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A Trilogy of (Acupuncture) Terror

A Trilogy of (Acupuncture) Terror

TAM is fast approaching, and I’ve been frantically trying to get my talks together. The theme this year is “Fighting the Fakers,” and one of my talks will be for the Science-Based Medicine Workshop on Thursday, in which I will attempt in a mere 15 minutes to explain what Science-Based Medicine is and how it can be used to combat the infiltration of quackademic medicine into medical academia. Then, the second talk will be a tag-team spectacular with Bob Blaskiewicz about Stanislaw Burzynski as an example of how some cranks skirt the edges of science-based medicine. That doesn’t make them any less dangerous (if anything, it makes them more dangerous), but it does make them not as easy to identify as someone like, say, Hulda Clark.

Trilogy_of_Terror_Poster

Unfortunately, between working on these talks, revising some papers, and having an unusually busy weekend on call, I wasn’t sure what I was going to come up with for the edification of you, our readers. Fortunately, right on the 4th of July holiday, there was an article that gave me my idea, particularly given that I had noticed a couple of studies on the very subject of the article in the week leading up to the long holiday in the US (at least for people not on call). As a result, I’m half tempted to refer to this article as a trilogy of acupuncture terror.

Oh, wait. I just did.

Book I: Acupuncture is harmless, right?

One myth that acupuncture apologists like to promote relentlessly is that acupuncture is completely harmless, that it almost never causes complications or problems. While it’s true that acupuncture is relatively safe, it still involves sticking needles into the skin, and, given that, it would be delusional to think that it couldn’t cause injuries. Rarely, however, have I seen a story like this in the Canadian newspaper the National Post, “Canadian Olympian’s ‘nightmare’ after acupuncture needle collapses her lung“. It is the story of what happened to Kim Ribble-Orr, a world-class judoka who had competed in the Olympics in 2000 and was harboring dreams of competing in the Olympics again, as a mixed martial artist. Those dreams were cast in doubt by a stray acupuncture needle:

When a massage therapist tried to treat the headaches she suffered after a 2006 car crash with acupuncture, however, he set off a cascade of health problems that would shatter Ms. Ribble-Orr’s sports-centred life — and raise questions about the popular needle therapy.

The therapist accidentally pierced Ms. Ribble-Orr’s left lung during acupuncture treatment that was later deemed unnecessary and ill-advised, causing the organ to collapse and leaving it permanently damaged. An Ontario court has just upheld the one-year disciplinary suspension imposed on therapist Scott Spurrell, rejecting his appeal in a case that highlights a rare but well-documented side effect of acupuncture.

Mr. Spurrell, who learned the ancient Chinese art on weekends at a local university, had no reason to stick the needle in his patient’s chest, and had wrongly advised Ms. Ribble-Orr that the chest pain and other symptoms she reported later were likely just from a muscle spasm, a discipline tribunal ruled.

Ribble-Orr had suffered many injuries due to her competition, including a dislocated elbow and shoulder, a broken hand, head injuries and repeated knee injuries. She had overcome them all to compete again, but appears unable to overcome this one. Basically, what happened is that in 2006, Ribble-Or was trying to get into mixed martial arts competition and was eying a job as a police officer. However, she was also recovering from injuries suffered in an auto collision and seeing Scott Spurrell, a massage therapist who had learned acupuncture during a weekend course at a local university. She was suffering from pounding headaches, and Spurrell convinced her that he could relieve those headaches by inserting a two-inch needle, according to the disciplinary ruling, “into a muscle located between the clavicle bone and ribs.” From the description, it’s not clear to me exactly which muscle they meant, although it could conceivably have been the scalenes, the sternocleidomastoid, or perhaps even just the pectoralis major. Whatever muscle Spurrell was targeting, going between the clavicle and the ribs is basically where surgeons stick the needle when trying to place central venous catheter into the subclavian vein, and, yes, a pneumothorax is a known potential complication of placing such lines. What also puzzles me is how on earth Spurrell could have stuck the needle in deep enough to cause a pneumothorax? It would be one thing if Ribble-Orr were a fragile little old lady, but she wasn’t. She was an athlete, presumably with well-developed musculature. It would take a lot to get a needle through all of that muscle and into the pleural cavity.

As can happen from a pneumothorax, even in a healthy person, Kibble-Orr developed pneumonia and required a thoracotomy. To be honest, it’s not clear from the account provided why she needed a thoracotomy, but it’s clear that the pneumothorax led to a cascade of complications, as described:

Shortly after leaving the clinic, Ms. Ribble-Orr began having difficulty breathing, chest pain and a “grinding” sensation. She returned to the therapist later, wondering if she had suffered a pneumothorax. He told her it was more likely a muscle spasm, but said she could go to the hospital if she felt it was more serious or if the symptoms worsened.

The next morning, she did feel worse and finally headed to the emergency department. Ms. Ribble-Orr’s lung had indeed collapsed and she spent the next two weeks in hospital, as a serious lung infection and then a blood infection followed. She was left with just 55% function in one lung.

One notes that if you do not have the knowledge to recognize symptoms and signs of potential complications resulting from your treatment, you have no business administering that treatment. It used to be that if you didn’t know how both to recognize and treat potential complications of your treatment, you shouldn’t be administering that treatment, but those days are gone. For instance, gastroenterologists do colonoscopies, even though they are not able to repair the inevitable (and thankfully uncommon) colon perforations that are a recognized risk of the procedure. But they can recognize the signs and symptoms. They know how to diagnose a potential perforation and when to call a surgeon to fix it. Spurrell was clearly utterly clueless, basically dodging responsibility by telling Kibble-Orr that she could go to the ER if she wanted to. Obviously, he didn’t think that she needed to. What should have happened, if Spurrell knew what he was doing, was a quick physical exam, which likely would have diagnosed a significant pneumothorax through decreased breath sounds or elevated diaphragm on the affected side, or both.

While the ruling against Spurrell is heartening, what is rather depressing is how Canadian authorities came around to it. Acupuncture is a licensed specialty. So authorities had to “prove” that Spurrell had no valid reason to insert a needle there (“valid” being defined within the system of traditional Chinese medicine undergirding acupuncture). In other words, they had to show that there was no reason under TCM to think that a needle stuck in that particular location would treat Kibble-Orr’s recurrent headaches. Moreover, it wasn’t the College of Acupuncturists who had jurisdiction, but rather the College of Massage Therapists, and the College only requires a certain number of hours of extra training to be able to administer acupuncture, a requirement that Spurrell had met. Of course, we at SBM would argue that there’s no science-based reason at all to think that sticking a needle in a point between the clavicle and the ribs would have any effect whatsoever on recurrent chronic headaches, and that should be enough. That’s the problem with regulating quackery; to prove misconduct or malpractice, you have to do it within the system of magical thinking of the quackery that has been licensed. If, for instance, Spurrell had been able to show that there was a valid rationale under TCM for inserting the needle there, he still might have been nailed for incompetence because he stuck the needle in too deep, but quite possibly he might not have been.

Particularly depressing are the comments. For instance, one commenter named Dr. Joanny argues:

Only a bonafide doctor of Chinese medicine or acupuncture is qualified to practice Chinese medicine. The problem is not acupuncture but who is inserting the needles into your body. Only someone who has trained and studied for several years, who has passed board/state/provincial exams, is qualified to practice. All reports of puncturing lungs involve people who are people who took a little bit of training.

Yes, this acupuncturist is seriously arguing that “well-trained” TCM practitioners wouldn’t have had this complication and then goes on to cite a paper from a very acupuncture-friendly source that shows a surprising number of serious complications from acupuncture, including cardiac tamponade, infection, various reports of needles breaking off and migrating elsewhere in the body (shades of the President of South Korea!), and even neurological injury. One remembers a recent review of the Chinese literature by Edzard Ernst describing complications of acupuncture, including pneumothorax (201 cases), spinal epidural hematoma (9 cases), subarachnoid hemorrhage (35 cases), right ventricular puncture (2 cases), intestinal perforation (5 cases), and a whole lot of other complications and infections. Indeed, Ernst found that pneumothorax was by far the most common significant complication of acupuncture, and, as we’ve discussed, acupuncture is not harmless. There are quite a few potential complications up to and including 90 deaths in the world literature.

All medicine is a risk-benefit analysis. All effective treatments have risks, and those risks have to be weighed against the potential benefits. When the benefits are significant (e.g., saving life), then greater risks are tolerable. When the potential benefits are minimal, then even minor risks might not be acceptable. When the potential benefits are none, no risk is acceptable. That is the case for acupuncture. It does not work, no matter how much acupuncturists try to prove it does.

Books II and III of The Trilogy of Acupuncture Terror are simply more evidence that this is true.

Book II: In which regression to the mean in a subgroup is mistaken for a real result

That acupuncture is nothing more than an elaborate placebo is now quite clear. In any case, none of this stops acupuncturists from claiming they can help in conditions with “hard” endpoints, such as in vitro fertilization for infertility. It’s all Tooth Fairy science, but they keep trying, and so they tried again recently. At least, Brian Berman tried again. Berman, as you might recall, makes his quackademic home at the University of Maryland, and last week my Google Alerts did their job, alerting me to a new systematic review published online late last week in the Journal of Human Reproduction Update. Berman is the corresponding author (of course!), and a research associate by the name of Eric Manheimer is the lead author, and together with other colleagues, they have produced yet another fine analysis of tooth fairy medicine entitled, The effects of acupuncture on rates of clinical pregnancy among women undergoing in vitro fertilization: a systematic review and meta-analysis.

Of course, as is the case for many acupuncture studies (actually, nearly all acupuncture studies), there is no prior plausibility. Think about it. How on earth would sticking needles into the skin improve the odds of conception? It wouldn’t, and it doesn’t. Through what biological mechanism would sticking little needles into the skin along fantastical “meridians” improve the likelihood of conception when embryos are transferred into the uterus? None that makes any sense, that’s for sure. That doesn’t stop acupuncturists and acupuncture apologists from heavily selling acupuncture as somehow managing to do just that, against all physiology and reality.

So here’s how the systematic review is being sold:

Acupuncture, when used as a complementary or adjuvant therapy for in vitro fertilization (IVF), may be beneficial depending on the baseline pregnancy rates of a fertility clinic, according to research from the University of Maryland School of Medicine. The analysis from the University of Maryland Center for Integrative Medicine is published in the June 27 online edition of the journal Human Reproduction Update.

“Our systematic review of current acupuncture/IVF research found that for IVF clinics with baseline pregnancy rates higher than average (32 percent or greater) adding acupuncture had no benefit,” says Eric Manheimer, lead author and research associate at the University of Maryland Center for Integrative Medicine. “However, at IVF clinics with baseline pregnancy rates lower than average (less than 32 percent) adding acupuncture seemed to increase IVF pregnancy success rates. We saw a direct association between the baseline pregnancy success rate and the effects of adding acupuncture: the lower the baseline pregnancy rate at the clinic, the more adjuvant acupuncture seemed to increase the pregnancy rate.”

It’s hard not to be a bit snarky here and say that if your clinic is doing well with its pregnancy rate, then obviously you don’t need mumbo-jumbo. However, if you’re not doing so well, maybe some bread and circuses will help.

So let’s look at the study itself or, as I like to say, go to the tape (or journal, or whatever). Basically, Berman and company examined sixteen trials with a total of 4,201 participants that compared needle acupuncture administered within one day of embryo transfer to sham acupuncture or no treatment. They left out studies that examined electroacupuncture (a famous bait-and-switch form of acupuncture frequently mixed in with regular acupuncture). Well, actually, not exactly. Their rationale for not using electroacupuncture studies was not what you would think, namely because they didn’t want to mix acupuncture studies with studies involving electricity, which didn’t exist at the time when acupuncture was allegedly invented. Rather, the rationale was that these studies involved studying electroacupuncture as an alternative to conventional anesthesia during oocyte retrieval and the points are therefore not chosen to improve fertility bur rather to reduce pain. Electroacupuncture was okay, as long as its intent was pregnancy. I kid you not. In other words, the authors excluded electroacupuncture, except when they didn’t.

In any case, the methods used were fairly standard systematic review/meta-analysis methodology, and when they were through they had 16 randomized trials. Now here’s the annoying thing. This is a negative study. Oh, the authors, as you can see from the press release, jump, jive, and wail to try to extract something out of it that can fool the rubes into seeming positive, but the bottom line is this. When they looked at the pooled studies, there was no statistically significant difference in pregnancy rates between the acupuncture and control groups. None. Nada. Zero. Zip. And any other word you can think of for “no” or “zero.” Or, as the authors put it, there was “no statistically significant difference between acupuncture and controls when combining all trials [risk ratio (RR) 1.12, 95% confidence interval (CI), 0.96–1.31; I2 = 68%; 16 trials; 4021 participants], or when restricting to sham-controlled (RR 1.02, 0.83–1.26; I2 = 66%; 7 trials; 2044 participants) or no adjuvant treatment-controlled trials (RR 1.22, 0.97–1.52; I2 = 67%; 9 trials; 1977 participants).”

That’s a negative trial. Acupuncture does not improve pregnancy rates. Did I say that enough times? Heck, consistent with what one would expect for an intervention that doesn’t have an effect, the asymmetric funnel plot showed a tendency for the intervention effects to be more beneficial in smaller trials. We see the same thing in virtually all clinical trials, but especially in clinical trials of CAM modalities. Homeopathy, in particular, is notorious for demonstrating this effect. So is acupuncture.

Of course, in so-called “complementary and alternative medicine” (CAM) or “integrative medicine” trials, there’s never such a thing as a negative study. So we have subgroup analysis, the better to seek statistically significant results in smaller pools of patients, where there might be more variability. All too often it’s not clear whether that subgroup analysis is prespecified or cooked up post hoc. To Berman’s credit, in this case, the subgroups were specified before the meta-analysis:

We conducted subgroup analyses on five clinical characteristics that might influence the effect of adjuvant acupuncture on clinical pregnancy success rates: (i) two acupuncture sessions or more than two; (ii) selection of meridian acupuncture points the same as the points selected in the first published trial (Paulus et al., 2002) that evaluated acupuncture as an adjuvant to embryo transfer, and which showed a large effect, or a modified version of this trial’s acupuncture point selection protocol; (iii) control group clinical pregnancy rate (as an estimate of the baseline clinical pregnancy rate) dichotomized as higher [32% or greater, which is the European average of pregnancy rate per embryo transfer (de Mouzon et al., 2012)] or lower; the control group clinical pregnancy rate was also analysed as a continuous variable to test whether the relation was linear and consistent with the findings of the categorical analysis; (iv) explanatory trials conducted to test the effects of adjuvant acupuncture under controlled conditions in which the acupuncture was administered onsite at the IVF clinic or pragmatic trials conducted to test the effects of adjuvant acupuncture delivered off-site, which might better approximate every day, ‘real life’ conditions since most IVF clinics do not have onsite acupuncturists (Arce et al., 2005); and (v) trials that involved a treating acupuncturist who was judged as adequately experienced or not adequately experienced, with such judgments made by acupuncturist assessors who were blinded to the identities and results of the trials.

One wonders what objective criteria these acupuncturist assessors use to judge other acupuncturists as “adequately experienced.” They also prespecified six “risk of bias” domains to be examined: random allocation sequence generation; concealment of allocation of randomization sequence; blinding of patients (i.e. use of sham control); blinding of embryo transfer physicians; incomplete outcome data; and unequal co-intervention. And guess what? These were nearly all negative, too. There was only one exception, which of course was touted in the press release above. Oh, the authors dance around several variables that they describe as “almost” statistically significant, but “almost” only counts in horseshoes and hand grenades (and nuclear weapons). To be honest, these subgroups weren’t even that close to being statistically significant. If I were reviewing this paper, I would have told the authors to cut out at least a couple paragraphs worth of verbiage dancing around these topics, although it is somewhat interesting to note that one of these “almost significant” subgroups was whether or not the physician doing the IVF embryo transfer was blinded to the acupuncture status of the subject.

In any case, there was an inverse correlation between the baseline pregnancy rate observed in a study and the effect of acupuncture. Studies reporting greater than average pregnancy rates (32% or greater) showed no effect of acupuncture. In fact, the risk ratio for such studies was 0.90 [95% confidence interval 0.80 to 1.01]. That’s almost, but not quite, a statistically significant negative effect on pregnancy rates! In contrast, studies for which the baseline pregnancy rate was less than 32%, produced a risk ratio of 1.53 [95% confidence interval 1.28 to 1.84]. Why is this? Who knows? The authors speculate that additional interventions have little or no value when pregnancy rates are already high, but acupuncture can help when pregnancy rates are low, but there are so many factors that determine pregnancy rates, including embryo selection, prevailing practice, number of embryos transferred, and many others. There could very well be a confounder there that the authors didn’t pick up.

There’s a better explanation, or maybe two explanations. First, there is the Hawthorne effect. Basically, it is quite possible that low-performing clinics, knowing that they were being watched carefully in a clinical trial, stepped up their procedures and did a much more rigorous job. That’s one possibility. Another possibility is even simpler. This could simply be regression to the mean. Think about it. The clinics that were low-performing before being involved in a clinical trial got better, and the clinics that were high performing beforehand got a little bit worse. True, the latter wasn’t quite statistically significant, but the trend is suggestive.

The hilarious thing about this study is that, no matter how much Berman tries to argue otherwise, it confirms what we already know. Acupuncture does not work. It does not improve the pregnancy rate. There is no physiological mechanism to think that it should, and this meta-analysis confirms it. The questions of whether a sham control intervention is needed or not, whether multiple treatments are needed or not, whether sticking to the meridians matters or not are all the equivalent of what Harriet Hall likes to call Tooth Fairy science.

Book III: Keep those acupuncture needles away from my lymphedematous arm!

So we’ve had in essence a case report of a horrible complication after acupuncture for headaches, followed by a systematic review/meta-analysis that tries to convince readers that acupuncture can improve pregnancy rates in IVF, even though the clear conclusion based on the studies analyzed is that it does not. Now let’s look at a study that tries to convince you that it’s OK to stick needles where they shouldn’t be stuck.

Lymphedema is a complication of breast cancer surgery that all surgeons who do breast surgery fear. Patients, of course, fear and detest it even more because, after all, they have to live with it. The limb swelling that is the primary symptom of lymphedema comes about because surgery on the axillary lymph nodes (the lymph nodes under the arm) that is part and parcel of surgery for breast cancer can interrupt lymph vessels and cause backup of lymph fluid in the affected arm. This backup has consequences, including skin changes, a tendency towards infections, and, in extreme cases, elephantiasis (which is, fortunately, rarely seen these days as a result of breast cancer surgery). Unfortunately, lymphedema is incurable, and the risk of developing it never goes away after breast surgery.

Lymphedema used to be much more of a problem back in the old days (say, more than 10-15 years or so ago), when surgery for breast cancer routinely involved an axillary dissection, or removal of most of the lymph nodes under the arm. (For surgery geeks, in breast surgery level 1 and 2 lymph nodes out of three levels, unless, of course, level 3 nodes are grossly involved with tumor, in which case they’re taken out too.) Frequently radiation therapy was needed as well, and the combination of axillary dissection and radiation therapy could produce a risk of lymphedema as high as 50%. Of course, in recent years sentinel lymph node biopsy, which involves removing many fewer nodes (usually 1-3) has supplanted axillary dissection for most cases of breast cancer, and, consistent with fewer nodes being taken, the risk of lymphedema from sentinel lymph node biopsy is much lower. However, none of this means that lymphedema isn’t still a problem after breast surgery; it’s just less of a problem.

There are only a few basic strategies for treating lymphedema. These strategies are sometimes referred to as decongestive lymphatic therapy. For the most part, these treatments involve physical therapy, compression sleeves to “squeeze” the fluid out of the affected limb, and sometimes the use of mechanical compression stockings that “milk” the fluid back. It’s all very inconvenient and unpleasant. There’s no doubt that this particular complication can take a major toll on a patient’s quality of life and sometimes even lead to hospitalizations for infection. It might be less of a problem than it was in years past, thanks to the increased frequency of much less invasive surgery, but it’s still a problem. As long as we need to evaluate the axillary lymph nodes in breast surgery, it will always be a problem. That’s why it needs better treatments.

Acupuncture is not one of those better treatments

Not that proponents of acupuncture don’t try to convince people that acupuncture is a treatment for lymphedema. To be honest, knowing the mechanism by which lymphedema develops, I can never quite figure out why anyone would think that acupuncture would do anything for lymphedema. How, pray tell, would sticking needles into the body, often in areas of the body not involved by lymphedema, be expected to cause lymphedema to get better? Yet, acupuncturists keep claiming that acupuncture can be used to effectively treat lymphedema. Indeed, if there’s one image that causes me to cringe when I see it, it’s the image of needles being stuck into a lymphedematous arm, often with the acupuncturist not wearing gloves. That’s why I cringed when I saw a recent study out of Memorial Sloan-Kettering Cancer Center (MSKCC) examining acupuncture as a treatment for breast cancer surgery-associated lymphedema in the ASCO Post:

Arm lymphedema affects approximately 30% of breast cancer survivors, with rates increasing with longer follow-up and cases presenting well beyond the active treatment period. Lymphedema is observed even with use of less-invasive surgical techniques for staging, and risk is further increased by such factors as radiation therapy, positive lymph node status, increased tumor burden, postoperative seroma or infection, obesity, and increased age. Current treatments for lymphedema after breast cancer treatment are expensive and require ongoing intervention. As reported by Barrie R. Cassileth, MS, PhD, of the Integrative Medicine Service at Memorial Sloan-Kettering Cancer Center and colleagues in Cancer, acupuncture may be an effective treatment.

The study appeared in the journal Cancer and was entitled “Acupuncture in the treatment of upper-limb lymphedema: Results of a pilot study“. It’s as fine an example of quackademia as I’ve ever seen, its lead investigator being our old friend Barrie Cassileth, the director of the integrative medicine department at Memorial Sloan-Kettering Cancer Center. This time around, it’s acupuncture for lymphedema. Truly, acupuncture is the therapy that can do anything, which is consistent with it being quackery. Certainly, no one has ever postulated a mechanism by which acupuncture can do all the things claimed for it, including (but not limited to) relieving pain, relieving hot flashes, treating infertility, improving asthma symptoms, and, of course, treating lymphedema. What’s the common unifying biological mechanism that could explain therapeutic effects in all these diseases and conditions? There is none, at least none that any acupuncturist has ever been able to explain convincingly to me, nor was any claimed in the ClinicalTrials.gov entry for this.

So what does this study purport to show? It’s a pilot study involving 33 patients with breast cancer-related lymphedema for at least six months but not longer than five years. This time period was chosen to make sure that the subjects were all out of the immediate postoperative period but not so many years out that they started to develop skin complications from chronic lymphedema. These patients all underwent twice weekly 30-minute acupuncture sessions for four weeks as follows:

Alcohol swabs were applied prior to insertion of sterile single-use filiform needles (32-36 gauge; 30-40 mm in length, Tai Chi brand, made in China and distributed by Lhasa OMS, Weymouth, MA) that penetrate 5-10 mm into the skin. A total of 14 needles were inserted: 4 in both affected and unaffected limbs, 2 in acupuncture points on both legs, and 2 in unilateral points on the torso. Selected acupuncture points (Fig. 1) were stimulated manually by gentle rotation of the needles with lift and thrust. The acupuncturists did not intentionally seek to achieve a de qi sensation.

Specific acupuncture points used in this study were determined on the basis of historical context, the published literature, and the consensus of our experienced group of MSKCC staff acupuncturists.[18-20, 34, 37] Many of these acupoints are used to treat pain, weakness, and motor impairment; others are traditionally used to drain “dampness,” a TCM concept similar to edema.

Did I just read what I thought I read? Seriously? The rationale for choosing these points was based on their being related to traditional Chinese medicine concepts to drain “dampness”? This is utter nonsense, the sort of silliness in which quackademic medicine corrupts academic medicine with concepts that have nothing to do with science. Just read about “dampness” in TCM:

In nature, dampness soaks the ground and everything that comes in contact with it, and stagnation results. Once something becomes damp, it can take a long time for it to dry out again, especially in wet weather. The yin pathogenic influence of dampness has similar qualities: It is persistent and heavy, and it can be difficult to resolve. A person who spends a lot of time in the rain, lives in a damp environment, or sleeps on the ground may be susceptible to external dampness.

Similarly, a person who eats large amounts of ice cream, cold foods and drinks, greasy foods, and sweets is prone to imbalances of internal dampness. Dampness has both tangible and intangible aspects. Tangible dampness includes phlegm, edema (fluid retention), and discharges. Intangible dampness includes a person’s subjective feelings of heaviness and dizziness. A “slippery” pulse and a greasy tongue coating usually accompany both types of dampness. In general, symptoms of dampness in the body include water retention, swelling, feelings of heaviness, coughing or vomiting phlegm, and skin rashes that ooze or are crusty (as in eczema).

As I said, none of this has anything to do with science.

So, based on a TCM concept of “dampness” being tortuously related to lymphedema, quackademics at MSKCC subjected patients to acupuncture and measured their limb circumferences. There are a few ways to measure lymphedema. One is water displacement, in which the subject puts her arm into a cylinder of water, and the volume displaced is measured. This method isn’t used much anymore because it’s messy and inconvenient to do, although it is arguably the most accurate. In most cases, lymphedema is measured by comparing the circumference of each arm at different locations defined by anatomy. Generally, this is done in four locations, the metacarpal-phalangeal joints, the wrist, 10 cm distal to the lateral epicondyles, and 15 cm proximal to the lateral epicondyles. Differences of 2 cm or more at any point compared with the contralateral arm are considered by some experts to be clinically significant. The authors used a two-point technique performed by trained research assistants 10 cm above (upper arm) and 5 cm below (lower arm) the olecranon process using nonstretch tape measures, which is said to be as sensitive and specific as any other methods. The median age of subjects was 55, and they were a mean of 3.9 years out from surgery. They were on the obese side, with a mean BMI of 30.4, which is above 30 and thus in the obese range.

The results were as follows. A 30% or greater decrease in arm circumference was observed in 11 patients (33%) and 18 had a reduction of at least 20%, a reduction reported to be across the whole range of severity of lymphedema. One notes that 31 subjects (94%) used other standard therapies during the study, although 30 reported no change in their standard regimen. Now here’s where how you present the data makes all the difference in the world. These percentages seem huge, but you have to remember that the way they were calculated was in terms of the difference between the two arms in circumference, normalized to the pre-treatment difference. If the pre-treatment difference is small, then it doesn’t take much of a decrease in lymphedema to produce a large percentage. That’s why the really telling figure comes from Table 3, which shows that the mean difference between pre-treatment and post-treatment arm circumference was 0.9 cm (95% confidence interval 0.72 to 1.07 cm). That is spectacularly unimpressive, particularly in a population that skews obese. It sure sounds a hell of a lot more impressive when expressed as a percentage.

Of course, the biggest problem with this pilot study is that it was uncontrolled. There is no control group. So we have no idea whether acupuncture had anything to do with the modest decrease in lymphedema reported. I will give Dr. Cassileth credit in that she does acknowledge this in the paper:

Whether acupuncture alone was responsible for this reduction was not evaluable in this pilot study. Our focus was on safety and potential efficacy, as current clinical practice to protect the lymphedematous arm prohibits needling.

Yet she also concludes, unfortunately:

The therapeutic and cost-reduction potential of acupuncture for lymphedema may yield an important tool in the arsenal of lymphedema management. Although randomized clinical trial results await, including our ongoing study, acupuncture can be considered to treat this distressing problem confronted by many women with no other options for sustained reduction in arm circumference.

This study is not good evidence that acupuncture works for lymphedema. There is no reason from a standpoint of prior plausibility informed by biology to think that acupuncture would do anything for lymphedema. On a Bayesian basis, exceedingly low prior probability plus an equivocal result (and, yes, this result is equivocal) equals a very high likelihood that the effect observed is a false positive. Even worse, the randomized clinical trial being carried out isn’t one that is likely to provide much of an answer. It’s a phase 2 clinical trial comparing immediate acupuncture to wait list for six weeks, after which wait listed subjects will cross over and receive acupuncture for six weeks. In other words, everyone in the study will receive acupuncture. I mean, really. Why are they even bothering? This study is unlikely to provide strong evidence that acupuncture works. Most likely, it will be another equivocal acupuncture trial. Of course, the ironic thing is that the crossover design was probably necessitated by the seemingly “positive” result of Cassileth’s currently reported trial. The IRB probably wouldn’t approve a no acupuncture arm in light of that, because then there wouldn’t be clinical equipoise.

Oh, the ironies of quackademic medicine, when the inevitable false positives that occur when treatments of low prior probability are tested in clinical trials complicate the next steps! It’s just infuriating how much time and resources are being wasted on studies that are so highly unlikely ever to produce useful results.

The Trilogy is complete

So what have we learned today? First of all, we’ve learned that, contrary to the claims of its practitioners and apologists, acupuncture is not perfectly safe. No one’s claiming that it’s particularly dangerous, but it’s definitely not perfectly safe. On rare occasions, it can even cause serious complications. Next, consistent with the overwhelming clinical evidence that acupuncture does not work, we’ve see two studies that desperately try to convince you that acupuncture helps infertile couples undergoing IVF to conceive and that it can be used for lymphedema. In the case of IVF, the study showed exactly the opposite of what the authors claim it shows. It shows that acupuncture doesn’t work for IVF. Finally, we learned that, despite what Barrie Cassileth says, there is no good evidence that acupuncture works for lymphedema, just as there is no good evidence that acupuncture works for anything. Even if its risk is very small, it is all risk and no benefit, and there is no science-based reason to ever use it.

Posted in: Acupuncture

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35 thoughts on “A Trilogy of (Acupuncture) Terror

  1. Jonathan Weavers says:

    Hey -

    Your last post [A Trilogy of (Acupuncture) Terror] was freaking awesome. I have gone ahead and added your stuff to my Feedly account. Please keep me updated if you post anywhere else.

    Keep rocking –

    Jon

    1. WilliamLawrenceUtridge says:

      You might try clicking on some of the other websites found in the “links” tab. I hear Respectful Insolence is just tops.

  2. Janet Camp says:

    How do we get the popular media to write about this?

    1. arsawyer says:

      @ Janet.

      Start getting science enthusiasts interested in journalism, and interested early. Upon entering college I was under the impression that the three career paths available to me were traditional engineer, doctor, or professor. I don’t see how you’ll ever get newspapers or popular news websites to write about medicine with a critical eye unless they start pulling in more people that have a natural inclination towards science and skepticism.

      1. Janet Camp says:

        Yes! and thanks, but that’s the long road, even assuming it will happen. Any shorter term ideas?

  3. Kim Wise says:

    One acupuncture treatment destroyed my life 11yrs ago. A needle went through my ulnar artery causing gangrene fingers and a fatal blood disease for life.I am on life long warfarin.

    1. WilliamLawrenceUtridge says:

      There’s a website called “what’s the harm” that documents situations where CAM has caused harm to people. You might try submitting yours as evidence, or passing it along to quackwatch – if you’re interested in sharing it more widely.

  4. Kara Besher says:

    Fatality occurred in Japan as well. In 2010 in Ikeda City near Osaka, a 54 y/o woman got acupuncture treatment and then collapsed, died in the hospital, respiratory failure due to puncture of the lung. Was mention briefly in local press:

    http://blog.goo.ne.jp/sokyudo/e/d5b90f20c9930f65a0846ee6d8accf6b

  5. Young CC Prof says:

    Hmmm. Maybe that acupuncturist was trying to do dry-needling for myofascial release? Still, that’s NOT an acupuncture technique, and due to the necessity of precise needle placement and risks of lung puncture, it has to be performed by a real doctor.

  6. pmoran2013 says:

    Inserting acupuncture needles into the “affected” limb in lymphedema will also inevitably have seriously consequences for some. If infection is introduced it can spread like wildfire, causing with septicaemia, also damage to the few lymphatic vessels that are still functioning.

    Understanding and managing risk is something that the mainstream has considerable expertise with, whereas it is a generally unfamiliar exercise for CAM practitioners. It is just not talked about much.

    This is why regulation of CAM does not have to be a bad thing. It depends upon the detail. Higher standards of education and personal responsibility and minimal safety standards should be the main objectives.

    We cannot see any good coming out of it because anything that goes against “science as we know it” to the degree that CAM does is just not tolerable to the scientific mind. It has no reason to exist, we think. The problem is that CAM has virtually nothing to with science. It is a phenomenon supported by other aspects of human behaviour.

    1. Harriet Hall says:

      @pmoran

      “CAM has virtually nothing to with science. It is a phenomenon supported by other aspects of human behaviour.”

      Can you explain further? Are you positing non-overlapping magisteria a la Stephen Jay Gould?

      1. pmoran2013 says:

        I’ve never been quite sure what that means, but I don’t think so.

        I am simply suggesting that CAM use is rarely the result of a conscious, truly scientific decision, whatever some may say when trying to justify treatment choices. It stems from a combination of common human characteristics and needs. Paramount among those is the underlying unmet medical need and the power of the personal testimonial or recommendation.

        The decision to try a CAM treatment can be looked upon as a highly evolved, almost reflex response to such a set of influences. We all possess those tendencies, but they can be overpowered by highly effective conventional medical treatments and inhibited by scientific awareness. .

        Likewise, the staunch belief of CAM practitioners in what they do can be understood. Daily medical practice is full of deceptive influences. If they like you, patients will do their very best to get better for you, and if they can’t, they may still tell you that they did, anyway.

        Both parties to this collusion will invest various levels of “let’s pretend”, wishful thinking, and self-delusion. But it is part of the spectrum of normal human behaviour.

    2. windriven says:

      Peter, you are walking the thin edge of heresy! Pristine dogma trumps ugly pragmatism.

      I have disused sCAM with a couple of WA politicians. They understand that it is hooey. They also understand that there is a market for it – an intense market here in the fruit loop belt. So their take is: better to regulate it than to have it grow like a slime mold in the dark and damp corners of the healing arts.

      See Maggie Thatcher’s sister Peggy below. SBM has been fighting the good fight for years but the quacks and bone-shakers are increasingly embraced by mainstream medicine.

      I hate it but I’m coming around to the point of view that we can’t stamp it out so we might be better off regulating the crap out of it. Perhaps along the way we can drag them – kicking and screaming no doubt – into something if not scientific then at least prepared to manage the risks associated with their misfeasance.

    3. David Gorski says:

      CAM has virtually nothing to with science. It is a phenomenon supported by other aspects of human behaviour.

      OMG. That’s what I’ve been saying all along!

    4. windriven says:

      Peter, as always your position is thoughtful and well articulated. But in this instance I think you are completely wrong.

      “I suspect that it is close to its peak, and mainly because other people are not as generally dumb as we expect…”

      I have no idea on what you base this suspicion. SCAM embrace by medical schools and medical centers is certainly more widespread than it was, say, thirty years ago. Further, a larger array of sCAMs are now recognized and licensed – at least in the US – than previously. What are the forces that will now or soon move the trend the other way?

      “!. The fact that some doctors and institutions are more tolerant of CAM than us does not necessarily, involve the abandonment of conventional medicine when needed, nor an abject surrender to pseudoscience.”

      I could not disagree more. It is to suggest that it is fine to treat patients with eye of newt and chicken bone canastas … except when it isn’t. Moreover, the patient is taught that MDs, chiros, NDs and assorted other practitioners are basically equivalent – or at least all part of the same health care delivery system. And that is just plain wrong. Bullshit is bullshit on Monday morning and on Saturday night. There is not a time when it turns into a bar of gold.

      Then you ask, “Are doctors, scientists and academics so impotent, is the logic behind medical science so feeble, are the relatives of injured persons so passive, are our legislatures and the general populace and legislatures so insouciant that we will be at the mercy of these supposedly unscrupulous persons once they get a footing in somewhere?”

      And I can only say, apparently so. A goodly number of doctors, scientist and academics are so impotent, their grasp of the logic behind medical science so feeble, that they countenance, nay, embrace! bald quackery in the suite next door.

      I desperately hope that you are right, Peter. But the evidence is pointing the other way.

  7. “I will attempt in a mere 15 minutes to explain what Science-Based Medicine is and how it can be used to combat the infiltration of quackademic medicine into medical academia…”

    Is there any evidence that SBM blog has been effective in doing so?

    1. windriven says:

      Good on you for having the stones to pose the question. I will join you in waiting breathlessly for a answer. Well, maybe not breathlessly. It might be a long wait.

  8. pmoran2013 says:

    Peggy T: “— combat the infiltration of quackademic medicine into medical academia…

    Is there any evidence that SBM blog has been effective in doing so?”

    How would we know? SBM is possibly unrivalled as an information source, and a demonstration of how good science works. or should work.

    It is mainly when questions to do with CAM use — why people do it — what do they get out of it — that I believe scientific rigour is easily lost and weakly supported notions can become barely tested dogma.

    For who is to challenge what we say, if we do not do it ourselves? Not only is CAM not introspective, or intellectually ordered, enough to have well-developed apologetics, any CAM supporter we get to talk to will certainly at some time have said something stupid or scientifically outrageous. SBM will not bother too much with anything else they say.

    There may yet be important things to know about CAM that neither party is elucidating — not likely answers to any of our major unsolved medical problems, of course, but matters which have importance for our dealings with CAM and its politics, and what kind of arguments we employ, and what ends we seek.

  9. windriven says:

    “SBM is possibly unrivaled as an information source, and a demonstration of how good science works. or should work.”

    At least within the realm of medicine, the regulars here would certainly agree. But Peggy’s question wasn’t about quality it was about impact. There the empirical evidence isn’t comforting. Quackery marches ever deeper into medicine as evidenced by its embrace by medical schools, hospitals and medical centers and individual physicians.

    It is one thing for the choir of molecular biologists and anthropologists and statisticians and true-believer physicians to celebrate this ‘unrivaled information source’ and quite another for the great unwashed in the medical community to be moved by it.

    On this issue we all have an obligation to confront quackery-embrace in the dank corners where it thrives: the weak willed, sloppy thinking dufuses (dufae?) who would rather turn a blind eye to quacks in their midst than to ruffle some feathers by pointing out that the emperor has no clothes.

    Smoking, a filthy and disgusting habit, was broadly tolerated in our society until enough people started to say: enough! Quackery is no less intellectually filthy and totally disgusting.in its debasement of medicine.

    When is the last time that anyone here said to any physician or administrator: ‘enough’?

    1. Well said, Windriven. You captured my concerns exactly.

      Do you think the problem of CAM in medical schools should call for another Flexner Report?

  10. WilliamLawrenceUtridge says:

    Do you think the problem of CAM in medical schools should call for another Flexner Report?

    I would argue “no”. For all that we here consider CAM to be a problem, could any of us really say it’s a serious problem? It’s corrosive to critical scrutiny and scientific literacy, it’s a complete waste of money, and in rare cases it can cause harm. But CAM is still two things:
    - relatively rare (particularly the hard-core nutter like homeopathy and even acupuncture)
    - “complementary”, few people use it as a substitute for real medicine

    In contrast, the Flexner report was about widespread scientific illiteracy, fundamentally useless practices in essentially every medical school and by every doctor in the entire United States and the selling of the title “doctor”.

    CAM will probably become marginalized with a couple well-publicized deaths from herbal medicine, or strokes due to chiropractic adjustments, or acupuncture driven too deep. The pendulum will swing towards skepticism. Medicine will get more and more effective, with fewer side effects (particularly once we get into the realm of the proteome and individualized genetic analyses). Hell, even the fact that the US is getting some version of a public health care option will probably help.

    It’s possible I will be proven wrong, and it sure would be nice if the cries of “enough” within academia become louder. But I still see CAM as a sideshow within the main tent of medicine. Doctors, real doctors who go through medical school and are forced to take care of greviously sick patients, are extremely unlikely to abandon real medicine for placebos and theatre. The ones we see doing so are the minority.

    Such is my opinion. Wouldn’t it be nice if I were right?

  11. windriven says:

    I will take the position opposite the esteemed WLU. I believe sCAM to be a serious and growing threat to the practice of medicine. Each medical school that takes an ‘integrative medicine’ program into the curriculum, each medical center that opens an acupuncture center or a ‘holistic healing’ center, each MD who sells useless homeopathics or refers to a chiropractor; each one chisels away at the notion of science based medicine. Each one says: horsecrap has its place in the armamentarium. Each one says, hey, what do we know? We can’t cure everything so you might as well give chicken bones and incantations a whirl.

    So yes, another Flexner. An outing of dweebs who celebrate the purple and gold robes that clothe the naked liars and charlatans. The fight to drive fantasy out of medical practice will be arduous enough without having top tier medical institutions aiding and abetting the fantasists.

    1. Egstra says:

      Why is there no “like” button? Sometimes I really need one.

    2. WilliamLawrenceUtridge says:

      Perhaps my disagreement is based on geography – these issues seem to be less prominent in Canada. We have a federally-funded, provincially-administered health care system that pays for some, but not all medical treatments. I remember several years ago (more than a decade I think) they stopped paying for chiropractic care. My private insurance allows for a “top-up” that will cover a limited amount of such treatments ($200 per year) along with physiotherapy and some other extras.

      It may be that an advantage of such a system is people have much easier access to care, and the care is much more carefully rationed – and systematically excludes the quacks in favour of science-based medicine as decided by genuine doctors and other experts. Patients don’t have to choose between paying for an expensive doctor versus a cheap homeopath/chiro/naturopath, with the result being a reduced demand.

      Hopefully Obamacare, in addition to bringing about the Nazi Antichrist Apocalypse (Complete With Death Panels) will bring about a similar effect.

      1. windriven says:

        Ah William, would that Obamacare would have that effect. But no, quackophilia is hard wired into the Affordable Care Act.

        Americans insist on the right to behave as idiots and our political class – barely able agree that water is wet – is happy to indulge them.

        As an aside, Obamacare is misnamed as Mr. Obama had little to do with crafting it. Pelosicare would be more accurate. And despite a wall of words, rosy promises, dire predictions and the possible end of life as we know it, all that ACA really does is force young and healthy people to participate in health insurance. This is a good and necessary thing to be sure. But understand that the Act is about cost redistribution and nothing much more.

        1. WilliamLawrenceUtridge says:

          Well, if insurance companies are now forced to provide coverage, and thus cost-cutting becomes more important than attracting customers, perhaps they themselves will stop supporting quackery.

          Meh, I’m glad Canada doesn’t have to worry about it, and I’m glad Dalton McGuinty had the stones to force OHIP to stop paying.

          1. windriven says:

            “Well, if insurance companies are now forced to provide coverage, and thus cost-cutting becomes more important than attracting customers, perhaps they themselves will stop supporting quackery.”

            The law really isn’t written that way. All of the insurers are in the same boat. Cost will, over time, continue to rise. Moreover, sCAM is generally cheaper than medicine so it is reasonable to expect some pressure to use those ‘therapies’ preferentially.

            ” I’m glad Dalton McGuinty had the stones to force OHIP to stop paying.”

            I wonder if we could import some stones for our politicians? I wonder if they’d know what to do with them if we did?

          2. WilliamLawrenceUtridge says:

            Moreover, sCAM is generally cheaper than medicine so it is reasonable to expect some pressure to use those ‘therapies’ preferentially.

            Only in terms of treating nonmedical conditions or those that get better without intervention. They are a net drain in all other cases. At best they would cut down on unnecessary testing and appointments.

            I wonder if we could import some stones for our politicians? I wonder if they’d know what to do with them if we did?

            Don’t start admiring Dalton McGuinty too much, when he retired from politics he was pretty much reviled. A shame, since from what I can tell he was pretty good at his job. Nobody got exactly what they wanted, yet everybody got something and the budget was balanced.

  12. pmoran2013 says:

    Windriven: ” I believe sCAM to be a serious and growing threat to the practice of medicine.”

    Well, I suspect that it is close to its peak, and mainly because people in general are not as dumb as we in SBM like to think. It was announced on the news last night that Maquarie University in Sydney is going to drop its chiropractic courses, because they regard the field as insufficiently science-based. .

    Let’s examine this threat to “the practice of medicine” using a bit of the legendary “critical thinking”..

    !. The fact that some doctors and institutions are more tolerant of CAM than us, does not necessarily, if hardly ever, involve the abandonment of conventional medicine when needed, nor an abject surrender to pseudoscience.

    It is surely, for many, the final common pathway for the following considerations: a pragmatic response to the interests and wants of some patients, a sensing that patients bring complex needs into medical interactions not all of which are easily examined by placebo-controlled clinical trials or satisfied under the conditions that apply in the average family practice, an awareness of other poorly understood aspects to medical interactions, and also an awareness of the limitations of present day medical care in some arenas.

    A degree of permissiveness thus does not require the acceptance of the validity of any CAM theory or buying into pseudoscience. As said in another context, CAM has virtually nothing to do with science, yet we on SBM always gravitate back to thinking that science is the key to that lock.

    2. How exactly would this slippery slope unfold? Are doctors, scientists and academics so impotent, is the logic behind medical science so feeble, are the relatives of injured persons so passive, are our legislatures and the general public so insouciant, that we will be at the mercy of these supposedly unscrupulous persons once they get a footing in somewhere?

    Overstating our case is one way of not getting to be taken too seriously.

  13. pmoran2013 says:

    Windriven: ” I believe sCAM to be a serious and growing threat to the practice of medicine.”

    I suspect that it is close to its peak, and mainly because other people are not as generally dumb as we expect. Maquarie University in Sydney has just announced that it is dropping its chiropractic course because it is considered not sufficiently evidence-based a field.

    Some “critical thinking” —.

    !. The fact that some doctors and institutions are more tolerant of CAM than us does not necessarily, involve the abandonment of conventional medicine when needed, nor an abject surrender to pseudoscience.

    It is surely, for many, the outlet for a combination of forces: undoubtedly a pragmatic response to the interests and wants of some patients, but also a sense that patients bring complex needs into medical interactions not all of which are easily examined by placebo-controlled clinical trials or satisfied under the conditions of the usual family practice, an awareness of other poorly understood aspects to medical interactions, also an awareness of the limitations of present day medical care in some arenas.

    A degree of permissiveness is probably rarely a strong intellectual commitment to CAM theory. As said previously in another setting, CAM use has little to do with science, yet we in SBM always gravitate back towards science being the key to that lock.

    2. How exactly would this slippery slope unfold? Are doctors, scientists and academics so impotent, is the logic behind medical science so feeble, are the relatives of injured persons so passive, are our legislatures and the general populace and legislatures so insouciant that we will be at the mercy of these supposedly unscrupulous persons once they get a footing in somewhere?

    Overstating a case can be one way of not getting to be taken too seriously.

  14. windriven says:

    Second shot at a response Peter. I’m still in the land of perpetual moderation but it has been long enough that I’m figuring my first response is lost in the aether.

    You argument is, as always, thoughtful and well articulated. But I disagree with your conclusion entirely.

    “I suspect that [sCAM] is close to its peak,”

    On what possible grounds? That people aren’t as dumb as we think? The empirical evidence suggests otherwise. There are more medical schools and medical centers with sCAM programs today than there were, say, 20 years ago. You see that as the zenith but what are the forces scaling it back?

    “The fact that some doctors and institutions are more tolerant of CAM than us does not necessarily, involve the abandonment of conventional medicine when needed, nor an abject surrender to pseudoscience.”

    No? How much leeway do we allow in deciding when conventional medicine is needed and when it is OK to just make stuff up? That may not constitute abject surrender but at a minimum it sounds like friends with benefits. Maybe we could call it Vichy Medicine. And what message does that send to consumers? MDs, NDs, Chiros, Homeopaths, all cogs on the same wheel. Doesn’t make much difference.

    “How exactly would this slippery slope unfold? Are doctors, scientists and academics so impotent, is the logic behind medical science so feeble, are the relatives of injured persons so passive, are our legislatures and the general populace and legislatures so insouciant that we will be at the mercy of these supposedly unscrupulous persons once they get a footing in somewhere?”

    Peter ??? How exactly would it unfold??? In the US at least it has already damned well unfolded. More and weirder sCAMs get state imprimaturs every year by way of licensure. There are huge stores in prime retail locations whose only products are ‘supplements’.

    “Are doctors, scientists and academics so impotent, is the logic behind medical science so feeble, are the relatives of injured persons so passive, are our legislatures and the general populace and legislatures so insouciant that we will be at the mercy of these supposedly unscrupulous persons once they get a footing in somewhere?”

    Apparently.

    “Overstating a case can be one way of not getting to be taken too seriously.”

    I agree Peter. But understating a case can be one way of not being taken seriously enough. I have never argued that sCAMs – at least not many of them – should be made illegal. People are entitled to be idiots so long as they are adults and pass for sane. But it is not acceptable for medical science to aid and abet this nonsense by pretending that it is something that it is not. That IS impotence, that is feebleness, that is beyond insouciance – it is callous disregard, it is dangerous, it sends a message that can be lethal to people who lack the technical skills to draw the distinction between medicine and mischief themselves.

  15. pmoran2013 says:

    Windriven:”“I suspect that [sCAM] is close to its peak,”

    On what possible grounds? That people aren’t as dumb as we think? The empirical evidence suggests otherwise.”
    ———————————-
    It doesn’t. In proportion to the overall use of CAM the percentage of people actually being harmed by CAM use is tiny and that surely is an important measure of both public wisdom and the cause for alarm. The harm looks massive to us because our confirmation biases cause us to treasure every instance we get to hear of.

    The main risks from CAM derive from extreme elements rejecting conventional methods altogether, yet the studies show that few people do that.

    And this despite all the early hype about CAM. It was predictable that CAM would eventually have declining credibility in the public mind, because of its grossly overblown early claims. Remember how Vitamin C was once held to be the answer to viral infections, and cancer, and CFS, and just about any other human illness? Who believes that now? ( —and why ever not? Perhaps anecdotal evidence can work both ways, given time. Or is CAM showing some responsiveness to our studies?)

    So perhaps CAM does have some capacity to evolve. I recently reported how attitudes seem to be changing on those deep, dark, CAM cancer discussion lists, where it was once anathema to show any support for conventional methods.

    We are exchanging opinions on other matters to do with the degree of respect that we have for our fellow man. I think as doctors we should be wary about anything that distances us from our fellows. The practice of medicine is still a very human activity.

    I outlined in the above why I think it is possible to be tolerant of some aspects of CAM without “pretending that it is something that it is not”.. The public is perfectly capable of understanding how dubious methods may help some people through placebo and other nurturing influences. I think they also can understand trying out a treatment that has no clear scientific basis, because this is what they are doing all the time themselves.

    Oh, and the MJA published an article recently showing that CAM use seems to be declining in South Australia in the latest survey. I will try and find it if you want.

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