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

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

  1. DW says:

    It depends on what is meant by “suppress.” There’s “suppress” as in banning, outlawing, and punishing offenders (prescribers of “woo”). Then there’s “suppress” by educating people about the uselessness and/or harmfulness of CAM. I would think most here are totally in favor of “suppressing CAM” in the latter sense, but generally not in the first. (Except in cases where something illegal is happening.)

    It can never be completely suppressed, probably, but suppression in this sense is a good goal.

    Then, what was meant by “ruthless”? That sounds pretty mean. But I think it was just melodramatic language. I think you just meant the people you’re arguing with aren’t going to back down. That’s not “ruthlessness” – that’s integrity. Calling people ruthless just because they totally disagree with you is silly.

  2. Scott says:

    Personally, the only thing I want to ban is practitioners making false claims in order to sell their products/services.

    If that ends up being an effective ban on the products/services, as said practitioners tend to argue, well, that says quite a lot about their quality.

  3. pmoran says:

    I know that few of you expect to be able to totally suppress CAM but can you see how this common perception arises, DW, David and others?

    It is not merely a logical extrapolation from prevalent SBM viewpoints that CAM is worthless, dangerous and pushing good science aside. Similar views have been explicitly stated as a desired end in some the comments, with nothing but rah! rah! in response.

    Of course, being desirous of something approaching “ruthless suppression” is a reasonably appropriate response to some of the more horrible elements of CAM. But muddled in with our natural emotional responses to matters like that, which may be better confronted directly anyway, is our over-arching concern for “good science” (as we interpret it) and our visions of that being overturned by prescientific superstitions.

    So it happens that we appear to be involved an undifferentiated, indeed “ruthless” crusade against anything that is not mainstream endorsed. Yet we are constantly exposed as not being so pure ourselves. I can sense how aggravating this will be to some, if you cannot.

  4. pmoran says:

    Karl 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.

    Well, not quite.

    I am still feeling my way, Karl, but I am presently inclined to allow for the validity of a beneficial (in limited ways), all-pervasive “generic medicine” based upon placebo influences and supportive human interactions. These can apply within any medical environment, no matter how stupid it might seem scientifically.

    Overlaid onto that scenario is the relative latecomer of “biomedicine”. That name seems meaningless to me and I sometimes wonder where it sprang from, but it is used to refer to methods that have intrinsic, special — if you like, “additional” therapeutic activity. They add a different quality of therapeutic activity to that vague cloud of it that surrounds any medical interaction. They are now indispensable and often life-saving, but they don’t provide sufficiently safe and effective answers for everything.

    Looked at this way, CAM is an inevitable phenomenon, merely the continuance of what went before, serving adequately as medicine for some, helping others with problems that the mainstream lacks wholly satisfactory answers for or patients that it cannot quite “click” with, while posing real dangers for others.

    Those who find the existence of CAM depressing and a frustrating nut to crack, might find some comfort in this way of looking at it.

    .

  5. Harriet Hall says:

    @pmoran,
    “serving adequately as medicine for some, helping others”

    Serving inadequately as medicine for some, making others think they have been helped, comforting them with misrepresentations of the truth.

    No, I don’t think eventual health outcomes are improved by reverting to pre-scientific medicine. I think you are advocating for “feel-good” things that are ultimately not in the patient’s best interests.

  6. DW says:

    pmoran:

    >we appear to be involved an undifferentiated, indeed “ruthless” crusade against anything that is not mainstream endorsed.

    Well, I think you’re saying that SBM-ers have an image problem. They look mean and nasty, while purveyors of CAM look warm and fuzzy. That *is* a problem.

    One piece SBM advocates might really work on is the mistaken perception that they/we are against “anything non-mainstream.” This perception needs to change to, We/they are in favor of TESTING such things in a scientific fashion. Of course, it isn’t quite that simple, ‘cus not everything is worth testing, and some things would go on simply being rejected as ridiculous. But somehow the perception needs to change from negative to positive. SBM advocates have a bad rep because they’re perceived as negative, taking something away that brings some people comfort; they need to be perceived as IN FAVOR of something, rather than against something.

    They also need to fight the image that they are supercilious and superior, making fun of the little guy who just wants to take something to feel better and doesn’t give two hoots how it works, or even, unfortunately, WHETHER it works, as long as it somehow brings quick if temporary relief.

  7. Scott says:

    I know that few of you expect to be able to totally suppress CAM but can you see how this common perception arises, DW, David and others?

    IMX it’s primarily because practitioners of CAM insist that they HAVE to be able to make false statements to their marks – err, patients – in order to stay in business. Their rhetoric directly equates “don’t let people lie” with “ban CAM” (albeit not in so many words). Which really does say a lot, both about their position and how divorced your view is from the actual reality of CAM practice.

  8. nybgrus says:

    I know that few of you expect to be able to totally suppress CAM but can you see how this common perception arises, DW, David and others?

    It arises because that is expressly and with intent how the sCAMsters paint the rhetoric. The same way that atheists are “attacking Christmas” or “trying to take God away from people” or trying to “ban all prayer in schools” which is patently not true at all. It is all PR – from the other side of this conversation – since they have no ther substance.

    I do not let the other side dictate how to “balance” my rhetoric… they are seeking to neuter it such that they have an easier time of it. “Don’t be so mean!” is essentially “give me a pass on a few things so I can still keep lying about others.” As DW said – “ruthless” in this case only means being adamantly consistent and never conceding simply for the sake of “not being mean.”

    So it happens that we appear to be involved an undifferentiated, indeed “ruthless” crusade against anything that is not mainstream endorsed.

    No. We are undifferentiated and indeed “ruthlessly” crusading against anything not supported by good evidence and science. It does not matter from whence it comes, as you may see in Dr. Hall’s recent post about the dis-utility of annual physical exams. As I tried to point out previously, it just so happens that most of what is clearly not supported by good evidence happens to be…. CAM.

    These can apply within any medical environment, no matter how stupid it might seem scientifically.

    Nobody is arguing this. It is the application that is of concern. Incorporating those things into actual medicine is not only uncontroversial here, but actively encouraged. Having them exist as stand alone “treatments” coupled with a heaping helping of inanity and woo is not. The fact that you continually and relentlessly (shall we say “ruthlessly?”) conflate the two is a source of frustration here.

    Overlaid onto that scenario is the relative latecomer of “biomedicine”. That name seems meaningless to me and I sometimes wonder where it sprang from…

    I know where it came from. It was a term coined by the medical anthropology contingent. It was a term lectured to me in my undergrad as a differentiator from “healing.” It was often coupled as the catch-all term “Western BioMedicine.” If you like I can dig up some of my old papers where I used the term, commenting on its novelty and descriptive power.

    However, it is a false term designed as a PR tool to further differentiate the “evil reductionist” ways of focusing only on symptoms and never to actually “heal” a patient.

    The remainder of your paragraph reads disturbingly similarly to what my old med anthro profs (or Moerman and Kaptchuk) would say.

    And you wonder why we here question your thoughts and rhetoric? You simultaneously lambaste our choice of words and apparent “stridency” whilst using the intentionally crafted verbiage of those who seek to promote CAM despite a lack of scientific evidence.

    hose who find the existence of CAM depressing and a frustrating nut to crack, might find some comfort in this way of looking at it.

    I find it depressing when I see examples of genuine harm come from it. I find it frustrating because it is like a zombie or The Black Knight – no matter how many times and how many ways it is utterly destroyed, it rises from the dead, re-iterates the same tired disproven claims, and then crows victory.

    I do not have any issue understanding how or why it arises nor why people seek it out, despite your assertions otherwise. In fact, I have argued (and will continue) that it is you that lacks a complete understanding of the topic, since you refuse to acknowledge that in addition to everything you have just stated (which we all here already know quite well) there is a concerted political and ideological effort (similar to that of creationists) to further push CAM down our throats.

  9. nybgrus says:

    @DW:

    Well, I think you’re saying that SBM-ers have an image problem. They look mean and nasty, while purveyors of CAM look warm and fuzzy. That *is* a problem.

    It can indeed be a problem. And something we should be on the lookout for. However, as I said above, the answer is not to kowtow to the CAM apologists and use their definitions, their vernacular, and accede to their PR interpretation of us (as Peter consistently does).

    When you are involved in a controversy, even a manufactroversy like this one, there will always be people who are insulted, think us mean, and attempt to use that to discredit us. Those people are simply not to be listened to – they are to be unflaggingly demonstrated to be wrong. If everyone likes you, then you are either doing something wrong or are so acqueiscent as to be completely impotent.

    No, I disagree. To a non-insignificant degree it is quite necessary that certain people find us “mean.” The other option is to spin our wheels and accomplish nothing.

  10. DugganSC says:

    Frankly, I don’t know that the “image problem” of us attacking non-mainstream methods is entirely undeserved. There an article not so long ago where one of the doctors of the site was talking about the results of an electromagnetic therapy for cancers. He acknowledged that the science behind it was bad, the original usage of the therapy was bunkus and have been proven so, and yet, it was getting results. Immediately, most of the site descended on the paper and tore it apart, not on the virtue of its methodology or results, but its origin. I don’t think we ever got a follow-up on whether or not the therapy was found to be wrong, but the immediate reaction from the people here was hostility, frankly livid rage that this paper was showing such an outlandish technique working. I suspect that ultimately, the therapy was disproven, but anyone looking at the reactions would be entitled to a belief that we do attack alternative methods because they’re not our methods, not because they don’t work.

    1. Harriet Hall says:

      @DugganSC
      “attacking non-mainstream methods”
      It’s not a matter of attacking something because it is non-mainstream, but of questioning it when there are strong reasons for thinking it is implausible. It speaks to the central issue of this blog: that we need truly “science-based medicine” instead of simply “evidence-based medicine” that relegates prior plausibility and basic science to too low a level.

  11. papertrail says:

    DugganSC said: “There an article not so long ago where one of the doctors of the site was talking about the results of an electromagnetic therapy for cancers. He acknowledged that the science behind it was bad, the original usage of the therapy was bunkus and have been proven so, and yet, it was getting results. Immediately, most of the site descended on the paper and tore it apart,…”

    Funny, I thought Dr. Gorski was too kind with that study. How do we know it was “getting results”? It’s a leap to come to that conclusion from that one study. If I remember correctly, it was a mainstream study.

    Given the purpose of this blog, of course the writers here are going to choose a subject that is appears very dubious and then “tear it apart” (critically analyze it) for their readers.

  12. papertrail says:

    Warm and fuzzy people? Not if you cross them (generalizing). And simply disagreeing with some of their claims is often perceived as a threat, or just not worthy of their attention. Personally, I am trying very hard now not to resort to name-calling or put-downs, and in fact I often try to avoid getting into a discussion in the first place, but some CAM proponents can sure dish out the hostility, not to mention try to push crap down your throat.

  13. papertrail says:

    @pmoran

    Dr. Moran, I wanted to try to understand better where you’re coming from and so I looked back at older posts here and at your site and then Googled. Right now, I just want to say that I appreciate the fabulous work you have done with one of the best, most comprehensive anti-quackery resource on the web. You have truly been a positive force in my own understanding of what to believe and why/why not, for more than a decade.

    Okay, back to criticizing you for your stance on integrated medicine and placebos ;-)

  14. pmoran says:

    Thanks for the kind remarks , papertrail. Criticise all you like, but also don’t take anything on faith just because others say so. Good science requires the ability to question basic assumptions and to challenge preconceptions.

    I contend that the somewhat understandable reflex impulse to regard CAM as an entirely worthless, dangerous and disposable human activity has inhibited examining the phenomenon in more impartial and rigorous ways. This should be the place for that.

  15. papertrail says:

    Dr. Moran said: “I contend that the somewhat understandable reflex impulse to regard CAM as an entirely worthless, dangerous and disposable human activity has inhibited examining the phenomenon in more impartial and rigorous ways. This should be the place for that.”

    It hasn’t been a reflex for me to reject all CAM outright, but more of a journey to figure out what is what with all the thousands of health claims (seems like thousands, at least), both conventional and so-called alternative – as well as things like anti-vaccinationist claims, climate change, paranormal claims, etc.

    My conclusion, and why I appreciate this site and your work, is that science/critical thinking is the route for the person on the street to figure out how to discern the truth, even if it’s an imperfect and bumpy road. Many of us regular people, present or potential patients, want to see us speed up the trip to the truth in medicine with reforms to current systems, not go backward toward superstition and magic. And if it means sacrificing a few possibly useful/helpful currently “alternative” practices due to a negative bias that is based on the worthlessness, dangers, and disposability of the vast majority of “alternative” practices out there, it would be worth it.

    So, anyway, I just hope you’re proud of the work you have done. I see (Googling) that you have had to put up with insults from people who didn’t want to hear the facts you presented about dubious cancer cure claims. It may have seemed as if no one was getting it. But I think there are plenty of people who are like me, who really want to hear the facts from science-based experts and don’t want to waste money and time and false hope on untested, or no better than placebo, treatments.

    I hope you aren’t abandoning that effort. There are still people out there who need to know if, for example, they should spend $800 on shark cartilege for pancreas cancer (came close to doing that with my own father but the surgeon said it was too late – would have greatly preferred if he had advised that it was too dubious), spend their last days flying out to Brazil to see John of God to have him poke a rod up their nose and cut their chest to cure their breast cancer, travel to India to get a special homeopathic remedy that sounded credible because they heard about it through a mainstream organization, hire a Russian trained psychic to stop a recurring brain tumor over the phone after reading about him in the newspaper, or sell everything they own to head on out to Texas for Burzynski urine treatments, and on and on and on.

  16. papertrail says:

    Dr. Moran said: “…has inhibited examining the phenomenon in more impartial and rigorous ways. This should be the place for that.”

    I would like to know which particular CAM claims you think haven’t been handled by SBM impartially and rigorously enough. Maybe you have already done this and I missed it. If you don’t mind repeating.

  17. nybgrus says:

    contend that the somewhat understandable reflex impulse to regard CAM as an entirely worthless, dangerous and disposable human activity has inhibited examining the phenomenon in more impartial and rigorous ways

    Reflex? Really? Need I remind again that I have a degree in this nonsense? As do many of the other like minded commentators here?

    This is grabbing for straws again Peter. “How can we spin placebo effects into justifying rank pseudoscientific garbage and quell our consciences to allow it to pass when our patients are desperate and we desperately want to help them?”

    Finding ways to turn a blind eye is unbecoming of you.

  18. pmoran says:

    I would like to know which particular CAM claims you think haven’t been handled by SBM impartially and rigorously enough. Maybe you have already done this and I missed it. If you don’t mind repeating.

    A bit much to summarise, but I’ll try.

    The only CAM claims that might be considered tolerable, within some contexts, are those obliquely made tenable by evidence concerning placebo responses, also by the recognition that patients often bring complex, individual human needs into medical interactions. I say “only” but this can potentially cover most of the subjective side of medicine

    SBM allows for such influences but wants to appropriate them as an exclusively mainstream prerogative.

    Limited acceptance of this side to CAM derives from considerations of honesty, fairness, self-awareness, and facing up to certain uncomfortable realities about medicine and its highly compulsive consumption rather than any enthusiasm for CAM on my part.

    Athough, it has its practical side. Every man in the street knows that the mind can influence how we feel. The notion of placebo influences is not in the least strange to him. So that holding out that the most credible of the benefits that CAM claims for itself are due to such non-specific influences is as destructive, if not more, of the associated pseudoscience than pages of detailed scientiifc debunking. It attacks the every-day basis for belief (or uncertainty) concerning the pseudoscience, while being a tad permissive where there is might be benefits without disproportionate risk.

    I have also challenged some other overly simplistic skeptical dogma concerning CAM, relating to why people do it and what they get out of it.

    Don’t forget that in forums such as this zealotry is rewarded, moderate good sense not so much, so that extreme positions, even quite repellent ones, can become accepted as normal — even though good science normally errs in the opposite direction, towards caution.

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