that is something conveniently ignored.

    As for how to prevent this downward spiral – a strict advocacy for rigor. Something like the Friends of Science in Medicine for example. I am a personal member, and will be working to affiliate my student organization with them as well. And in my correspondence with their founding members, the head of my IM department whom I have referenced many times, is indeed someone they are “interested” in because of exactly the fact that he is credulous and believes in inane things like energy healing.

    This reminds me of a PZ Myers post about the journalist who suddenly realized that people actually believe the Jesus stuff and was shocked – he had been under the erroneous assumption that it was just ritual that brought comfort but people didn’t actually believe in a literal talking snake and a rib-woman. Shock of all shocks when he realized they actually do.

    It seems as though Peter doesn’t believe that these professors and heads of IM departments in hospitals and medical schools actually believe they are channeling the “one true universal energy” or such nonsense and that they are talking about the comforting ritual of the patient-practitioner interaction. Perhaps he will be shocked as well when he realizes that is actually not the case.

  67. David Gorski says:

    …those studies that David is disingenuously pretending he has never heard of

    Now I’m “disingenuous,” eh? Apparently along with close-minded, too strident, and uncaring as well, all of which are things you’ve either said or strongly implied about me in the past. Funny, Peter, how you constantly cry out for “civility,” but when challenged you are every bit as capable of getting down and dirty with the rest of us, all while adopting the mantle of seeming civility while throwing smugly dismissive invective at my fellow bloggers Kimball and Mark (“Those who don’t [allow that placebos may have a place under some circumstances] are self-deceiving fools — or anaesthetists or infectious diseases consultants where the question will indeed hardly ever arise). Ah, well. It is what it is.

    In any case, I value precision and specifics in any sort of debate. When someone starts pointing to “evidence,” I want to know which specific evidence; i.e., which studies. The reason is so that I can try to be precise as well. You pointed to a body of studies that may or may not support your point of view; so I wanted an example (or two or three). I don’t consider that unreasonable. It might be calculating in that I want something firm to grasp on to in this discussion given that you’ve provided nothing more than vague proclamations as difficult to nail down as Jello to a wall, but it’s not insincere or dishonest. Whether you believe me or not is up to you.

    Be that as it may, let’s take a look at your viewpoint again. I’m still with Harriet here. In spite of your efforts to convince yourself and us that it is not, what you appear to be advocating does indeed appear to me to be placebo medicine, with the differences you cite being distinctions without real differences. For example, you say, “What we are against is the systematic incorporation of placebo medicines into the mainstream. We have limited right to condemn them outisde that province, so long as the claims being made are consistent with placebo potential and well-meant.” Yet what is the vast majority of CAM (particularly some of its most popular modalities, such as acupuncture, “energy healing,” and homeopathy, which is not that popular in the US but still very popular in Europe) but placebo medicine? By your own words, you should be alarmed at CAM becoming so accepted in not just mainstream medicine but medical academia because you say you’re against the the “systematic incorporation of placebo medicines into mainstream.” There’s a reason I use the term “quackademic medicine” so frequently, after all. But then you give yourself an out. The placebo medicine that is CAM is apparently OK to you as long as the practitioner’s heart is in the right place and he doesn’t claim too much for his placebo medicine.

    Nybgrus has you pegged, though. What is taught as CAM is not the “judicious use” of placebo effects (whatever “judicious” means in that context). Rebranding “CAM” as “harnessing the power of placebo” is a relatively recent phenomenon that is a direct result of the utter failure of most CAM modalities, when rigorously tested, to have any detectable efficacy above and beyond that of placebo. In fact, I just wrote about that “rebranding” (now there‘s something that’s really disingenuous) a couple of months ago:

    http://www.sciencebasedmedicine.org/index.php/the-rebranding-of-cam/

    Even then, CAM apologists can’t resist infusing advocacy of placebo medicine with “The Secret”-like wishful thinking:

    http://www.sciencebasedmedicine.org/index.php/does-thinking-make-it-so-cam-placebo-fantasy-versus-scientific-reality/

    The problem with your apparent viewpoint with respect to CAM placebos is that the practitioner advocating the “judicious use” of placebos without deceiving patients is either a mythical beast that doesn’t exist or such a rare beast that it might as well be mythical.

  68. papertrail says:

    “Nybgrus has you pegged, though. What is taught as CAM is not the “judicious use” of placebo effects (whatever “judicious” means in that context). Rebranding “CAM” as “harnessing the power of placebo” is a relatively recent phenomenon that is a direct result of the utter failure of most CAM modalities, when rigorously tested, to have any detectable efficacy above and beyond that of placebo.”

    Yup, that just about sums it up.

    First recognize that certain practices are anything from outright scams or fraud to well-intentioned use of the placebo effect. Then, the ethics of (“judicially”) using known placebos can be addressed.

    Pmoran’s viewpoint is familiar to me. I heard the same type of argument from a doctor friend who accused me of being just as much of an a-hole as the CAM proponents when I expressed disgust over a new reiki hands-on (not just hand waving) training program for nurses and staff at our local hospital. I’m seeing a slippery slope movement away from science and toward magical thinking/practices while he argues that certain practices are CAM-lite: they’re popular, can do no harm (supposedly), comforts patients and gives them hope, and are not imposed on any patient. Offer it, I say! But call it what it is, maybe “New Age Spirituality.” Offer it through the religious/spiritual support department just as other religions are represented. At the same time, realize that some patients benefit from human touch from their medical practioners (except those who don’t like touch).

    I say reiki “supposedly” does no harm because nocebo effects are as real as placebo. I know someone (otherwise bright) who suffers from the belief that she picked up a sick friend’s negative illness energy while trying to help her through healing touch. (I shouln’t have laughed.)

  69. papertrail says:

    I said: “First recognize that certain practices are anything from outright scams or fraud to well-intentioned use of the placebo effect.”

    Just to be clear, by “well-intentioned use of the placebo effect” I meant that they don’t realize that their method is nothing more than the placebo effect (which includes misattributing patient improvement to their intervention).

  70. nybgrus says:

    (whatever “judicious” means in that context).

    I agree. Whatever that means indeed. However, I was granting that to Peter since the argument simply hasn’t progressed to the point of determing what a “judicious use” might be.

  71. David Gorski says:

    Fair enough. I was mainly using that little aside to tweak Peter to start to define what he means by “judicious.”

  72. papertrail says:

    It appears that China is increasingly moving away from traditional Chinese medicine (TCM) – realizing it’s mostly ineffective and superstition – even as TCM has been part of their national pride, culture, and medical education. Good article about that here: http://www.chinadaily.com.cn/life/2008-08/27/content_6975080.htm

    This first person article conveys the slope that I see western nations sliding down with our sCAM/integrated medicine movement, as Chinese medicine begins to crawl its way up: Tao of Traditional Chinese Medicine – Part I and II by Yau-Man Chan, Nov 2008

    http://www.skepticblog.org/2008/11/02/tcm-1/
    http://www.skepticblog.org/2008/11/09/tcm-ii/

  73. nybgrus says:

    @papertrail:

    China actually long ago realized that TCM was useless. It was Mao himself that purged the notion and demanded scientific rigor… until he realized that he needed to appease the masses and it was easier to feed them TCM than actual medicine (in large part because there were already 10s of thousands of TCM practitioners around, but very few science based ones). There was, of course, also a pushback from the lower classes since they genuinely believed in their TCM, even though Mao tried to send educated practitioners out to the countryside. It was forced to be so as a political move that Mao used to gain more power and authority. Since then it became part of the cultural identity of China and was promoted for tourist purposes. However, even Mao himself did not use TCM and none of the elite class did either.

    Post-modern Westerners under the logical fallacies of naturalism, vitalism, and especially ancient knowledge combined with some potent PR and a general call for tolerance and acceptance of all ideas and conventions (cultural relativism) led to the upsurge in developed nations. I remember being taught in my Med Anthro degree that hospitals in China had two sides – the “Western” side and the “TCM” side. This was said to be because “Western” medicine was useful in treating acute illness and trauma whereas TCM was useful for chronic ailments (hmmm, where have we heard this before?). In reality, it was primarily a split between the haves and the have-nots and driven purely by political necessity and not from an sort of actual science or top-down belief in its efficacy.

    What we here in the US (and Australia as well, actually) think of as TCM and its history is a very romanticized and “Hollywooded” version of reality.

  74. pmoran says:

    <I think the time has come for you to specify what you think the place of placebos is and under what circumstances.

    You first, Harriet. You have elsewhere allowed that their use may be occasionally justified.

    This is a diversion that I should have avoided. My interest is not what mainstream doctors might sometimes find it wise to do (yes, “judiciously”) under unusual circumstances, but what attitudes we should adopt to the inevitable, widespread, compulsive use of placebo medicines that is likely to continue for the foreseeable future, not only as CAM, but often as over-the- counter remedies using poorly validated but traditional pharmaceuticals, or as folk remedies, or as dietary and supplement mythology.

    I am merely suggesting that some SBM assumptions deserve re-examination, for example as those put forward to explain why people use placebo medicines and what they get out of it. My worst heresy on these pages, if you want a really good reason to set me alight at the stake, is to imply aloud that CAM is not necessarily all bad.

    How might it transform our discussions with and perhaps even our influence over CAM-using practitioners if we are able to admit that they not only think they are doing good, they sometimes actually are, only not for the reasons that they think? Is that naive? Possibly, but it would surely defuse some of the allegations of turf protection and blind bias. It also puts us more squarely on the side of the patient when we are to regard their interests as the paramount concern rather than scientific niceties that in the main need not concern them.

    I am suggesting that a slightly different, less aggressive approach, one that shows a quieter confidence in our scientific footing, may put us in better position to confront those areas where CAM presents real dangers.

    The rhetoric of Nybgrus, David, and a few others can logically sustain only one course of action — the ruthless suppression of all forms of CAM. They will deny that they really intend that while bemoaning that just such zero tolerance has not worked that well even where it should be most effective, with our supposedly scientific peers and in our own institutions. You and papertrail are, I think, somewhat less down that path.

    I freely that my ideas are still half-baked in some respects. I am engaged in an evolving thought-experiment. It was triggered a few years ago by modern studies suggesting that placebo influences could be more “real”, substantial and widespread than generally allowed. That along with the simple fact that science does not supply very useful (or appealing?) answers to human existential questions led me to consider whether CAM and its spiritual and patient-centred pretensions can have positive effects for some under the conditions that apply within medicine right here and now.

    Once I started thinking along those lines a lot of my own prior assumptions began to look thin, including the one that people who didn’t think quite the same as me (“shruggies” etc) just didn’t understand the problems as well as I.

    The embracement by certain elements of CAM of the idea that what they do is recruiting psychological “healing” forces means that the scientific “battle” is all but won with them. It is not in my view grounds for switching to another, higher level of rejection and condemnation at the expense of dialogue concerning certain lines that (still) must not be crossed.

    The problem is partly one of communication. There is no entirely suitable vocabulary for describing certain aspects of medical interactions. Some of our vocabulary has too much adverse history attached to it — for example a lot of different ideas and emotions get stirred up in the mind by “placebo effects”. making it almost impossible for us to think of them as being the “good thing” that they surely are within many medical contexts.

    That statement, will of course now be portrayed as “advocacy” by by your own straw man mongers, when I have already stated that placebo effects are not a suitable tool for mainstream medical practice, for several reasons, although the availability of safe placebos for common conditions could be beneficial from a public health perspective, if they were able to reduce the use of of more risky measures.

  75. pmoran says:

    Sorry, italics and some grammar corrected (I hope)

    I think the time has come for you to specify what you think the place of placebos is and under what circumstances.

    You first, Harriet. You have elsewhere allowed that their use may be occasionally justified.

    This is a diversion that I should have avoided. My interest is not what mainstream doctors might sometimes find it wise to do (yes, “judiciously”) under unusual circumstances, but what attitudes we should adopt to the inevitable, widespread, compulsive use of placebo medicines that is likely to continue for the foreseeable future, not only as CAM, but often as over-the- counter remedies using poorly validated but traditional pharmaceuticals, or as folk remedies, or as dietary and supplement mythology.

    I am merely suggesting that some SBM assumptions deserve re-examination, for example those put forward to explain why people use placebo medicines and what they get out of it. My worst heresy on these pages, if you want a really good reason to set me alight at the stake, is to imply aloud that CAM is not necessarily all bad.

    How might it transform our discussions with and perhaps even our influence over CAM-using practitioners if we are able to admit that they not only think they are doing good, they sometimes actually are, only not for the reasons that they think? Is that naive? Possibly, but it would surely defuse some of the allegations of turf protection and blind bias. It also puts us more squarely on the side of the patient when we regard their interests as the paramount concern rather than scientific niceties that in the main need not concern them.

    I am suggesting that a slightly different, less aggressive approach, one that shows a quieter confidence in our scientific footing, may put us in better position to confront those areas where CAM presents real dangers.

    The rhetoric of Nybgrus, David, and a few others can logically sustain only one course of action — the ruthless suppression of all forms of CAM. They will deny that they really intend that while bemoaning that just such zero tolerance has not worked that well even where it should be most effective, with our supposedly scientific peers and in our own institutions. You and papertrail are, I think, somewhat less down that path.

    I freely admit that my ideas are still half-baked in some respects. I am engaged in an evolving thought-experiment. It was triggered a few years ago by modern studies suggesting that placebo influences could be more “real”, substantial and widespread than generally allowed. That along with the simple fact that science does not supply very useful (or appealing?) answers to human existential questions led me to consider whether CAM and its spiritual and patient-centred pretensions can have positive effects for some under the conditions that apply within medicine right here and now.

    Once I started thinking along those lines a lot of my own prior assumptions began to look thin, including the one that people who didn’t think quite the same as me (“shruggies” etc) just didn’t understand the problems as well as I.

    The embracement by certain elements of CAM of the idea that what they do is recruiting psychological “healing” forces means that the scientific “battle” is all but won with them. It is not in my view grounds for switching to another, higher level of rejection and condemnation at the expense of dialogue concerning certain lines that (still) must not be crossed.

    The problem is partly one of communication. There is no entirely suitable vocabulary for describing certain aspects of medical interactions. Some of our vocabulary has too much adverse history attached to it — for example a lot of different ideas and emotions get stirred up in the mind by “placebo effects”. making it almost impossible for us to think of them as being the “good thing” that they surely are within many medical contexts.

    That statement, will of course now be portrayed as “advocacy” by by your own straw man mongers, when I have already stated that placebo effects are not a suitable tool for mainstream medical practice, for several reasons, although the availability of safe placebos for common conditions could be beneficial from a public health perspective, if they were able to reduce the use of of more risky measures.

    1. Harriet Hall says:

      @pmoran,

      “You first, Harriet.”[about when it is acceptable to use placebos]

      I WAS first, a long time ago. You have apparently forgotten. I gave the example of an elderly patient with mild dementia and a short life expectancy who asks me to give her a monthly B12 shot like her other doctors have been doing for decades. She doesn’t need it, but it isn’t likely to harm her. I am reasonably sure she will not understand or accept my science-based explanation of why she doesn’t need it. I think it is kinder to just give her the shot. Even then, I would feel a bit guilty.

      I’ve also given the example of a patient who brings up CAM and really wants to try it; I would try to find a way to explain my thinking to the patient without alienating him and if he still wanted to try it I would support him and see him for followup after the CAM.

      I guess my stance really boils down to this: I wouldn’t misrepresent the facts to a patient, but if the patient already believed a misrepresentation of the facts, I wouldn’t necessarily try to disabuse him. Out of my desire to “do something” and to please the patient, I have been guilty of finding a rationale for prescribing something that I knew was probably no better than placebo (i.e., antibiotics for a sinusitis that was probably viral, using the rationale that I couldn’t be sure that it might not actually be bacterial and that treatment might prevent bacterial superinfection). If a patient said he had had the same symptoms before and they always responded promptly to X, I might agree to give him X while explaining the post hoc ergo propter hoc fallacy and making sure he knew about any possible risks.

      We doctors sometimes “break the rules” when we feel it is more humane, but when we do we are acting paternalistically, treating without true informed consent, and having the hubris to think we are wise enough to know for sure what’s best for the patient. We must have rules: we should break those rules rarely and when we do we should feel guilty. We should leave the consultation room wondering if we really did the right thing, and we should worry about it when we are trying to go to sleep at night.

  76. weing says:

    @pmoran,

    “The rhetoric of Nybgrus, David, and a few others can logically sustain only one course of action — the ruthless suppression of all forms of CAM. ”

    Shining the light of reason and science on CAM is not suppression by any means.

    “the availability of safe placebos for common conditions could be beneficial from a public health perspective, if they were able to reduce the use of of more risky measures.”

    Besides use of placebos in studies, could you give an example of this?

  77. WilliamLawrenceUtridge says:

    Calling for the testing of compounds and procedures like vitamins and acupuncture respectively is not the “ruthless supression of all forms of CAM”. Given the many times the old CAM joke is made (What do you call CAM that has been tested and found effective? Medicine!) it really looks like what most of the editors here would like would be the testing of CAM modalities with sufficient prior probabilities. If it fails, it should be discarded (and certainly shouldn’t be promoted as effective). If it passes, it becomes part of the evidence-based armenture of real medicine (like, for instance, St. John’s Wort for mild depression).

    On purely effectiveness grounds, by failing to test their modalities CAM practitioners fail in two respects. If it’s ineffective or harmful, they provide an intervention that is either a waste of money or actively causing harm and thus shouldn’t be offerred (not banned, intellectually honest and ethical practitioners should simply cease to provide it). If it is effective then by not testing it, they are actually depriving the vast majority of the non-CAM using population from having access to an effective treatment. How would we feel if Big Pharma hid their best chemotherapeutic drugs or most effective antibiotics from everyone but their stockholders?

    And of course, there is always the more abstract, philosophical harm – the erosion of critical thinking and self-definition through contrast to “nasty, harmful, allopathic medicine”, which generally results in attempting to persuade patients to avoid or supplement real treatment.

    Peter, I had read and enjoyed your website about cancer in the past. Your comments in support of CAM are surprising to me and I have to wonder about the reception of the same standards you seem to advocate for here would receive in your own specialty. Would you be OK with providing an unproven chemotherapeutic drug to a desperate cancer patient? What do you think of Laetrile? Drs. Gorski et. al. are simply arguing for a unform standard for all proposed medical interventions – evidence of effectiveness before promotion of, or charging for, medical goods and services. I can’t see how this is a bad thing.

  78. nybgrus says:

    but what attitudes we should adopt to the inevitable, widespread, compulsive use of placebo medicines that is likely to continue for the foreseeable future

    In other words – give up and accept the fate that we can never expect everyone, not even actual doctors and scientists, to use critical thinking and evidence to base their decisions on.

    I am merely suggesting that some SBM assumptions deserve re-examination, for example those put forward to explain why people use placebo medicines and what they get out of it.

    You are merely suggesting a straw man. Gorski, Hall, and myself do not have a different interpretation of why people use placebo medicines nor what they get out of it. We have a different thought as to the validity and ethics of that line of thought and delivering said placebo medicines to them.

    My worst heresy on these pages, if you want a really good reason to set me alight at the stake, is to imply aloud that CAM is not necessarily all bad.

    Agreed. I’m getting my matches. (Just kidding). But yes, this is a legitimate point of contention, IMO.

    How might it transform our discussions with and perhaps even our influence over CAM-using practitioners if we are able to admit that they not only think they are doing good, they sometimes actually are, only not for the reasons that they think?

    Getting it right, on occasion and by accident, does not in the slightest justify CAM nor offer even the tiniest reason for us to support it (unless you have given up on the concept that we may be able to continue shedding light on these concepts for both ourselves and the public….). It is nothing more than grasping as straws to try and justify your stance. And it cannot even begin to outweigh the negatives associated with actual harm done, monies lost (by both public spending and research), and the erosion of critical thinking involved in “accepting” the utilization of CAM – not even individually and certainly not in aggregate. You are asking me to transform my rhetoric on an argument as thin as trying to say that amputating my toe is a good idea because it will help my shoe fit better, when I am saying we should just get new shoes.

    Possibly, but it would surely defuse some of the allegations of turf protection and blind bias. It also puts us more squarely on the side of the patient when we regard their interests as the paramount concern rather than scientific niceties that in the main need not concern them.

    And this is precisely the rhetoric employed by many an IM practitioner. “If you can’t beat ‘em, join ‘em!” Well, the first premise hasn’t been met, IMO. And standards dictate that the last should never be acceded. But more importantly… well, I’ll just invoke Dr. Crislip for an excellently succinct comment here- adding cow pie to apple pie does not make the cow pie taste better.

    I am suggesting that a slightly different, less aggressive approach, one that shows a quieter confidence in our scientific footing, may put us in better position to confront those areas where CAM presents real dangers.

    I get it. Fight the good fight. Ignore the benign stuff so you can really go after the bad stuff. Be able to say “See, look. I’m one of you. I totally dig this groovy (harmless) Reiki stuff, so we’re like, totally cool, man… but that other stuff over there… that’s some bad stuff man.” Except it just doesn’t work out that way in real life. That is more or less how this all got started… and how you end up with IRBs approving things like BAL for testing Prodantim and professors in my medical school claiming that thought alone can cause and cure cancer. Do you believe that last bit is perhaps a wee bit dangerous Peter? Do you think that teaching 1st and 2nd year medical students that though can cure cancer is not the wee-est bit dangerous? And what if I told you (again) that said professor told me, personally and verbatim, that he though homeopathy was BS and that he went into IM in order to co-opt what was good from CAM and horn “them” out of actual medicine? And in that same conversation told me he believes there is something more to reiki than just placebo effects?.

    Or will you stick to your guns again, and try and make the “judicious use of placebo” argument again, ignoring the fact that your rhetoric is exactly what is espoused by many an IM practitioner and leads to exactly the more dangerous modalities you are trying to eschew? Nevermind the money and erosion of critical thinking involved.

    The rhetoric of Nybgrus, David, and a few others can logically sustain only one course of action — the ruthless suppression of all forms of CAM.

    No. I am advocating the ruthless teaching of critical thought and evidence. And that anything taught in medical school pass that same (high) bar. I’m one heretical enough to point out that Swan-Ganz catheterization has little evidence to support its use. When asked outright by an attending I said “Yes, that means I would not use it.” This is not some CAM-only bash session. It just so happens that, by its very nature, CAM becomes the primary topic. It is the most common and the lowest hanging fruit. It’s akin to people asking why, in my secular groups, Christianity is “bashed” on so much. Why not Islam, Judaism, Hinduism? Well, because in the US Christianity is 85% of the population and 90% of the problem. Same with CAM in this context.

    They will deny that they really intend that while bemoaning that just such zero tolerance has not worked that well even where it should be most effective, with our supposedly scientific peers and in our own institutions.

    It hasn’t worked, because it hasn’t actually been done. Which has been explained many times. But when you can’t (yes can’t) point out that someone is laughably wrong due to political and social pressures, what do you think happens? Bad ideas flourish. It has nothing to do with a push back against “zero tolerance” it has to do with a social pressure that “there is no such thing as a bad idea.” As Dr. Novella said, “Standards are sacrificed at the altar of equality.”

    I freely admit that my ideas are still half-baked in some respects. I am engaged in an evolving thought-experiment.

    That’s fine. Honestly I have never begrudged you that (and I think that Drs. Hall and Gorski have not either). But when you consistently fail to address the very specific and demonstrably true counters and critiques to your stance… what can you expect? As I said, you even now continue to bring the conversation to the power and use of placebo medicine. We are not having that conversation. We are discussing the notion that in my medical school (ranked in the top 40 in the world) a professor is allowed to teach that thought can cure cancer. Full stop.

    That along with the simple fact that science does not supply very useful (or appealing?) answers to human existential questions led me to consider whether CAM and its spiritual and patient-centred pretensions can have positive effects for some under the conditions that apply within medicine right here and now.

    I wholeheartedly disagree and the fact that you simply assert it is a fact does not make it so. However, that is entirely irrelevant to the conversation and I won’t digress further than this.

    The embracement by certain elements of CAM of the idea that what they do is recruiting psychological “healing” forces means that the scientific “battle” is all but won with them.

    I actually don’t (fully) disagree here, believe it or not. It simply misses the mark again. While I don’t think there is such a thing as a “psychological healing force” there is indeed a grey area that is an interesting discussion. However, the problem is that CAM proponents do not claim just a marshalling of said forces via placebo in certain limited cases. They claim efficacy and utility well beyond that. (And of course, erode critical thinking at the same time). So even if your statement was 100% true, it still does not pan out in the real world.

    That statement, will of course now be portrayed as “advocacy” by by your own straw man mongers, when I have already stated that placebo effects are not a suitable tool for mainstream medical practice..

    Nope. I don’t even need to go there.

  79. nybgrus says:

    We doctors sometimes “break the rules” when we feel it is more humane, but when we do we are acting paternalistically, treating without true informed consent, and having the hubris to think we are wise enough to know for sure what’s best for the patient. We must have rules: we should break those rules rarely and when we do we should feel guilty. We should leave the consultation room wondering if we really did the right thing, and we should worry about it when we are trying to go to sleep at night.

    Extremely well said, Dr. Hall.

  80. jre says:

    I’m late to the party as usual, but figured I’d cross-post a comment from that other blog anyway:

    The NEJM article’s full text is, of course, behind the paywall.
    One notes with hope, however, that Dr. Srivavasta is not only prolific, but also one of those public-spirited folks who posts her papers:

    http://www.ranjanasrivastava.com/articles/

    Perhaps, when NEJM loosens its grip, this article will be posted there, too.

  81. pmoran says:

    Drs. Gorski et. al. are simply arguing for a unform standard for all proposed medical interventions – evidence of effectiveness before promotion of, or charging for, medical goods and services. I can’t see how this is a bad thing.

    That looks eminently fair and reasonable on paper, but how does it not imply that anything that cannot be shown to work better than placebo should be banned?

    When we in addition get nearly as uptight about pretty harmless nonsense like TT as we do about cancer quackery we project a daunting public image. Few might doubt that methods and practitioners lacking mainstream approval on its strict error-averse standards would be swept from the face of the earth if only we could twist enough arms and find a way around pesky personal freedoms.

    But my ruminations go beyond the image we may unthinkingly provoke in certain minds. They start from what modern placebo studies suggest i.e. that mankind has evolved the ability to beneficially respond to any kind of well-meant treatment ritual in ways that are very difficult to distinguish from a “real” treatment effect.

    This, together with religious understandings of illness — also exploited by CAM and folk medicine — is medicine “as it always was” over the untold millennia during which when there were few truly effective medical treatments. We have no scientifically valid way of excluding the likelihood that despite marked cultural differences in the paths that primitive medicine followed, and horrendous mortality rates from now preventable or treatable conditions, those cultures derived substantial non-specific comforts and symptomatic benefits from their culture-specific medical activities. Note that placebo theory allows us to say that without the need for post-modernist cultural relativism.

    So a lot depends upon how you look upon medicine as it stands today. Do you see it as having provided complete enough medical answers that we should lightly abandon all that went on before? I am not sure that is wise. There is still a lot of unmet medical need — people still need help with symptoms and existential threats.

    Another thing to think about — I have contended that most of the public would see Reiki as a rather silly activity. Yet I suggest that very few would regard it as something worthy of any great condemnation. Their approach will almost certainly be similar to papertrail’s, that so long as it is being practiced pretty harmlessly, “good luck” to those who think it helps them. Now these are the very people who have entrusted us with the job of sorting out the medical sheep from the goats. How come we turned out to be less tolerant than our employers? Are we putting scientific orthodoxy on too high a pedestal sometimes, at the expense of simple humanity? Which approach is more “correct”?

    That brings us to the supposed slippery slope, another very arguable skeptical platform.

  82. Harriet Hall says:

    @pmoran, “how does it not imply that anything that cannot be shown to work better than placebo should be banned?”
    Oh, come on, Peter! There’s a big difference between having a uniform standard for scientific evidence and banning things!

    “When we in addition get nearly as uptight about pretty harmless nonsense like TT as we do about cancer quackery”
    We don’t get “as uptight” about the practice of TT as about cancer quackery because it clearly has less potential for harm, but we do get equally uptight about any misuse of scientific reasoning because that is a serious underlying problem with a huge impact on every aspect of human life.

    “those cultures derived substantial non-specific comforts and symptomatic benefits from their culture-specific medical activities.” We don’t deny that; we can build on it: those same benefits are available in the context of effective science-based care.

    “Do you see it as having provided complete enough medical answers that we should lightly abandon all that went on before?” That doesn’t follow. We see it as providing the only way to find true medical answers. We don’t see that pre-scientific medicine provided any answers, or anything more than non-specific placebo benefits.

    “There is still a lot of unmet medical need.”
    Yes, and we should aspire to really meet those needs, instead of offering false information and false hopes.

    “[Reiki is not] something worthy of any great condemnation.”
    We are not “greatly condemning” the practice of Reiki so much as condemning the false information offered by practitioners, and the kind of faulty thinking that goes into accepting beliefs that are false.

    “Are we putting scientific orthodoxy on too high a pedestal?”
    No, we are not putting orthodoxy on any pedestal. We are promoting science and reason because they are the only way to approach the truth about how the world works.

    “at the expense of simple humanity?”
    True humanity means telling patients the truth and doing what is best for them in the long run.

    Now, please give us a direct response to my previous request, which you continue to evade: I think the time has come for you to specify what you think the place of placebos is and under what circumstances.

  83. weing says:

    @pmoran,

    I can see not telling kids that there is no Santa Clause and the gifts really come from us. But you can see how paternalistic that is. Do kids have a need for Santa? Do adults. We are trained to treat our patients as partners in dealing with their health problems. Sorry, but I cannot treat them like children. I have to tell them the truth as I see it.

  84. papertrail says:

    I need to get caught up on this thread but meanwhile, I wanted to share this article. The cartoon is on topic. I’m cheering.

    “Homeopaths are facing a fight to defend their practice in Australia after the National Health and Medical Research Council flagged it might declare their work baseless and unethical.”

    Read more: http://www.theage.com.au/opinion/political-news/alternative-medicine-crackdown-20120313-1uyiw.html#ixzz1p3uhBkwX

  85. pmoran says:

    Weing: @pmoran,

    “The rhetoric of Nybgrus, David, and a few others can logically sustain only one course of action — the ruthless suppression of all forms of CAM. ”

    Shining the light of reason and science on CAM is not suppression by any means.

    No, but our objectives are never clearly stated. They are left to the imagination. See comments to WLU.

    “the availability of safe placebos for common conditions could be beneficial from a public health perspective, if they were able to reduce the use of of more risky measures.”

    Besides use of placebos in studies, could you give an example of this?

    It’s largely hypothetical, I admit, but if we were to succeed in eliminating placebo use altogether we are left with pharmaceuticals and procedures that in general carry more risk than the placebo medicines that many at present resort to initially on a trial basis. Doctors would be under even more relentless pressure to prescribe NSAIDs, major antidepressants and tranquilizers, sleeping tablets and stimulants etc. when often all that is needed is a crutch to get the patient over a bad patch. It can be argued that no treatment at all should be needed for many minor complaints but in practice that such an ideal will never be approached.

    One simple example might be osteoarthritis, which often goes through prolonged exascerbations, sometimes provoked by trauma, and then settles right down again. If a relatively harmless agent such as glucosamine, or a topical counter-irritant can tide someone over, it has the potential to reduce serious ADRs from NSAIDs, and possibly even the premature resort to surgery in some.

    Thanks for the polite comments.

  86. WilliamLawrenceUtridge says:

    That looks eminently fair and reasonable on paper, but how does it not imply that anything that cannot be shown to work better than placebo should be banned?

    That’s quite the is/ought dilemma, but implication isn’t reality. Without any evidence, this seems more a fallacy of a slippery slope than an actual argument. Making it, let’s say ironic, that in your last sentnce you’re claiming I’m making a slippery slope argument.

    When we in addition get nearly as uptight about pretty harmless nonsense like TT as we do about cancer quackery we project a daunting public image. Few might doubt that methods and practitioners lacking mainstream approval on its strict error-averse standards would be swept from the face of the earth if only we could twist enough arms and find a way around pesky personal freedoms.

    And now this reads like health freedom. I think the specific arguments regarding therapeutic touch from the Drs. here would be more along the lines of “stop teaching it as part of nurse training, advertise that it has failed testing, and stop allowing it to count for continuing professional education hours”. In addition, in any country with a national health care system, you’re paying people for magick. If it were actual magic in the form of a conjourer performing tricks to cheer up patients, I’d be OK. But TT isn’t magic or magick – it’s neither entertainment nor is it a supernatural way of making people feel better. A responsible hospital should, on the balance of evidence, fire any TT practitioners, use the resulting savings to hire more medical staff and enhance the healing effects of medicine by allowing more time and attention be paid to patients. That is a reasonable, fiscally responsible way forward that would actually help people, rather than simply hoping at them that they get better. A good use of placebo effects is enhancing actual recovery rather than fooling people into shutting up.

    But my ruminations go beyond the image we may unthinkingly provoke in certain minds. They start from what modern placebo studies suggest i.e. that mankind has evolved the ability to beneficially respond to any kind of well-meant treatment ritual in ways that are very difficult to distinguish from a “real” treatment effect.

    And I have no problem with that, but it’s best incorporated as part of real treatment, and separated from the rhetorical assertion that “allopathic” medicine is ineffective and harmful. Particularly when humans have also evolved the ability to lie to themselves quite handily and decieve others for personal gain.

    We have no scientifically valid way of excluding the likelihood that despite marked cultural differences in the paths that primitive medicine followed, and horrendous mortality rates from now preventable or treatable conditions, those cultures derived substantial non-specific comforts and symptomatic benefits from their culture-specific medical activities.

    If there is no scientifically valid way of deciding something, it’s not a scientific question – it becomes a political and economic one. Which comes back to my earlier point – tax dollars and institutional resources should be put towards the greatest gain for the most people. And if we’re building placebo effects into this, that means giving doctors and nurses more time with patients – not wasting money paying someone to think happy thoughts.

    So a lot depends upon how you look upon medicine as it stands today. Do you see it as having provided complete enough medical answers that we should lightly abandon all that went on before? I am not sure that is wise. There is still a lot of unmet medical need — people still need help with symptoms and existential threats.

    Medicine moves forwards with more research, which means dropping settled scientific questions – like homeopathy, therapeutic touch and related nonsense. Again, meed medical needs through more time spent with real doctors – and add to it two public education policies. First, mental illness is still illness and is neither a source of shame nor a weakness. Second, ensure people understand the difference between medicine (a scientific product) and CAM (a rhetorical device).

    How come we turned out to be less tolerant than our employers? Are we putting scientific orthodoxy on too high a pedestal sometimes, at the expense of simple humanity? Which approach is more “correct”?

    As a taxpayer, I don’t want any of my money going wasted on something as absurd as reiki. Period. The advantage of living in a country with a public health option is we can have experts deciding what to fund and what to axe – and I damned well want the people making those decisions to be intolerant of nonsense.

    The best use of resources is one that genuinely heals and doesn’t cost us our humanity. You’re proposing a false dilemma here – that we can only have medicine plus nonsense, or our health care system becomes one that completely lacks any humanity, compassion or care. That’s false. We can have an effective, caring, evidence-based health care system that doesn’t include CAM. Preventing tax (or insurance) dollars from being spent on homeopathy does not turn your doctor into a monster, but it does mean more money to cover genuine health concerns.

  87. papertrail says:

    RE: WilliamLawrenceUtridgeon 14 Mar 2012 at 11:12 am

    Well said, well said!!!

    Pmoran, no, I’m very close to the “zero tolerance” camp, that is, zero tolerance for pseudoscience and magical thinking being taught to and supported by real doctors and nurses; bad enough that it persists outside of the mainstream.

    Pmoran said: “One simple example might be osteoarthritis, which often goes through prolonged exascerbations, sometimes provoked by trauma, and then settles right down again. If a relatively harmless agent such as glucosamine, or a topical counter-irritant can tide someone over, it has the potential to reduce serious ADRs from NSAIDs, and possibly even the premature resort to surgery in some.”

    So, you would advice me, your patient, to buy glucosamine or a topical irritant, knowing that its effects would be placebo-based at best, with unknown safety? How do you know that I wouldn’t decide to use glucosamine and this unnamed irritant for an extended period believing that it was actually healing my osteoarthritis instead of pursuing surgery, which, if I waited too long, could cost me an extended recovery period with less effective results? If you were my doctor, I’d fire you!

    That example hits home for me because osteoarthritis runs in my family. My brother was about to try an untested substance he had heard about. I Googled it and talked him out of it. You would talk him into it?!

    You need to decide: Are you on the side of science-based medicine or not? Pure and simple.

  88. papertrail says:

    This discussion reminds me of the “selective vaccination” debate. Selective science-based medicine.

  89. Harriet Hall says:

    @pmoran,

    I agree with papertrail. Moreover, we know that not everyone responds to placebos. How many of those osteoarthritis patients will get NO relief from glucosamine and topical irritants, will suffer needlessly, will curse you, and will not trust you to care for them in future when they find out you intentionally fooled them with a placebo treatment?

    How paternalistic of you! You unilaterally decide it is in the patient’s best interests to take something with no side effects and to believe they are getting an effective treatment when they aren’t, you give them an inferior treatment, and you fail to inform them.

  90. papertrail says:

    And what will you do, pmoran, when a patient tells you his symptoms worsened from the glucosamine? Will you then tell him that that wasn’t possible because it was just a placebo anyway? Or would you then send him for Reiki healing to remove the negative energy?

    Being unregulated, you don’t even know what’s in the bottle labeled “glucosamine.”

    Probably everyone already saw this, but worth sharing again. It’s a hilarious parody of integrative medicine, Mitchell and Webb. http://www.youtube.com/watch?v=HMGIbOGu8q0

  91. papertrail says:

    Harriet said: “to take something with no side effects…”

    Or more likely *with* side-effects, or unknown.

    Look at all the possible side-effects of glucosamine. http://www.mayoclinic.com/health/glucosamine/NS_patient-glucosamine/DSECTION=safety

  92. pmoran says:

    WLU:The best use of resources is one that genuinely heals and doesn’t cost us our humanity. You’re proposing a false dilemma here – that we can only have medicine plus nonsense, or our health care system becomes one that completely lacks any humanity, compassion or care.

    Not really, what I am talking to is another objective of a rational health care system, which is to keep patients with relatively minor conditions out of doctors’ offices and off unnecessarily powerful pharmaceuticals unless really needed. We know that seeing a doctor carries risk and often disproportionate taxpayer costs.

    This is where our “other” health care “systems” i.e. over-the-counter, folk medicine, and parts of CAM are probably helping the mainstream right now, through taking some of the potential workload off us, through being mostly funded by the user, through being mostly safer, and despite being largely placebo-based. (All the systems carry risk, but surely they can be addressed directly)

    Again I am coming up against the “ownership of medicine” issue. It is difficult for we doctors to envisage medicine as something that is not entirely under our control and responsibility.

    (I have agreed previously with your main point about CAM not being funded or generally endorsed by the mainstream)

  93. papertrail says:

    @pmoran
    “… to keep patients with relatively minor conditions out of doctors’ offices and off unnecessarily powerful pharmaceuticals unless really needed. We know that seeing a doctor carries risk and often disproportionate taxpayer costs.”

    Can’t doctors honestly tell a patient: “you have a relatively minor condition that doesn’t warrant medical treatment at this time and the risks/costs of prescribing you pharmaceuticals would outweigh any benefits. Meanwhile, here are some things you can do to maintain your health…).

  94. Harriet Hall says:

    “… to keep patients with relatively minor conditions out of doctors’ offices and off unnecessarily powerful pharmaceuticals unless really needed.”

    Not necessarily out of doctors’ offices, since doctors can do much to educate and comfort patients.
    Powerful pharmaceuticals should not be prescribed in the first place unless they are really needed.
    It’s not a question of who “owns” medicine, but of aspiring to optimum care of patients in the long run.

  95. It seems to me, and I may be off here, that pmoran is essentially advocating a compatiblist concept of non–overlapping magistria between (CAM based) placebo medicine and objectively effective/ Science Based Medicine. He puts forth the concept that each has its proper place and the two can successfully coexist and be integrated together without compromising the quality and integrity of the practice of medicine.

    Ethical considerations aside, he seems to believe that the use and promotion of certain modalities with firmly rooted bases of implausible underlying mythology and pseudoscience can be adequately confined to specific applications &/or practiced in such a was as to not result in the erosion of the science based practice of medicine for either the practitioner or the recipient.

  96. David Gorski says:

    The rhetoric of Nybgrus, David, and a few others can logically sustain only one course of action — the ruthless suppression of all forms of CAM.

    You say that as though it were a bad thing.

    I kid, of course, but, really, Peter. You don’t help your case when you use the same sort of rhetorical exaggeration that you accuse me of using.

  97. David Gorski says:

    (I have agreed previously with your main point about CAM not being funded or generally endorsed by the mainstream

    Funny, then, that you spend way more time and effort castigating SBM proponents for being too “strident” about examples demonstrating that CAM is, in fact, infiltrating the mainstream and being funded (by NCCAM, for instance) than you do complaining about CAM being funded by government and infiltrating the mainstream. It rather suggests some muddled, confused thinking, with two points of view (“we’re being too hard on CAM” vs. “we mustn’t tolerate quackery”) fighting it out for supremacy, with the “we’re being too hard on CAM” viewpoint marginally winning.

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