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269 thoughts on “An ICD Code for the Running Piglets!

  1. Ben Kavoussi says:

    @ Alison Cummins

    Just like we had the 4 elements in the Arabo-European alchemy, the Chinese had 5 phases (wu xing): Water, Wood, Fire, Earth and Metal. To each corresponds a planet, a sound, a color, a season, a weather, a humour, an organ etc.

    Take a look at the wu xing article on Wikipedia:

    http://en.wikipedia.org/wiki/Wu_Xing

    wu xing and the yin/yang principles are at the foundation of TCM “pathology.”

    That’s why they have disease categories such as wind-cold, wind-heat, wind-damp, liver wind, wind-fire whirling
    internally, etc.

    This is all alchemy talk.

  2. Zetetic says:

    In medical billing, there’s a complex web of combinations of ICD codes and CPT codes that insurance companies will pay for. Just having an ICD code doesn’t gaurantee payment. A CPT code is assigned to anything that could be billed for – an X-ray, lab test, procedure performed, treatment, supplies, office visit charge, injection, etc. and every CPT billed for must be accompanied with an ICD code. A wrong combination, as defined by the insurance companies, will not be paid. Example: A blood glucose test for a patient with only a sprained ankle would not be paid.

    However, allowing ICD codes for TCM would definitely be a foot in the door for legitimizing billing if the insurance companies recognize them. Will there be a domino effect?

  3. Zetetic says:

    What I’ve said applies to non-HMO type outpatient care organizations that still have the luxury of discrete billing!

  4. Ben Kavoussi,

    Yes, I am aware of the Asian hot/cold dry/damp properties. I studied them briefly in my international nutrition class. The class was primarily targeted at dieticians who would be counselling people from different backgrounds, and it was helpful to understand what would be important or make sense/ not make sense to their clients.

    I never asked about alchemy, so I don’t know why you are referring me to an article on wu xing.

    Look, you and I might as well be speaking Hausa and Trukhmen to one another for all the communcation that we accomplish. I don’t know how to be any clearer with my questions and you don’t know how to be any clearer about what you’re trying to say, and we aren’t getting anywhere.

    We can drop it. If I want to know more about the project and what’s actually being done with it I’ll do like @US and sit up one night and try to figure it out myself.

  5. Ben Kavoussi says:

    @ Alison Cummins

    The question was:

    If someone is “making a chart,” I want to know whether they are actually proposing the incorporation of earth, air, wind and fire into the modern periodic table or making a handy-dandy quick reference chart for academics reading alchemical texts. Then I can decide whether we are looking at a problem or not.

    The answer was, yes, they are directly incorporating the equivalent of “earth, air, wind and fire”, which are the 5 phases of wu-xing, into modern ICD because their diseases categories are based on alchemy and other pre-scientific worldviews.

  6. Ben Kavoussi says:

    @ Alison Cummins

    Are you writing an article about this, or is this just for personal knowledge?

  7. pmoran says:

    So, nybgrus, you are another who thinks that having once dragged medicine out of a mire of superstition and illusion, science is unable to look after itself, in a generally more enlightened age?

    I don’t buy it.

    You said: That IS a failing on our part and we ARE partly to blame. Even one death from an asthmatic being treated by a naturopath because that person had a bad experience/poor education from US is intolerable. Yet in the same breadth you basically say “Let the CAM enter our academia and eventually it will correct itself. Science will win out.”

    That’s not quite what I said. I should reveal that I am actually very uncomfortable about teaching about CAM in any way that endorses pseudoscience or ancient superstitions. If the biochemistry department started doing it I would be the one organizing the petition.

    So anything even hinting at that has to be kept apart. Most people understand that “CAM”, “alternative” medicine, and “Integrative Medicine” are a different category of thing to scientific medicine and they do employ it differently.

    I won’t expand on that here except to add that while integrative medicine practitioners can indeed be somewhat pretentious regarding their i scientific credentials, they do eschew dangerous claims.

  8. David Gorski says:

    I won’t expand on that here except to add that while integrative medicine practitioners can indeed be somewhat pretentious regarding their i scientific credentials, they do eschew dangerous claims.

    You can’t be serious about this.

  9. Ben Kavoussi says:

    @ Alison Cummins,

    You did ask about alchemy: earth, air, wind and fire are four alchemical elements.

  10. nybgrus says:

    @pmoran: I tried to elucidate a clear example of why you are wrong in your assertion. Granted it was an anecdote, from my own personal experience in my medical school from the chair of the “integrative medicine” department but there is a plethora of data that corroborate and support my anecdote. Just look at the 10 billion words or so (a kind jab) that Dr. Gorski has written on the subject alone.

    But my anecdote had a point – I was illustrating a real life example of the harm caused by integrative medicine lectures to budding physicians. Perhaps you’d like me to add that this selfsame lecturer claimed he wanted “hard evidence” of alternate modalities and that he was “purely evidence based” and eschewed homeopathy as bunk during his lecture. He was actually quite, shall we say, animated in this claim to the class. Then, AFTER class I approached him and started a conversation. He agreed with me he did not like the false dichotomy of CAM and medicine and claimed he only did it to “sneak in” and work from the inside to destroy homeopathy etc. Then, when I questioned his acupuncture claims, he resorted to citing reiki (yes REIKI!!) and claiming that since studies showed more effect from experienced practictioners over less experienced ones that there “must be something to reiki” since attendings have better outcomes than first year residents. When I pressed the issue, speaking intelligently and citing references thank to blogs like this, he then asked my name, shook my hand and told me I was a “very intelligent young man” and quickly said he had a meeting he needed to get to. He then turned tail and left.

    How does this NOT do harm to the education of my colleagues?

    And as I said, and you conveniently ignored, how many people must be injured or killed through the propagation of CAM before we let science correct itself? How can an ethical person sit back, KNOWING these things and just say “Oh well, science will get there eventually”

    It sounds to me like you are in denial. Either that, or you just don’t care about pseudoscience unless it invades your field at your institution. That is disingenuous.

    And no, I do not claim that ” having once dragged medicine out of a mire of superstition and illusion, science is unable to look after itself, in a generally more enlightened age?” But who is supposed to do the looking? Is it some disembodied spirit we call science? Is it the physical paper upon which this tripe is written? Do we expect the printed journals to vomit out the pseudoscientific papers leaving only the good ones for us to read? No, sir. It is people that must look. It is Dr. Gorski, myself, and others who care to understand and make noise about it. The “enlightened age” as you call it is not an inherent state of being. It is a phenomenon of the composition of the PEOPLE in that age. Yes, we are generally more enlightened because we have more enlightened people. But that does not mean EVERYONE is enlightened. So that means… yep, you guess it – PEOPLE like us are the ones that offer the enlightened review to correct science.

    And as far as I am concerned you deserve that snark.

  11. Ben Kavoussi,

    Just for my personal knowlege. I’m a corporate drone.
    I understand most posts on SBM and I get frustrated when I’m unable to make sense of them. I’m analytical. I don’t assume I can fill in the gaps, so the gaps stand out to me.

    On a different level, it’s helpful to me to understand how health care providers see the world so that I can advocate effectively for myself.

    For instance, I had a lot of trouble getting someone to prescribe me antidepressant medication because I knew that “drug-seeking” was bad. I was afraid to volunteer that I was interested in trying medication so as not to piss off the people I was trying to recruit to help me. It took me years until I had lost it to the point of crying uncontrollably in public (at which point I was of course also unemployed, poor, in a crappy relationship I didn’t have the means to leave etc.) before someone noticed I was in trouble and wondered tactfully if maybe I would consider trying an antidepressant?

    That was about thirteen years ago. Now I have a job, a satisfying relationship and internet access. Through the miracle of the internet I have been able to determine that actually, it would have been just fine to bring up the possibility of antidepressant medication. “Drug-seeking” typically means “opioid-seeking.” Ah. I get it. Oh well, that’s two years of my life gone unnecessarily, but now I know.

    This has nothing to do with your post except that I want to understand. If health-care providers’ concerns are opaque to me then I may be in danger.

    Until today I had no idea that there was any connection between reimbursement in the US and anything to do with a UN body. So now I’m interested: I want to know if Québec works the same way. I want to know if our overburdened health care system really is in danger of being eroded by this particular outside force, or whether it’s just a hypothetical with lots of ifs. As micheleinmichigan said, I vote. I want and need to know how things work.

    Another example completely unrelated to your post: When I say to my beloved, “I’m going to the grocery store for bread, is there anything you need?” and he answers “No, we’re out of bananas,” I get really upset. Does he want me to get bananas or not? If he does, what is the No referring to? If he doesn’t, what is the causal link with being out of bananas? Is there something I’m missing? What is going on here that I can’t see? Really, it’s very upsetting to me.

    You aren’t here to make sure I don’t get upset by answers that don’t make sense, that’s not what I’m getting at. But when an answer doesn’t make sense I am going to keep investigating until I find one that does. If you can’t provide one, I’ll get it on my own.

    None of this has anything to do with you, but you asked about my motivations for wanting to know. They are multileveled. I’m curious and stubborn and I feel directly concerned. (And maybe a little aspie somewhere in there, but I make great eye contact.)

  12. Ben Kavoussi: “You did ask about alchemy: earth, air, wind and fire are four alchemical elements.”

    Yes, I know. But I never asked you to explain them, I used them in responding to Harriet Hall’s analogy. What I asked you about was the purpose of the ICD.

  13. pmoran says:

    nybgrus:”– the enlightened review to correct science.

    I am not in denial. I can be fairly sure I have breathed more fire on pseudoscientific nonsense than you or possibly even David over the last twenty years or so, and I will continue to do that to the extent that the actual science permits me to do.

    I am mainly drawing attention to poorly examined skeptical assumptions, ones that mold our rhetoric and our stances on many matters. They may be relevant to why we are proving less effective than we might expect in many arenas.

    Our claim to supreme enlightenment is itself a hazard. People stop listening if they think we are out of kilter with actual reality to the slightest extent or if we seem to be exaggerating anything for effect.

    One of the critical assumptions is that CAM methods are of no value at all to those using them. What science allows us to say that?

    If the science is not absolutely clear i.e. that even placebo reactions are non-existent, why would we say or imply something that is so contrary to a presumably highly evolved relationship of mankind to his medicine?

    Why would we risk sabotaging our own endeavours at the very first hurdle?

  14. Ben Kavoussi says:

    @ Alison Cummins

    Thank you for the clarification.

  15. S.C. former shruggie says:

    I hope we’re not in for another outbreak of the framing war.

    Our claim to supreme enlightenment is itself a hazard. People stop listening if they think we are out of kilter with actual reality to the slightest extent or if we seem to be exaggerating anything for effect.

    I have to disagree right there. The CAM crowd has been crowing for years that doctors are arrogant and dismiss them, poor poor pitiful me. It isn’t so much a problem of real arrogance on the part of doctors as it is of the Alt Med crowd poisoning the well with their doctor and scientist demonizing talking points and emotional sucker punches.

    One of the critical assumptions is that CAM methods are of no value at all to those using them. What science allows us to say that?

    For homeopathy? Conservation of matter, for a start. What science supports these ideas? Homeopathy rests on a Law of Similars and a Law of Infinitismals. Those laws have as much to do with science as do the Highway Safety Act or the Laws of Manu. I would think that’s a red flag right there.

    The value CAM offers to its patients is all in emotional re-assurance. It’s a case of starting from the wrong kind of first principles, defending it with the wrong kind of supporting arguments, and producing the wrong kind of value.

  16. pmoran says:

    The value CAM offers to its patients is all in emotional re-assurance.

    There is a lot of science suggesting the likelihood of symptomatic relief, if only from placebo-related influences. Otherwise, why do we go to such lengths to eliminate placebo influences controlled clincial trials?

    It’s a case of starting from the wrong kind of first principles, defending it with the wrong kind of supporting arguments, and producing the wrong kind of value.

    Actually medicine was always thus. In a real sense scientific medicine is the odd man out, the Johnny-come-lately.

    It becomes rather pointless to describe something as “wrong”, if it is the inescapable end point of hundreds of thousands of years of evolution and it is also mainly being used to fill in gaps in what scientific medicine can offer.

    I think we MUST better understand what we are dealing with. We are allowing ourselves to be propelled along by our righteous indignation at the pseudoscience, the fraud, and the undoubted dangers of some aspects of CAM without stopping to consider what else we might be trampling upon in the process — or why a lot of people don’t seem to be receptive to our message.

  17. nybgrus says:

    pmoran: Your claim notwithstanding you clearly seem oblivious. I fully agree with SC. De facto, there are people more enlightened and more expert than others. Period. It is the job of such people to disseminate this info. The problem is that the fad of the last few decades has been equality of opinion – the sCAMmers yell that their “opinion” is just as valid as those of a medical scientist. Jenny McCarthy cries over the fact that the “powers that be” disregard her assertions about her son’s autism and is amazed that they refuse to study him based on her opinion. Not all things are opinion and not all opinions are created equal. Does that mean you and I run around, arrogantly yelling how much smarter we are than everyone else, tell people they are stupid for not vaccinating, etc? No. If you assumed that was what I was referring to then you give me no credit and assume too much. You also lack nuance and understanding. I am speaking her to an audience – a skeptical community. I will not expound for pages about the nuance of how enlightened people should correct the problems of science and public opinion – that is not the point here.

    Further I am losing respect for you by the post. You continue to promulgate the same false dichotomy we here fight against.

    “One of the critical assumptions is that CAM methods are of no value at all to those using them. What science allows us to say that?
    If the science is not absolutely clear i.e. that even placebo reactions are non-existent, why would we say or imply something that is so contrary to a presumably highly evolved relationship of mankind to his medicine?
    Why would we risk sabotaging our own endeavours at the very first hurdle?”

    Explain to me how that is any different than saying there is CAM and “western biomedicine?” Apparently it is lost upon you that trampling all over CAM loses us nothing and gains us everything. For the moment a “CAM” modality is proven effective it ceases to be CAM. It is simply medicine. We here, including Gorski, have re-iterated this innumerable times. The parts of “CAM” that you could possibly be referring to as being “lost” in the trample are in fact already included in science based medicine – lifestyle, mental health, diet, exercise, herbal remedies (pharacognosy), even massage therapy are all explored from a scientific basis and incorporated into medical science when – wait for it – proven effective.

    People are not receptive to our message. Fair enough. That is not because our message is wrong – it is because we need to find better ways to say it. But you don’t stop your critiques there. The point of your posts is not, as Phil Plait put it “Don’t be a dick.”

    And yes, things like homeopathy, acupuncture, reiki, therapeutic touch, “the Secret,” etc NEED To be railed against and shut down. You deny these are problems – how many times must I remind you that my very own professor of “integrative medicine” (which you claim “eschew dangerous claims”) actually PROMULGATES DANGEROUS CLAIMS! And continues to perpetuate the false dichotomy you seem to be enamored with. In medical school. To future doctors. But don’t take my word for it. Read Tim Krieder’s posts here. Or a few more of Gorski’s. Or Novella’s. Or, really, anyone here. How is this lost upon you?

    You are correct that medicine was originally built around making the patient feel better and offer emotional re-assurance. I would also agree that science based medical practice is a new-comer. I would EVEN agree that in our zeal for application of such medicine the patient feeling better and taking care of their emotional well being was sidelined and marginalized. What is your point? Because SBM is a newcomer and because 1000 and even 100 years ago the first principle of medicine was emotional well being we should, what? Go back to the old ways and drop the science bit? Or call ourselves equivalent to CAM since we have the same historical “first principle?” Or maybe, just maybe, we should recognize this flaw in our current practice and add it back in. You know. Keep the science and the good stuff and go back to treating our patients like people – using SBM instead of pseudoscientific magic water and liver stimulation in the feet. And I’ll let you in on something – that is what we are doing. In just a few hours, for example, I have a clinical communication class where we will discuss how to relay risk information to our patients in an emotionally sensitive and understandable (to the lay person) way. Last week was palliative care. The week before was breaking bad news and euthanasia. And I will be tested on this – they will record me on DVD with an actor patient and then my skills will be dissected as to how well I communicate. This module has nothing to do with science. We aren’t even expected to know the details of what we are talking about here… just HOW to talk.

    So once again – what is your point? We illustrate to you the dangers of CAM. We give you examples of how it is infiltrating our medical schools and population via the media and political movement devoid of scientific understanding. We explain to you the dangers with having this taught to and endorsed by physicians. And all you can come up with is a continuation of the false dichotomy and a plea that we are arrogant bastards trampling over the placebo effect that is CAM.

    “We MUST better understand what we are dealing with.”

    Yes. And we seem to. You don’t. There is no righteous indignation propelling us. There is science, fact, experience, and nuance.

    My “indignation” is actually personal frustration at your inability to process what we are saying. That is a privilege of such a forum. I do not speak this way to my colleagues, professors, or patients.

  18. pmoran says:

    What makes you think I cannot process what you are saying? You are ME ten years ago. I still despise pseudoscience. I still attack cancer quackery. I still try to get CAM practitioners and their supporters to understand that most of their beliefs are based upon certain powerful illusions that permeate the practice of medicine.

    I suggest that you try and understand what I am saying, and the true intent of it, rather than what you assume I am saying.

    Why cannot our message be “yes, these methods can help people feel better but they should not be relied upon to treat serious conditions”? That is a more easily sold message. It is a better fit for the actual evidence. It is easier to argue through because effects upon serious illness should be easier for CAM to demonstrate.

  19. David Gorski says:

    Ah, I get it now. In other words, what’s the harm?

  20. nybgrus says:

    The fact that you STILL promulgate the false dichotomy. That is what makes me think you cannot process this. And argument from authority (I was you 10 years ago) does nothing to advance your points.

    I am not commenting on how much you may or may not fight against CAM. I am commenting on what you have said here in this blog. And what you have said is patently wrong.

    To re-focus here (and perhaps correct me if I am wrong) but your message thus far has been:

    “CAM has certain value and is useful for treating some conditions and offering emotional support to patients. Integrative medicine does not lack an evidence base and eschews dangerous claims. Science is self correcting and the validity and practice of CAM will self correct.”

    These are your arguments as I see them (and have quoted in prior posts) and are all false.

    You go on to say “yes, these methods can help people feel better but they should not be relied upon to treat serious conditions” and that this would be a “better fit for the actual evidence.” Once again, this is wrong and further demonstrates you work within the framework of a false dichotomy. There is NOTHING that CAM could or should be relied upon to treat. Period. Because IF something CAN be relied upon to treat anything it ceases to become CAM and is instead medicine. CAM, by definition is either unproven or doesn’t work. You touch on the “what’s the harm” gambit which has been addressed heavily here as well and I will not go into. Suffice it to say, “yes. There is harm!”

    Even Gorski took the time to quote you incredulously. Yet you still hang on to some wishy-washy dichotomy and try and hold out that science will correct itself.

    Unless you can explain how your comments do not demonstrate invocation of the false dichotomy and explain why you seem to think that integrative medicine taught in medical schools is completely apropos I do not think this discussion has anything left to say. You are welcome to sit in your ivory tower in your chair of authority and concern troll me for being “righteous” and “indignant” but I am the one here having my own classmates question “what’s the harm” in endorsing acupuncture and therapeutic touch for our future patients and professors telling us that reiki must have “something” behind it. I am seeing the harm and I won’t just kick back and let science correct itself.

  21. Ben Kavoussi says:

    @ US

    Also, bloodletting actually WAS a medieval treatment. . . that which evolved into current medicine . . but not so much a East Asian traditional medicine practice.

    Ah really!?

    Obviously you are not well informed about Chinese bloodletting!

    Here’s a second video:

    http://www.youtube.com/watch?v=FYC4CnPMd5w

  22. pmoran says:

    “You are welcome to sit in your ivory tower in your chair of authority and concern troll me for being “righteous” and “indignant” but I am the one here having my own classmates question “what’s the harm” in endorsing acupuncture and therapeutic touch for our future patients and professors telling us that reiki must have “something” behind it. I am seeing the harm and I won’t just kick back and let science correct itself.”

    Wow! At least it is reassuring that a presumed medical student feels so strongly about science. It reinforces my suggestion that before too long there will be a reaction to the pseudoscience underlying these methods, that there are limits to tolerance.

    Integrative medicine is likely to remain safe because its practitioners know that their very existence is based upon sufferance. If they overstep the mark they will be out on their arses. So they are on about relatively benign activities such as acupuncture and Reiki that even most of the general public understands the limitations of.

    One of the potentially damaging skeptical assumptions that I challenge is that the public is so stupid they need us to look after them. This is another way in which we can completely alienate a lot of moderate minded people. They may value our opinion on dubious matters but they resent it intensely whenever we seem to be trying to extend authority over areas where our own offerings are lacking.

    As your studies progress try to note that despite its triumphs conventional medicine does lack simple, safe and entirely effective answers for a lot of common conditions. This is where the attentions of CAM may be doing a little good through placebo and other non-specific influences. We may not want to use those methods ourselves but do try to understand how deeply counterproductive it is if we appear to be wanting to deny them to others. It is incomprehensible to those outside a our very narrow circle why we would want to do that.

    So, will you be effective in countering the pseudoscience? Just bear in mind that the approach you are adopting has not obviously worked that well so far. In fact, who does not already know that that there are people like you who violently despise everything that CAM stands for?

  23. nybgrus says:

    I do note the “lack of simple, safe and entirely effective answers for a lot of common conditions.” The answer is not to absolve ourselves and let the “attentions of CAM” minister to these. Just because medical science doesn’t know the answer does not mean we just throw up our hands and say “OK – have some magic water that does nothing.” I’ve said it before and I will say it again – that is a calling for us as medical scientists to fill that void currently met by “placebo and other non-specific influences.”

    As for whether I will effectively counter pseudoscience – like all science, it is not a one man endeavour. I am doing my part. I am educating myself, understanding the issues and arguments, and yes, in fact I am helping a number of my classmates to understand as well. It is frequently that I get asked “what’s the harm” and I can answer these questions and speak intelligently on the topic. I have sent links to these blogs and have had ongoing conversations with numerous students who are now “converts” if you will. At some point, I will have a degree behind my name and more power and authority that comes with it. And as that grows, I will use it to continue my cause against pseudoscience and CAM. I will speak kindly and intelligently to my patients and educate THEM on the topic as well. Besides actively believing in the pseudoscientific claims of CAM, a physician will fail to keep his/her patients out of its harmful reach through a lack of knowledge and understanding of the topic. If you just tell a patient “Acupuncture bad. No go there” that won’t work. Explain WHY it is a poor choice and frame it so they make the decision themselves and you have a vastly greater chance. These are skills I have practiced with friends and friends of friends who are quite heavy on the woo. To beat my own chest a bit, I have so far convinced an acupuncture believing ballerina to stop seeing her acupuncturist and a creationist that the earth is not 6,000 years old and evolution is indeed a valid theory (the latter taking 7 months and 60 pages of my own writing on the topic). So yes, so far, I have been as effective as I reckon I can be.

    The fact that you continue to proffer some sort of false dichotomy that grants CAM a valid place in patient care is not my failing, it is yours.

  24. pmoran says:

    It is not so much that we “grant CAM a valid place in patient care”, but that we have no right, power, or valid basis upon which to actively deny it to patients who may wish to try it, especially those with difficult problems that we have no complete answer to.

    So far as trying to dissuade a patient from using acupuncture (who wanted to try it) is concerned, I would too, if they had unbrealistic expectations or there were superior medical treatments. Not so confident otherwise.

    Re the supposed false dichotomy– once we allow that placebo and other non-specific beneifts can accrue from these methods with certain subjective complaints, then we have a standard cost/risk/benefit assessment to make. There is no other ethical option. Some skeptics deal with this by dismissing placebo reactions altogether. That is a shaky position on present evidence, but I admit we have much yet to learn.

    In other settings e.g. treating cancer the concept of a “what works”/ “doesn’t work” dichotomy is more apt.

    Good for you if your approach sometimes works.

  25. Dr Benway says:

    While we wait for the inevitable reaction against CAM, any advice regarding the little boy under my care on daily hydrocortisone as prescribed by an MD ND for “adrenal fatigue” presumably causing ADHD symptoms?

    It’s kinda been my impression that long term oral hydrocortisone FOR NO GODDAM REASON was not wise.

  26. Dr Benway says:

    Ooooohhh…The Evil Koch Brothers.

    Lesse, they fund that evil right wing anti-science show Nova that runs on…Oh, PBS. Uh. Never mind.

    Other than spitting out random CNN/DNC talking points do you have any evidence for that?

    Actually all I got right now is a big tub of popcorn.

    Say do you have “Koch Brothers Wisconsin Anon” on Google Alerts or something? Cuz you don’t come here often.

  27. nybgrus says:

    Ah. Now we get to the crux of our disagreement.

    “..we have no right, no power, or valid basis to actively deny it to patients…”

    When, pray tell, did I ever say I wanted to actively deny patients their right to do what they wish? When have I said that I am against patient autonomy? I do not wish to actively deny my patients and strip them of their autonomy and my discourse reflects that. I have been speaking out in regards to your comments that integrative medicine is “not dangerous” when taught in medical schools and that “science will correct itself.” I am not railing against patient rights. I am railing against the entrenchment of pseudoscience and woo-ful thinking into the academia of medical science. I am vehemently against the indoctrination of a cohort of future doctors who believe there IS a dichotomy and that the answer is “integration.”

    My goal is not to deny my patients, but to educate them and give them the means by which to make the best decisions. And I am sorry, but you are sorely mistaken if you believe there is ANY circumstance in which acupuncture is the best decision. You speak of ethics, and weighing cost benefit. The data show us that there is no benefit to acupuncture yet there is definite and definable risk. Ethics demands of us that we not subject our patients to risk knowing there is no possible benefit.

    On the broader scope, assuming some sort of placebo effect in the course of “treating” self limiting conditions, that is STILL not a reason to advocate for the use of CAM or to blithely assume you (as a physician) have no recourse but to say “what’s the harm.” I do not deny the placebo effect. However, I do believe that it is manifest primarily (if not solely) in SUBJECTIVE measures. Insofar as we are talking about a person with the flu seeing a homeopath and “feeling better” then not TOO much a problem arises. Except that once again, the ethics you claim to know about dictates that we have an extra onus to steer our patients clear of such scheisters. I could go on about “what’s the harm” but that’s already been done on the blog quite nicely. The point being, the onus upon us as professionals taking on the task of learning and applying that knowledge to help people should lead us to the inevitable conclusion that false hope and placebo effects are not a proper “benefit” to our patients. Knowledge and the best evidence and intellectual honesty can offer is a proper benefit. Thus, a risk/benefit is a moot point in your discussion of “placebo and non-specific benefits.”

    And ultimately, having one unified “medicine” instead of nebulous “alternative” modalities that have “non-specific” benefits is the best solution. By advocating against CAM and using evidence to stop practices we know do not work and have no basis we are moving towards that goal. But that, of course, is a tough battle, one that requires thought, effort, and being outspoken against a popular movement. Something perhaps you might have had the energy for 10 years ago. But forgive me if I don’t rush to being tired of fighting it quite yet.

  28. Dr Benway

    “While we wait for the inevitable reaction against CAM, any advice regarding the little boy under my care on daily hydrocortisone as prescribed by an MD ND for “adrenal fatigue” presumably causing ADHD symptoms?

    It’s kinda been my impression that long term oral hydrocortisone FOR NO GODDAM REASON was not wise.”

    Dr Benway – I know this wasn’t addressed to me and you have probably already done this…but I wanted to offer a possible approach. Print out 1-3 straightforward articles on the risks of long term oral hydrocortisone in children. Tell the parent you are concerned about the prescription for these reasons, that they are usually only prescribed by more serve symptoms of auto-immune disorders, asthma, etc (if that is correct, me-not-doctor).

    And then give the parents space to process the information through the next number of months. It is possible that Grandparents, aunts, uncles of the child are already voicing concerns, or that even the parents talking about it to friends or relatives will cause some of those friends or relatives to voice concerns, which might make the parents think again.

    Obviously no guarantee that it’d work, but it gives the parents the opportunity to make an informed decision, which the NP may not have done.

    No offense intended if this an overly obvious answer or if it has obvious flaws from a doctor’s standpoint.

  29. US says:

    @ Ben Kavoussi

    Are you kidding me? This is your defense?

    First, your entire blog was based on an interview with some person from the American Association of Acupuncture and Oriental Medicine. After railing against them in the blog, you criticize that “American acupuncturists have given over one million dollars. . .”

    Yes, I clearly misunderstood and thought you were referring to the same group. Kudos to your writing skills.

    However, this doesn’t address the point that you are STILL wrong, and that the acupuncturists in the US don’t have a million dollars, nor could WHO accept money from them, anyway. Have you bothered to check the (public record) finances of the WHO? Do you have any response to this, or are you just going to point a finger at me and and respond that I had a typo?

    Also, I don’t claim to be an expert on Chinese Medicine. You, however, apparently do. One would have thought you could have noticed then that, despite the titles of the YouTube videos you posted referring to “Chinese Bloodletting” (I paraphrase), the people doing the bloodletting are not actually Chinese.

    Initially I thought maybe you just needed a lesson in researching your blog posts. Now, however, . . .

    In any case, I don’t really care about this whole thing. I would have thought, however, in a blog called “Science Based Medicine”, there would have been some support for science. There is apparently no data (or at least not enough) on TM and whether or not it works. The science-based approach to this would be to let them build the tool to collect data and do research. . . which is what ICD actually is. If you really think it’s nonsense, then you should support this even more. After all, if the science will eventually show that it’s worthless, all they are doing is making the rope that they’ll eventually hang themselves with.

    Objecting to them developing research tools on the grounds that they don’t have any research to support themselves, however, sounds like the circular argument of someone airing a grudge in a public forum under the guise of science.

    Oh, and to head off the next argument, ICD is not made for reimbursement. In the US, it appears that reimbursement is based on CPT codes, which are owned by the American Medical Association.

  30. “And ultimately, having one unified “medicine” instead of nebulous “alternative” modalities that have “non-specific” benefits is the best solution. By advocating against CAM and using evidence to stop practices we know do not work and have no basis we are moving towards that goal. But that, of course, is a tough battle, one that requires thought, effort, and being outspoken against a popular movement.”

    nybgrus – While having one unified medicine may be the best approach, I think medicine is always going to have to deal with alternative approaches. While I believe it’s true that much progress could be made in discouraging disproven treatments and encouraging proven treatments. I believe ultimately you will alway have to deal with the issue that science can only offer reality, sometimes that is an unpleasant reality. Some people just do not do unpleasant realities. Those people will buy, build or create some “treatment” that will cure them or their loved one, regardless of the availability of CAM insurance payments, sellers, etc.

    I am not saying that discouraging disproven medicine is pointless! It seems there is lots of room for improvement. There is a big difference between a patient who is engaged in denial and one who has been misled by a practitioner. But, what I am saying that CAM’s attractiveness appears to be rooted in the human psyche. It is an offer of a fantasy, while science can only offer hard reality. One must figure out a way to deal with that. If there is a way.

    To some extent, that is what I read pmoran as addressing. How do you cope with the person who has chosen a fantasy because they will not or can not cope with the reality? (he may correct me if I’m wrong.)

    I have heard an answer on that questions from the CAM tolerant side(as folks seem to think of pmoran, although I don’t think he would agree :)) I don’t think I have yet heard in answer from the CAM intolerant side.

  31. micheleinmichigan,

    I think the answer from the CAM-intolerant is that it’s not possible to stop patients from engaging in denial or fantasies, but that it is absolutely possible not to teach Reiki in medical school.

    I do advocate courses on CAM in medical school so that physicians will be familiar with the pseudoscience. When I was studying nutrition, one of the alternative nutrition statements that came up over and over again was that the body produces mucus in response to irritants, that milk is mucus-promoting, therefore milk is toxic.

    When I asked my professors where this idea came from they just looked blank. They could tell me how milk is produced by a mammal, the nutritional content of milk, how that is measured, why breastfeeding is preferred to formula, how formula adapts cow’s milk to the requirements of human infants, what to do when you need to supplement/ replace breastmilk but don’t have access to formula, the geographic distribution of lactose intolerance, how lactose intolerance generates symptoms, different ways of dealing with lactose intolerance, how to make cheese, how to measure the colour of cheese for quality control, what the laws regarding cheese production, labelling and marketing are, the origin of food safety legislation, how milk physically gets from the cow to the grocery store… and on and on.

    But when I went out into the world, the first question anyone ever asked me was about the mucogenicity of milk and why it needed to be excluded from the diet. Not a whisper in any of our classes. There was one small book in our library describing and ridiculing common woo-y practices like colonic irrigation, but nothing specific to nutrition. I could find scholarly articles on how much water to add to sheep, goat, cow and yak milk to feed a child with diarrhea and how this correlated with the Asian category of coolness, but no scholarly articles on the origin of the idea that milk is mucogenic. This was before the internet so it wasn’t possible for me to just google milk+mucus+myth to find out the backstory, so I asked my profs. No clue. Nobody knew.

    When I first heard of CAM classes in med school I assumed they met the same need. I am flabbergasted to learn hear that no, they actually promote quackery. This should not be happening.

  32. Ben Kavoussi says:

    @ US

    A document posted by the American Acupuncturist posted at

    http://www.aaaomonline.info/ameracu/V37P33-AAOM_Advisory_To_World_Health_Organization.pdf

    about the ICTM plenary sessions (6 To 8 June 2006 – Seoul, Korea) states that:

    “Dr. Jeannie Kang, LAc (CA) was the Advisor selected to represent the American Association of Oriental Medicine (AAOM)
    at this meeting, and Marilyn Allen, AAC Public Relations and Marketing Director & Acupuncture Today Editor and Chief,
    participated as an Observer for Media Relations on behalf of the AAOM.”

    Marilyn Allen, by the way, is the current director of marketing for the American Acupuncture Council, a malpractice insurance company:

    http://www.acupuncturecouncil.com

    The document also states that:

    “The purpose of the classification is to promote standardization in traditional medicine terminology and data for communication, sharing of knowledge and resources, analyzing and reporting. Its aims are to avoid duplication of effort and create economies of scale, raise the standard of traditional medicine in clinical practice, public health, research, clinical trials, education, policy development, resource allocation and allow exchange of health records and inclusion of TM data in health information systems”

    Then, Jeannie Kang states in her interview in Qi-Unity Report:

    “Incorporating traditional medicine into the ICD coding system for medical records and billing…”

    BILLING is the key word

  33. yes, I agree on the keeping CAM out of med school. I was thinking more in terms of the in office interaction between doctor, patient.

    But not just that, I wondered if there may be some sort of systemic (is that the right word?) change that could better support people who are facing some of the tougher realities.

    For instance anecdotal, I have noticed that parents of children with autism seem to seek less alternative treatments when they have a good solid education/medical system in place. Folks struggling with the education or medical component seem more vulnerable. I couldn’t really say if there is causation here, could be that folks who are good at advocating for education/medical services are less likely to seek out iffy therapies.

    But if one found there was causation there, one could imagine a systemic change that would be more proactive about initiating education/medical support for children with autism and checking with parents on their coping levels. (A checklist that integrated medical and educational interventions?)

    I guess that was the sort of thing I was imagining. But, I was hoping to hear some other ideas, cause mine is based on a shallow understanding of the processes involved.

  34. Dr Benway says:

    I would have thought, however, in a blog called “Science Based Medicine”, there would have been some support for science.

    0/10

    Do trolls all take the same correspondence classes or something?

  35. I always figured it was some sort jungian archetype thingy.

  36. S.C. former shruggie says:

    micheleinmichigan,

    Intigrating CAM does not appear to be a viable harm reduction strategy for those who prefer magic over hard realities.

    1 – Where it is already being taught, it is not offered as harm reducing placebo. It is taught as equal to non-placebo treatment.

    Consider homeopathic “vaccination” for pertussis. CAM replaces non-placebo life saving treatments.

    2 – Harmful modalities are not abandoned.

    Consider DAN! practicioners chemically castrating autistic children and giving them kidney damaging chelators.

    Consider spinal injury following chiropractors adjusting cervical vertibrae.

    Consider cases of sepsis following accupuncture or Chinese bloodletting.

    CAM does not limit itself to safe placebos.

    3 – CAM advocates are not interested in living peacefully with scientific practice. Check out Age of Autism. Check out Mike Adams’ Natural News. Google search Gary Null or Joe Mercola. These people despise real medicine. The talk of integrating magic with science, veracity and inanity living together in harmony, is a ruse.

    Something should be done to help people who prefer magic over hard realities and scary surgeries. Integrating CAM is not it.

    Pmoran said:

    One of the potentially damaging skeptical assumptions that I challenge is that the public is so stupid they need us to look after them.

    Not stupid. Immature, maybe. Conspiratorially minded, probably. Prefering magic promises over hard realities, definitely. Most people I have ever met fit these discriptions. So do most people need their more level-headed friends, family, colleagues or doctors to steer them clear of danger? YES. Abso-censored-lutely, yes!

  37. Alison – I admit, I don’t quite get the milk/mucosa example, but I have tons of (incredibly boring) art fair applications to do, so I will have to resist the much more alluring task of figuring out how the difficulty of finding an explanation on milk and mucus production relates to CAM education.

    I am not being ironic.

  38. “Something should be done to help people who prefer magic over hard realities and scary surgeries. Integrating CAM is not it.”

    Once one decides integrating CAM is not it, what are some other options or innovations?

    (someone slap me, I’ve got to finish them damn applications.)

  39. Dr Benway says:

    I just want to go back to the 1980s, when a doctor could call the Board of Medicine (not yet infiltrated) and say, WTF? Then the Board would call Dr. Woo and he’d be in a heap of trouble and would be forced to do some remedial education.

    The set of dangerous bullsh_t that can be inflicted upon children is infinite. If the half dozen or so in my specialty in my state have to drop what we’re doing to educate against bad ideas promoted by other MDs, we are cooked. Which I notice is the CCHR plan, actually.

  40. Harriet Hall says:

    It has been claimed that incorporating this terminology into ICD will facilitate research, etc. If that is true, one can only wonder why astronomy organizations are not involved in a similar effort to integrate astrological terminology. :-)

  41. micheleinmichigan,

    My point is that milk-is-mucus-forming-therefore-toxic was woo and what the general public thought was cutting-edge “nutrition science” at the time. And that focussing entirely on reality-based training for dieticians did nothing to prepare them to address the questions of the general public regarding pseudoscience — although they may have been perfectly competent to run a hospital kitchen or counsel a family with a PKU child.

    I believe doctors should be familiar enough with major pseudosciences to be able to address questions from the general public, which may bear little relationship to the conventional reality-based medical curriculum. Staring blankly and saying “Um, I’ve never heard of that” is unlikely to convince a patient that you know what you’re talking about.

    That’s all.

  42. Dr Benway says:

    Staring blankly and saying “Um, I’ve never heard of that” is unlikely to convince a patient that you know what you’re talking about.

    But the woo buggers keep making up new nonsense. It’s impossible to keep up.

  43. David Gorski says:

    It has been claimed that incorporating this terminology into ICD will facilitate research, etc. If that is true, one can only wonder why astronomy organizations are not involved in a similar effort to integrate astrological terminology

    Oh, it’s so unbelievably obvious that the true purpose of trying to “integrate” so-called “traditional medicine” diagnoses and procedures into the ICD coding system is a first step to being able to bill for them that it boggles the mind that anyone would defend it. Hint: You do not need an ICD code to do research on a procedure or diagnosis. Indeed, except for retrospective research using insurance billings to identify patients with a specific diagnosis, medical researchers usually don’t even bother with ICD codes when doing research.

  44. S.C. former shruggie says:

    I posted just before running to class and realized, hey, that last paragraph was unnecessarily abbrasive.

    I was suckered by some hormone and herbal woo as a young(er) arts undergrad. Having learned the hard way, and now having some biology education behind me, should I use what I’ve learned to try to help others who don’t have that experience avoid unsafe or unproven treatments?

    Hell yes.

  45. Alison – Thanks, got it. Growing up, one of my bests friend’s dad (a runner) was into all the nutrition mythology. So many of the things I heard from him were not correct, I’ve just grown to assume anything he told me was wrong. I suppose “it’s wrong cause Margrat’s dad told me it was true” isn’t going to fly, with a patient, though.

    Dr. Benway – Con artists, urban legends, viruses are quickly evolving, that’s why Quackwatch, snopes, symantec are good tools.

    Perhaps the answer isn’t educating future doctor’s about possible CAM they may come across…

    Maybe you need a QuackApp

  46. Ben Kavoussi says:

    @ David Gorski

    … it’s so unbelievably obvious that the true purpose of trying to “integrate” so-called “traditional medicine” diagnoses and procedures into the ICD coding system is a first step to being able to bill for them that it boggles the mind that anyone would defend it.

    You are absolutely right. Now, look at what Gene Bruno, the “President Emeritus” of the American Association of Acupuncture and Oriental Medicine (AAAOM) wrote in Acupuncture Today of February, 2008:

    WHO is also working to implement traditional diseases and pattern diagnoses into the newest version of the ICD (International Classification of Disease) codes. This development is of great significance to Western practitioners, as the implementation of traditional medicine into the ICD-11 codes will set the stage for enhanced future health care integration by providing diagnostic and billing codes for traditional patterns and disease categories.

    Here’s the whole article:

    http://acupuncturetoday.org/mpacms/at/article.php?id=31657

    Oh, by the way, Acupuncture Today’s Editor, Marilyn Allen, who went with Jeannie Kang, to Korea to represent the AAAOM, is an insurance insider. She is the current director of marketing for the American Acupuncture Council, a malpractice insurance company.

    This ICD 11 is indeed the first step to being able to bill for the running piglets and steaming bone disorder.

    This is so important to AAAOM that it is taking online donations for its ICD11 – Traditional Medicines fund:

    http://www.aaaomonline.org/donations

    Unbelievable.

  47. JMB says:

    @nybgrus

    If you are in medical school, your current job is to be the best medical scientist. Medical school is about medical science, residency is about learning the skills required to take care of a patient. In medical school, you get the impression that all you need to practice medicine is scientific knowledge. After your first year in residency, you will begin to appreciate wisdom (usually, the only thing you appreciate in the first year of residency is sleep). When you begin to practice medicine, your job is to get the best results possible for the patient, not be the best medical scientist.

    While the cynical, sarcastic, antagonistic, confrontational approach would be appropriate for banishing the study of CAM in medical school to a course on placebo effect, it may alienate a patient you are trying to keep on a treatment regimen. I think pmoran is making an important point about the medical practice side of medicine. Part of your responsibility as a physician is convincing the patient to stay on the SBM treatment regimen, if that requires some acquiesce to the patient receiving CAM elsewhere (after an attempt at education fails), so be it.

    Trying to defeat CAM on the political arena is more like treating a patient than winning arguments in medical school. So if you are going to make presentation to general audiences, it may be better to cover the skepticism with humor so it doesn’t seem too cynical.

    In the arena of an internet blog, I think the best approach remains to be determined by experience. Early internet users before web browsers became available were pretty snarky nerds that set a tone that has persisted into the Web era. A cynical, sarcastic, antagonistic approach that retains a sense of humor may gain the highest numbers of hits. In the political arena, I think they are impressed by the number of web site hits (politicians seem to think that hits are a gauge of public opinion). So the blog SBM may have the best strategy for deflating CAM.

    So I am sure that pmoran is right about the best approach with a patient. He is probably right about the best approach in a political arena. I would vote for the more confrontational approach on an internet blog, I think internet audiences kind of expect it. Maybe that will change in another decade.

  48. David Gorski says:

    Lest anyone think that I don’t understand that different approaches are called for in different situations, please go back and revisit this post I wrote for SBM a couple of years ago:

    http://www.sciencebasedmedicine.org/?p=306

  49. Ben Kavoussi says:

    @ Alison Cummins

    Concerning the milk-mucus hogwash:

    In TCM, dairy products are believed to increase “Phlegm” (痰). The same ideogram also means sputum. I believe the person who told you about “mucus” mistranslated 痰.

    TCM nonsense says that Phlegm interacts with the functions of the “Spleen” (which likes dryness), and therefore you become lethargic.

    We had the same exact thing in medieval Europe when physicians believed that an excess of Phlegm causes slow and stolid temperament — hence the word “phlegmatic.”

    Hogwash.

  50. pmoran says:

    Nybgrus” When, pray tell, did I ever say I wanted to actively deny patients their right to do what they wish?

    Yes, every skeptic says something like that when it is pointed out that CAM may in certain contexts be satisfying deep human needs and compulsions and relieving symptoms in ways that conventional medicine is not well geared towards.

    Yet elsewhere the same people will use a violence of language, slippery slope arguments, bald “it doesn’t work” assertions and other attacks that are rightly or wrongly interpreted as meaning precisely that. So people switch off. They sense, probably correctly, that here is a crusader who would stop at nothing if allowed.

    It is possible to impart the required information without subtexts that risk turning off the very people who need it most. Look at Harriet for a very consistent example.

  51. Dr Benway on being prepared to respond to CAM: “But the woo buggers keep making up new nonsense. It’s impossible to keep up.”

    Agreed. Still, there are constants. Hulda Clark’s zapper may be fading, but there will be high colonics for eternity. And probably homeopathy and acupuncture too.

  52. David Gorski says:

    Yet elsewhere the same people will use a violence of language, slippery slope arguments, bald “it doesn’t work” assertions and other attacks that are rightly or wrongly interpreted as meaning precisely that. So people switch off

    All right Peter. We’ve been down this road before, but I’ve never gotten what I consider to be a satisfactory or specific answer from you about it. Quite frankly, my impression is that you dance around the question endlessly, but never quite manage to answer it.

    So, what, exactly, would you do?

    You’ve all but advised that we become shruggies and tolerate quackery as long as it doesn’t appear to be dangerous quackery, or am I misinterpreting? (Note: I don’t think that I am.) Let’s see if you can actually give a clear, coherent, and specific answer to the question: How do we speak to believers in medical pseudoscience to communicate to them that these things don’t work? Or are you burned out fighting quackery? I get that sense about you sometimes.

  53. Ben Kavoussi on a long-standing mystery: “In TCM, dairy products are believed to increase “Phlegm” (痰).”

    Oh how very cool! I had no idea. If I could have said, “Oh, no, that’s not cutting-edge science, that’s TCM astrology” or something, I think that would have helped enormously. Too late now, but thank you!

  54. pmoran says:

    While we wait for the inevitable reaction against CAM, any advice regarding the little boy under my care on daily hydrocortisone as prescribed by an MD ND for “adrenal fatigue” presumably causing ADHD symptoms?

    That does make me uncomfortable . It triggers my “down with CAM!” reflex, too.

    I have had to learn in relation to cancer quackery that often there is nothing you can do. You can be compassionate, express opinions, provide information and still not prevail over desperation.

    But here a child is involved. Depending on steroid dosage he could be seriously harmed. Have you talked to child protection agencies?

    Is this a licensed naturopath? If so I would want to know if the licensing board condones such practices and take it to the media if they do.

    There is nothing in what I am saying that prevents vigorous opposition to dangerous practices.

  55. Ben Kavoussi says:

    @ Alison Cummins

    You are welcome. Next time hear similar hogwash, send it to me, I will tell you the underlying nonsense!

  56. pmoran says:

    David Gorski: Alright Peter. We’ve been down this road before, but I’ve never gotten what I consider to be a satisfactory or specific answer from you about it. Quite frankly, my impression is that you dance around the question endlessly, but never quite manage to answer it.

    So, what, exactly, would you do?

    I gave you a tentative answer above —

    Why cannot our message be “yes, these methods can help people feel better but they should not be relied upon to treat serious conditions”? That is a more easily sold message. It is a better fit for the actual evidence. It is easier to argue through because effects upon serious illness should be easier for CAM to demonstrate.

    and got this response —

    Ah, I get it now. In other words, what’s the harm?

    I have never denied that alternative medicine has its dangers. This whole argument is about how we might best minimise them. Making it about “the science” tends to distract from what is most important here.

    For Nature has played a trick on us, one that makes that task very complicated. I refer to the dissociation that exists been the true intrinsic medical activity of a medical treatment, and its ability to at least seemingly serve as medicine in some contexts. We don’t yet have a good scientific handle on this phenomenon.

  57. nybgrus says:

    Dr. Gorski, I believe you have adequately summed up my argument against pmoran.

    As I have said – and others have started picking up on – the teaching of CAM and integrative medicine in med school is not a lesson in how to recognize pseudoscience and understand the placebo effect – it is to give credulity to dubious and disproven modalities. Full stop. And THAT practice should FULLY STOP.

    What would I do? Well, perhaps I have not elucidated it fully enough. Here, on this blog, which is all about the science I will by snarky and intolerant of woo. This is the forum to be that way and do thoroughly denounce wooful thinking. Being wishy-washy here is a complete waste of time. The purpose of this and other such blogs is to offer a bastion of hard science and how it relates to the clinical picture WITHOUT equivocation. So that people like myself can learn (and educate others), so that other posters and readers here can learn as well, and so that if and when a person on the fence about some CAM modality does a google search they at least have a CHANCE of finding something hard to tell them the CAM idea is wrong. Can you imagine searching and every website you find has pmoran’s wishy-washy “what’s the harm” rhetoric? Please.

    In terms of school – yes, I am aware this is the time to hone my scientific skill and that in 3rd and 4th year and especially residency I will learn to apply it clinically. I used to work for 3 years as an othro/trauma/critical care tech in a level 1 trauma facility and I am more familiar with the clinical side of medicine than the vast majority of my colleagues (please don’t read that as saying I know everything, but I at least have a flavor of it). The point being is I have seen patients ask for and about woo and I even witnessed our EMR documentation system change to woo. Yes, that’s right – we had to document pain as a vital sign. And if the patient responded 4 or greater the system MADE us record an intervention that was done in response. One of these was “therapeutic touch.” Really? So yes, while I have a VAST amount of clinical learning to do, I must also learn to be very familiar with science AND pseudoscience to give myself the best chance of educating my patients and colleagues. In school now, as I have said, I take opportunities to educate my classmates. They come to me and ask “what’s the harm” – I answer and they are fascinated. They are blown away by looking at things this way – something they have never been exposed to before. And I teach. I teach USMLE prep to the first year students and I take a few minutes each time to give them insights like these as well. That is what I can do now as a medical student.

    You ask what about your patients? You can’t just tell them not to do something, it doesn’t work, and you’re stupid. Of course not. That is why I also spend time trying to have conversations with creationists and religious fanatics (it drives my girlfriend nuts – she can’t stand those people). Because, as Allison and Michelle have pointed out the need for wishful thinking and searching of woo is ingrained into the human psyche. Indeed, in my research, reading, and interactions I have come to the conclusion that the ideas behind CAM, religion, creationism, fundamentalism, etc are all rooted in the same exact mindset and type of thought manifest in different directions. So my goal is to find ways to effectively communicate and educate my future patients so that they understand WHY not do CAM modalities and let them decide that on their own. Will I be 100% successful? Not even close. But if I can manage even 1 case of success I will be happy – and I will get better and better over time.

    Michelle says there will always be the need for the alternative. I agree. However, we can work to minimize and limit the scope of it. Historically we as a species are getting more refined and less prone to woo. But it is a slow process. However, doing as pmoran suggests and throwing up our hands is not the answer.

    Let me be clear – unlike Mike Adams would claim I am all about treating the root cause, not the symptoms of CAM. I want to be able to stop CAM in med schools, destroy this stupidity about “integration,” and give people a reason NOT to choose CAM. Yelling at the end product of a complex tree of processes leading to CAM use is ineffective and will only make your hoarse. I think sites like this, advocacy in medical schools, and a solid understanding of CAM and pseudoscience are the first steps.

    I’ll finish by saying – once again – that I believe medicine, as I will practice it, can incorporate the parts of CAM that entice people to the dark side.

    “There is a big difference between a patient who is engaged in denial and one who has been misled by a practitioner. But, what I am saying that CAM’s attractiveness appears to be rooted in the human psyche. It is an offer of a fantasy, while science can only offer hard reality. One must figure out a way to deal with that. If there is a way.”

    There is a way. Science is not a cold harsh b*tch. And it is too easy to make her one. I see no reason why education, enlightenment, science, and empathy are mutually exclusive. That IS a failing in modern medicine. In no small part because physicians are often afraid of dealing with emotions, dealing with sad people, saying “I don’t know,” or admitting mistakes. There is this notion that we should be super humans. Hogwash. Saying to a patient “I don’t know, but I promise you I will do the best I possibly can” is a wonderful thing to say. Giving them hope even when the science says something terrible is a skill and something we need to offer our patients. Anything else is active denial. Anything else is pushing them into the arms of CAM. But that takes some extra time in the consultation and some extra effort. It is much easier to fall back on cold hard science and bug out – we are quite busy after all. That is a change in the culture of medicine that I think needs to happen. That is the solution to “integrating” cold hard science with humanity. Saying anything else is basically saying that medical science cannot be human science. And that is just bullsh*t.

  58. Dr Benway says:

    Is this a licensed naturopath? If so I would want to know if the licensing board condones such practices and take it to the media if they do.

    Yes he is licensed. And yes, the naturopaths generally are diagnosing and treating something they call, “adrenal fatigue” all the time.

    Protective services will defer to the treating physician.

    I cannot report the MD to the Board of Medicine, as the bad guys have changed the rules to make “integrative medicine” non-actionable.

    My plan at the moment is to pretend I’m not actually the doctor for this kid so I’m not made to write an order for hydrocortisone in any chart notes. This is a day student who can take his meds at home in the morning. If he were a resident, I would have to write the order or the nurses would not be able to give the med.

    Last time I went through this with a DAN! doctor, it got kinda ugly. There’s no easy way to talk on the phone to a “colleague” about stuff like this. Those guys are touchy about defamation and trade interference.

    The CCHR has done a good job. I hear, “You’re only addressing the symptoms; you’re not getting at the cause,” repeated like a mantra.

    I have a trick I use to help me sleep. I say, “Very well. I hope you enjoy your Reiki and Dianetics, America!” and then I let go my worry and just watch the show as it happens.

  59. Dr Benway says:

    Science is not a cold harsh b*tch. And it is too easy to make her one. I see no reason why education, enlightenment, science, and empathy are mutually exclusive.

    My latest metaphor:

    Heart or feeling is: Measure once, cut once.

    Reason or science is: Measure twice, cut once.

    Anyone who favors “heart” over “head” is simply hoping you won’t want to double-check their figures.

  60. nybgrus “There is a way. Science is not a cold harsh b*tch. {snip} That is a change in the culture of medicine that I think needs to happen. That is the solution to “integrating” cold hard science with humanity. Saying anything else is basically saying that medical science cannot be human science. And that is just bullsh*t.

    Here, Here! As a patient, my favorite doctors are one’s who are willing to say “I don’t know”, when needed. Sounds like you are on the right track.

  61. nybgrus says:

    Thank you Michelle. Sincerely.

  62. Heart or feeling is: Measure once, cut once.

    Reason or science is: Measure twice, cut once.

    Anyone who favors “heart” over “head” is simply hoping you won’t want to double-check their figures.

    Dr Benway, the whole point is that if you cut incorrectly, your trim won’t fit into the miter…nobody has to check your figures, reality does it for you. I suppose the medical equivalent is, if you measure wrong, then the patient doesn’t wake up.

    Interesting though, I’ve never heard it use to describe feeling vs reason. It’s always been an sloppy vs craftmanship analogy for me. I’m going to have to think on that.

    Carpentry metaphors in medicine…I had no idea. :)

  63. Harriet Hall says:

    @pmoran,
    “It is possible to impart the required information without subtexts that risk turning off the very people who need it most. Look at Harriet for a very consistent example.”

    Thank you for the compliment. I’ve said it before, but I’ll say it again: Don’t recommend CAM to a patient, but if the patient brings it up, tell him it is not supported by science but that some people have thought it helped them, and if he wants to try it you will support him and want to follow his progress. I think that approach preserves scientific integrity while respecting patient autonomy and not insulting belief systems. I’m retired, so I don’t have to actually do this, and I’m not entirely sure I could do it with a straight face and without projecting my disdain, but it’s a goal to aspire to.

    Thinking of CAM as a religion helps.

  64. nybgrus says:

    I agree Harriet. The worst outcome would be losing a patient to CAM with no recourse. Letting them know you still support THEM even though you can’t scientifically support the CAM they are interested in at least lets you monitor them and perhaps eventually they will make a different decision. Derision and snobbery are surefire ways to lose a patient.

  65. Dr Benway says:

    … tell him it is not supported by science but that some people have thought it helped them, and if he wants to try it you will support him and want to follow his progress.

    Could you really do that when the patient is a young child and the intervention is hydrocortisone for adrenal fatigue, chelation for vaccine poisoning, diflucan for candidiasis, long-term antibiotics for chronic Lyme, gluten-free/casein-free diet for “leaky gut,” mega-vitamins for “detox,” expensive supplement blends for autism…? Cuz all that is my bread n butter right there.

  66. “Heart or feeling is: Measure once, cut once.

    Reason or science is: Measure twice, cut once.”

    Sorry – off topic.

    This in not to disagree with your point – Dr. Benway, but upon reflection. I think, for me, no. This analogy makes it look like feeling and reason are opposite sides of the coin and that reason and science synonymous.

    Where is creativity?

    People are too inclined to group creativity in with “feeling” (oy, the seventies) this leaves those people with the impression that science is without creativity. So utterly wrong, that.

    But creativity is different than reason (although ultimately subject too reason) It may be a leap from reason, to some unpredictable place. Or maybe it’s the back side of reason, that you never really knew had that interesting texture until you held it up to the the filtered light.

    Right?

  67. nybgrus says:

    Dr. Benway – cases like that I would try my best to dissuade the patient. But if you push too hard you will lose them as a patient. And hard as it is, keeping them around during their chelation is a better option than writing them off and letting those quacks poison that poor child. But perhaps in cases like that, after the fact, charges of misconduct can be brought? I’m not sure and it wouldn’t help that child, but maybe future children?

    Michelle – there is much creativity in science. And even in art there is science – I read Kandinsky’s book on how to draw abstract art and there are recommendations for flow and shapes and lines that attract the eye. Think about that – abstract art can still be rooted in a scientific thought process. That is why people ask what the difference is between that and a monkey slapping paint on a canvas. There IS a difference – albiet sometimes small and often subjective. The point is that the science tells us when things work (or more oftenly when they dont). The creativity comes in two ways: before, when we must get creative with how to find those answers, and after when we must figure out the best ways to apply those answers. IMHO anyways.

    I think it is a tired old dog of the religious apologists that “reductionism” leads to a sterile and cold understanding of the world devoid of feeling and “wonder.” Bah. The more I learn about how things work the more I am enthralled by the possible applications. I think that is also a base human desire – one I exploited during my surgical elective last year. I would speak to patients in greater detail than they have ever heard from a doctor and got resoundingly positive feedback. Understand WHY the abdominal pain came in waves 10-15 minutes apart (migratory motor complex) gave them such comfort and took away fear that they took the extra 5 minutes to understand what (to them) was foreign and complex physiology. I used to play poker for a living in college and one rule that must never be broken is never show your cards unless you have to. Your opponents are always afraid of the unknown. That is the basis for religion and CAM – patients and people dont like the unknown. Some are quite content with magical fairytales to fill that void. But if you give people the option of knowledge they will often take it.

    Sorry, totally off topic, but an interesting discussion we’ve been having here. And sorry to have hijacked your thread Ben.

  68. Harriet Hall says:

    Dr. Benway,

    I was thinking of interventions likely to be harmless. Your example is another kettle of fish entirely. Gee, I’m glad I’m retired and don’t have to deal with cases like that!
    In a case like that, I would first want to make sure the parents fully understood my concerns about the risks involved. I would let them know how passionately I felt about it; I might cry. I might try meeting with the parents along with other family members and the CAM provider and maybe a religious adviser or mediator to see if some compromise might be reached. If all else fails, when a child is in danger the courts can intervene. Do you have any objective evidence of harm you could present to a judge, like immune suppression or side effects from the treatments? If there is no imminent danger, maintaining supportive contact with the family might be very painful but might eventually help them realize the CAM treatments aren’t working, and would at least keep you in the loop in case the child’s life is in danger later on.

    If an adult understands, gives informed consent and is willing to reject conventional medical advice even if it means he will die, we have to respect his autonomy and let him die, no matter how much we deplore his decision. But society has an obligation to protect children from their parents.

  69. David Gorski says:

    Why cannot our message be “yes, these methods can help people feel better but they should not be relied upon to treat serious conditions”? That is a more easily sold message. It is a better fit for the actual evidence. It is easier to argue through because effects upon serious illness should be easier for CAM to demonstrate.

    and got this response —

    Ah, I get it now. In other words, what’s the harm?

    I have never denied that alternative medicine has its dangers. This whole argument is about how we might best minimise them. Making it about “the science” tends to distract from what is most important here.

    This might be to some extent justifiable when dealing with some individual patients, it is not at all justifiable when discussing the infiltration of quackademic medicine in to medical academia. the simple reason is that we expect our academic physicians to know better. Worse, the seeming acceptance of quackery in academia gives the impression to lay people that quackery is all right. In any case, what you describe is to some extent what most physicians do: Tell patients the woo doesn’t work, that it is unsupported by science, but nothing more. Patients are, after all, autonomous and have a right to decide for themselves. Worse, your attitude imparts an impression of physician approval, or, at the very least, undeserved tolerance.

    That aside, I would also disagree with you in that your approach of taking on a “shruggie,” “What’s the harm?” attitude you advocate would lead to the proliferation of more alternative medicine, this time with the blessing (or at least tacit approval_ of physicians, thus increasing the potential number of patients who could be harmed.

  70. Ben Kavoussi says:

    @ nybgrus

    And sorry to have hijacked your thread Ben

    No problem.

  71. Dr Benway says:

    Like I said earlier, my biggest worry is getting suckered into writing orders for this crap.

    Orders are written upon admission. If I don’t sign off, the meds can’t be given by the nurses. So the day will come when a kid arrives on bizzaro juice and my hand will not be capable of transcribing the order for it into the chart.

    Chatting with the parents is problematic, as Doctor Number 2 has a relationship with them and he is not in the room.

  72. “That is why people ask what the difference is between that and a monkey slapping paint on a canvas. There IS a difference – albiet sometimes small and often subjective. ”

    Often it’s much easier to see the difference when you look at the body of work of an abstract expressionists like Jackson Pollock and compare it to one of an ape. But considering that many apes can learn sign language helps to understand that neither the person or the ape is using color or line in a random way, as some people assume.

    Apes painting (sorry, off topic)
    http://www.youtube.com/watch?v=lkMTRme7xHY

  73. Re Harriet Hall & Dr Benway,

    Harriet Hall – IMO, from the viewpoint of a parent who advocates for their child’s medical needs, I like your approach. I particularly agreed with the fine point you put on how one might deal with a situation where the child is in imminent danger vs not in danger.

    Dr. Benway – It takes a lot of emotional fortitude to work with children. Often, more than it should. My mother was a teacher/principal and I know the things that really got to her were not the kids behaviors, but the points where the parents behavior clearly harmed the children, but in a way that one couldn’t report the behavior to CPS and make it stop. Helplessness.

    Sadly, the more passionate and committed one is to their work, the more of an emotional toll it takes to see things screwed up by thoughtless, uncaring or misguided individuals or systems.

    Of course, if those passionate about their work don’t stay in the field, the situation will only get worse and those children in need will lose the only competent advocates they have.

    So maybe it isn’t worth much, but thank you for your efforts. If there is something that I can do that will help resolve these issues, in the long run, such as write a letter to a congressmen and ask friends to do the same, or donate to a particular organization, let me know, I will do what I can.

  74. Dr Benway says:

    I think we should divide and conquer. I’ll leave the general public to you. I’m primarily interested in fixing my own profession.

  75. Jan Willem Nienhuys says:

    Back to the Running Piglets!

    I noticed that the references to
    http://www.scribd.com/doc/47499812/WHO-FIC-2007-D023-ICTM
    and
    http://www.scribd.com/doc/47499931/WHO-FIC-2007-D023att-ICTM
    are gone and replaced by
    http://www.wpro.who.int/NR/rdonlyres/14B298C6-518D-4C00-BE02-FC31EADE3791/0/WHOIST_26JUNE_FINAL.pdf

    where one will find the Running Piglets as 3.1.140 whereas in the other source it is also embellished with ICD K40 and TM code a53.

    Also a short YouTube movie has been added, in which it is emphasized that this new terminology is necessary for quality control, such as a uniform registration of adverse events.

    It sounds almost reasonable, but I think it is illusory. If that is done the next step is to introduce homeopathic registration of adverse events. In homeopathy there is (at least in the classical kind) no real sickness classification. The sickness is, so to speak, the sum total of all symptoms, and the axiom is that there is a medicine that most resembles it.

    Many people think homeopathy is: combat sickness A by diluted stuff that causes A in healthy people, when given undiluted.

    Wrong. The majority of all symptoms in homeopathy books are obtained from tests with C30 diluted stuff. If you dilute (potentize in the parlance), then at the first step you may get a more potent stuff, but if you go further you get entirely new symptoms (when applied to healthy people, says the creed). So a homeopath can prescribe any remedy in a great number of ‘potencies’. That would open the way for adding 50,000 items to the ICD code, namely the drug pictures of all combinations of remedy and potency. The homeopaths would love that! For the sake of registration of adverse events!

    You bet. It is just a ploy to gain respectability. The TCM are also trying to get ISO-norms approved for whatever they do. They will try anything to get out of kindergarten and into the world of real grownups.

    Have those TCMers (and generally the altmeds) ever been into systematically keeping records, doing followups, and so on? No! We know about adverse events with acupuncture only from people that arrived in hospitals with collapsed lungs (pneumothorax) and so on, and that were reported in the regular medical literature.

    Let those altmeds first show they are able to keep records at all, so regular doctors don’t have to guess how many people got sick from ‘herbs’ (getting veno-occlusive disease or bad kidneys or lead poisoning), how many people got strokes from neck manipulations and so on and so on, before they try to split this up in subcategories such as ‘after acupuncture on the fangpi point of the triple warmer meridian for blazing saddles disease’.

  76. pmoran says:

    David: “That aside, I would also disagree with you in that your approach of taking on a “shruggie,” “What’s the harm?” attitude you advocate would lead to the proliferation of more alternative medicine, this time with the blessing (or at least tacit approval_ of physicians, thus increasing the potential number of patients who could be harmed.

    I don’t have a “shruggie, what’s the harm” approach because I am well aware of the potential risks that you raise. I merely think they are overstated and very likely to be balanced by the positive effects of a clear, well-targeted message as opposed to a rambling, excessively nerdy one that that leaves the listener to guess at its owners’ ultimate intentions.

    My mantra ” these methods can help people feel better but they should not be relied upon to treat any serious condition” sums up in few words precisely what the science entitles us to say, and that can’t be bad in any context.

    WRT encouraging CAM use, it is clear that the alternative medical movement was well away long before any university or hospital had a CAM department. Their development was a reaction to the apparent popularity of CAM, never a cause.

    They may have some small influence, but there are powerful OTHER forces determining CAM use,as I have listed several times here. They will remain dominant influences, until or unless advances in medicine can remove any need for them.

  77. Dr Benway says:

    They may have some small influence, but there are powerful OTHER forces determining CAM use,as I have listed several times here.

    I think we go around in circles because of that stupid word “CAM” or “alternative” or “unconventional” or “Eastern” or “Holistic” or “Integrative” or whatever word is most fashionable at the moment. The word itself is a big fat lie, so using it in a sentence is a set up for disaster.

    Imagine if you repaired cars for a living. You notice that other people in your line of work sometimes don’t do a very good job. They’re not systematic. They waste time and money on useless repairs, and so on. Is there a word for all that? Not really, but maybe we could call it “alternative repair.” Or maybe we could call it, “doin it rong.”

    But wait, no one would pay for it if we called it DoinItRong, so we probably should call it, “Alternative Automotive Repair.”

    Humans are easily fooled by words it seems and so CAM will always be with us. However, we shouldn’t pretend logic or science has anything to do with CAM as that is dishonest.

    By DoinItRong, I don’t mean the evidential gray areas. I mean homeopathy, Reiki, and chelation for autism.

  78. Ben Kavoussi says:

    @ Jan Willem Nienhuys

    Indeed I replace the links. The WHO International Standard Terminologies on Traditional Medicine in the Western Pacific Region has the advantage of explaining what some of terms mean in a section of Basic Theories.

    However, all these documents are written by people who do do not know much about medieval medicine in Europe and how similar some of its core concepts are with the co-called “Chinese medicine.”

    Blazing saddles? Is it a type of “restless organ disorder? or is a type of “heart phlegm misting the mind”?!

  79. “I think we go around in circles because of that stupid word “CAM” or “alternative” or “unconventional” or “Eastern” or “Holistic” or “Integrative” or whatever word is most fashionable at the moment. ”

    One thing that you can learn from observing politics (or watching West Wing) is that it’s very dangerous to let the opposition set the vocabulary for the topic under debate.

    What better word to use in reference to the above? One that is recognizable, but more accurately delineates the difference between CAMesk techniques and SBM.

    Maybe something along the lines of unproven or disproven methods or remedies (for CAM, ALTMED, TCM, etc) vs proven medicine or SBM.

  80. Jan Willem Nienhuys says:

    Blazing saddles?

    I made it up, I was thinking of the Mel Brooks 1974 movie
    http://en.wikipedia.org/wiki/Blazing_Saddles

    See also
    http://www.sciencebasedmedicine.org/?p=10843#comment-62812

    You probably knew that, but the idea is that the readers use their own private fantasies.

    I noticed that this whole list (your original list) hardly contains any psychiatric (ICD code F) diseases. In the section a24-a29 = 3.1.74-3.1.81 we find some psychiatric terms lumped together with ‘lily disease’ which is assigned F43: ‘Reaction to severe stress, and adjustment disorders’, which is strange for a neurosis (there is no reason to assign lily disease to any particular F40 category, so it should go into F48.9.

    Then there is hysteria which was assigned F40. But in the ICD-10 we find F60.4 Histrionic personality disorder, and F44: Conversion disorder, which includes hysteria, whereas F40 refers to Phobic anxiety disorders. The TCM puts it under obs/gyn (last line of code c), just below pudendal pain and vaginal flatus (associated with N85.9 Noninflammatory disorder of uterus, unspecified ; do those TCM people actually know anatomy?)

    Should we conclude from this that even if the best minds in TCM are put together, they are unable to recognize serious psychiatric conditions?

    The whole idea of classifying TCM is not bad, but it should be put into an international catalogue of medical superstitions (ICMS).

  81. David Gorski “That aside, I would also disagree with you in that your approach of taking on a “shruggie,” “What’s the harm?” attitude you advocate would lead to the proliferation of more alternative medicine,”

    It seems to me that we all take on a shruggie attitude, when it applies to people in areas outside our influence or interest. Dr Benway is interested in the children in the U.S.*. pmoran is interested in the best approach for cancer patients in Australia (If I have that right.) Ben Kavoussi is interested policies in the U.S.

    “I recognize that the Korean research institute, the Kyung Hee University, and the health care community in Asian countries are free to believe in the existence of pestilence or miasmatic malaria, and can treat their populations with incantations, amulets, talismans, lancing, or even bloodletting, if they so choose.”

    Isn’t that shrugging off the harm that can be done to these children? http://www.halfthesky.org/work/littlesisters.php http://www.interlinkresources.org/Kids/Orphanages.php
    Many children in orphanages throughout Asian do not receive adequate vaccination, not to mention the conventional medical interventions they need.

    Yet, at least in Kazakhstan, money is spent on unproven drug or vitamin regiments, sometimes, from my understanding, with needles that are reused. If acupuncture becomes popular there, I doubt it will be with concern to sterile conditions. There are also children who’s families in poverty, whose governments may have an incentive to offer cheaper ALT remedies with the tactic approval of updated WHO ICD codes.

    Do we really want to say that other nations are free to offer homeopathy instead of vaccination to their children? Or bloodletting for their children with diabetes or corticosteroids for their children with autism?

    If we want to say that, why shouldn’t ALTMED parents in the U.S. ask why they can’t have the same freedoms?

    I can understand if we don’t make frowning on TCM a feature in the U.S. international policy, but I wouldn’t think we have to visibly shrug off using antiquated medical interventions as a countries right as a sovereign nation, either.**

    I may be confused (again). When I figured out the ICD codes effect on the U.S. I thought I had it. Bad to use TCM here in the U.S., but in Asia…oh well, they can do what they want.

    But, the policies in Australia that pmoran mentioned are “shruggie”.

    Is there something that I’m missing that delineates when it’s okay to shrug and not? Or is it just personal preference? Who we relate to more…

    Or was Ben’s statement irony and missed it…I do that sometimes.

    ——————–

    *Okay, bad example, I have never seen Dr. Benway do anything even close to a written shrug. :) That’s why I like reading her posts. (can I just say how screwed up I get by pronouns when referring to a female writing with a male pseudonym)

    **Did that sentence make any sense? I revised it three times and I give up.

  82. Sorry, I did not provide a source for my representation of medical interventions of orphanages in Kazakhstan (very similar to Russia). The only evidence I have is anecdotal, based on an article by a doctor who reviews medical records for international adoption. “http://www.orphandoctor.com/services/assessment/guidelines.html” scroll toward bottom of page.

    “Medications and Therapies
    Children living in orphanages are inevitably treated with an assortment of medications that are commonly not used in the U.S. Medications that are focused on improving blood and cerebrospinal fluid circulation are administered as are sedatives and anti-seizure medications like Phenobarbital (Luminal), carbamazipine (Tegretol), and phenytoin (Dilantin). Children receiving these medications do not necessarily have a diagnosed condition that necessitates treatment with these drugs. Digitalis (Digoxin) has been given to children with simple functional heart murmurs. Vitamins, magnet therapy, paraffin wax treatments, ultraviolet light treatments, electrophoresis, vacuum therapy of the eyes, and massage therapy are all treatments commonly mentioned in medical abstracts.”

  83. Dr Benway says:

    Michele,

    I think of a shruggie as an “accommodationist,” to borrow a term from the evolution verses creationism debate –meaning, someone who advocates for tolerance toward opposing views rather than direct confrontation leading to one winner and one loser.

    Doctors went to med school rather than law school for a reason. As a rule, doctors do not like to upset people. They don’t like conflicts. They are people pleasers. They are shruggies by nature.

    “What’s the harm?” is a justification for taking the shruggie stance.

    What you describe are personal areas of focused concern. I think it would be a mistake to assume that someone is a shruggie regarding issues outside their focus.

    In taking care of patients, its generally not appropriate to argue the evidence as if trying to establish the facts in favor of some treatment. It’s assumed a debate already happened someplace else and the doctor is simply following the standard of care.

    Bringing patients into debates over matters of scientific evidence is harmful. It’s like being sick and having no doctor at all. It’s like your parents trying to get you to take sides in a messy divorce, which is like having no parents at all. So let’s get our own house in order as physicians, leaving out the patients for now.

    When I am concerned about MDs advocating for bad science, pmoran shifts the setting to a doctor-patient encounter. That confuses things a bit. The MD-MD relationship is different from the MD-patient relationship.

    We must be clear with each other as doctors about what is true, what is supported by evidence, and what is justified. With patients we also must take into account their emotional needs. With patients we are justified in some degree of paternalism.

    The pro-alt med people pretend they are “empowering” patients to “take control” of their own health. But deception –even when well intended and justified– is paternalism.

    Paternalism toward other MDs is just crazy.

  84. Dr Benway “I think of a shruggie as an “accommodationist,” to borrow a term from the evolution verses creationism debate –meaning, someone who advocates for tolerance toward opposing views rather than direct confrontation leading to one winner and one loser. ”

    I am new to this shruggie thing and am often mystified by the doctor-patient-doctor-doctor relationships.

    So, when we say the medical communities in other countries are free to believe in TCM (or homeopathy or biomed, too I guess), and treat their population, including the children, with bloodletting or other disproven methods. Is that shruggie or not?

  85. nybgrus says:

    michele: i can really only speak for myself here so I will give my opinion on the matter. Firstly, I full agree with Dr. Benway’s assessment. There is a vast difference between the doctor-patient and doctor-doctor relationship. Evidently I did not make this clear enough and with pmoran’s shifting the conversation from the latter to the former there has been some confusion. Consistently doing this gives me pause in regards to his motives and understanding. But I have learned and will rectify this for the future.

    In regards to being a shruggie – I think the language chosen above was poor. I am most certainly not a shruggie, yet if pressed in a conversation I would say something to the effect of “yes, let the koreans have and practice whatever they want” That is not because I don’t care about the Koreans or because I am OK with CAM practice over there. It is because I simply cannot advocate against CAM around the world – my focus needs to be somewhere. Obviously, where I trained and where I practice will be the area of my focus. However, at the same time, I don’t want to sound paternalistic towards a foreign culture – partly that is my undergrad background (I have a degree in cultural anthropology with a focus in worldwide medical practice) and partly this is because giving that impression is a quick way to shut down a conversation and be labeled an intolerant reductionist. But you are right. And I will think on a better way to say things in that regard for the future.

    In regards to our patients, Dr. Benway is on the money again. We SHOULD NOT include them in the “controversy” here. That is inane. We need to inform and educate them as best we can – that is distinctly one of our roles – and let them decide. In cases like this, and where the CAM is clearcut and total BS I believe we can exert SOME paternalistic steering as best we can, but ultimately it is the patient choice. However the MD-MD relationship is very different and there needs to be NO tolerance of CAM BS being bandied around amongst us as professionals. That is where the culture needs to change and that is very hard, especially in a hierarchical profession as ours. I am in a very hard place to go and speak to an attending and tell them they are wrong. I still do it – but I do it very tactfully and I damn well better know what I am talking about. But I think my generation of doc will be the most radically changed of the “new docs” – more approachable, more open to being questioned by junior docs or allied health workers, and thus more open to either moving towards or away from CAM. I’m sure you can guess where my aspirations lie.

  86. Ben Kavoussi says:

    @ Jan Willem Nienhuys

    TCM people in the US actually do not know anatomy, because they think they do not need to.

    In China things are different: you have the folk-healer in rural area and you have college educated general practitioners who specialize in TCM.

    The level of knowledge of a TCM provider in the US is below a vocational nurse with 2 years of college, even if they have an unaccredited masters degree!

    But their level of knowledge in feng shui surpasses most interior decorators!

    TCM is a type of willful ignorance: students willfully do not want to learn chemistry, biology, clinical medicine, etc. They think needles and herbs can cure all diseases. It’s almost a cult.

    I will have a special place in the international catalogue of medical superstition!

  87. nybgrus “In regards to being a shruggie – I think the language chosen above was poor. I am most certainly not a shruggie, yet if pressed in a conversation I would say something to the effect of “yes, let the koreans have and practice whatever they want” That is not because I don’t care about the Koreans or because I am OK with CAM practice over there. It is because I simply cannot advocate against CAM around the world” through the rest of the paragraph

    Thanks for the thoughts.

    In my reasoning, if a medical approach or philosophy is harmful or unethical here in the states, it is likely harmful or unethical in another country.* Suggesting anything else creates cognitive dissonance and a headache. It’s very difficult to say ‘They are free to do something harmful, we are not…’

    In terms of avoiding taking on a battle outside your sphere of interest or influence as well as avoiding being paternalistic. My attempt might be.
    —-
    We believe that advocates of science in S. Korea and Asia can best determine the appropriate response to TCM and the revision of ICD codes in their regions. Our main focus is how new ICD codes could effect the U.S.

    Or

    While TCM has a rich tradition caring for the populations in S. Korea, some of it’s treatments have been scientifically shown to be ineffective or even harmful. While tradition and history are important, we hope that decisions made within the S. Korea medical community will first and foremost advocate for the health and safety of the S. Korean people.
    —-
    or similar. Of course paternalism is often in the eye of the beholder.

    *unless it’s a matter of a regional risk/benefit difference, such as malaria, famine, epidemic

  88. In terms of patient doctor communication

    Dr Benway”In taking care of patients, its generally not appropriate to argue the evidence as if trying to establish the facts in favor of some treatment. It’s assumed a debate already happened someplace else and the doctor is simply following the standard of care.”

    “Dr. Benway is on the money again. We SHOULD NOT include them in the “controversy” here. That is inane. We need to inform and educate them as best we can – that is distinctly one of our roles – and let them decide. In cases like this, and where the CAM is clearcut and total BS I believe we can exert SOME paternalistic steering as best we can, but ultimately it is the patient choice.”

    From a patient and patient/parent perspective, I agree with you both in that arguing evidence or including a patient in a doctor/CAM or doctor/doctor controversy can be a detriment to the patient and undermine their trust in the doctor.

    That said, it can be enormously helpful for a doctor to reveal the thought process behind their recommendation, such as the risk/benefit that they are considering, the amount of research available on the topic (lots or not enough) or their concerns with a different approach. This not only helps the patient to make a decision, if more than one option is available. It shows the patient that the doctor is paying attention and not just make route decisions, or guesses. :) That probably goes without saying…

    On the matter of airing important disagreement in front of the patient. I would agree, not a good idea. Although, if a doctor is making an incompetent, dangerous recommendation, and I don’t know about it, and there’s no other way to tell me than to put me in between two doctors…, I’d kinda rather be stressed out than dead.

  89. Dr Benway says:

    I agree with what you say, Michele. I’m a patient myself from time to time. When worried and in pain I’m not in the mood for a tl;dr Dr. Gorski breakdown of the literature. However, a brief summary like, “a recent large study involving several thousand patients showed some advantage to blah blah blah over the other idea..” Mostly I just want a read on the doctor’s confidence in his own opinion, from “very confident… pretty sure… it’s a crap shoot.”

    The “I” in “ICD” means “International.” So they can’t write a separate one for certain countries. One book for the planet, just like physics.

    To get in the book these days a proposed diagnosis is expected to come with *measurable* reliability and specificity. I really hope the TCM guys work on that for the running piglet thing. Their efforts at getting independent parties to verify the presence or absence of the diagnosis should bring the lulz.

    I wish I could count on MDs at the WHO holding the line on the reliability issue. It makes me sad that I cannot.

  90. Ben Kavoussi says:

    I guess you count the piglets!

    For “pattern/syndrome of dampness-heat steaming the teeth” you might measure the amount of steam!

    But how do you measure “liver fixity”?

    One things remains beyond measure: the profound ignorance of people who want to provide healthcare in 21st-century U.S. based on this nonsense!

  91. Dr Benway – “The “I” in “ICD” means “International.” So they can’t write a separate one for certain countries. One book for the planet, just like physics.”

    Yes, that’s the issue with our whole globalicious* existence. We can’t really say, “They can have their science, we’ll have our science.” “They can have their health policy, we’ll have ours.”

    Even if you set the morality of wasting money on unproven treatments while children are recieve substandard care aside. Your still have things like SARS.

    *sorry, I’m making donuts.

  92. Dr Benway says:

    Well other countries are entitled to their own policies and opinions. But objective facts shouldn’t change from one country to another.

    Mmm. Donuts.

  93. Agreed, I meant more to suggest that we can be effected by other countries health policies and they ours, not that countries shouldn’t have autonomy in their health policies.

    The donuts, sadly were disappointing. Deep frying is not my strong point.

  94. nybgrus says:

    michelle: thanks for your comments. I’m impressed this thread is STILL going and is not about vaccination nor does it have our usual trolls. That makes for a good conversation.

    In regards to the concept you posed:

    “In my reasoning, if a medical approach or philosophy is harmful or unethical here in the states, it is likely harmful or unethical in another country.”

    I agree. My undergrad training elicits a reflexive response of “No! You’re wrong!” – because one of my degrees is in cultural and medical anthropology. It amazes me in retrospect how much of this false dichotomy bunk and absolute reverence for cultural relativism I was required to know and believe in to graduate (with honors!) in that degree. But know I know better – I danced with the dark side and have come out of it stronger. But do be aware that if you make a claim like that many of my (former) ilk will shoot you down with something to the effect of “Ethics and moral or culturally rooted and so their application in your society is not reflective of others.” Most of my professors would even take you to task about “harm” saying you cannot objectify or quantify that and everything must be examined through a relativistic lens.

    For those reasons, and the fact that, as I said I simply do not have the time/resources/energy to advocate for the world, I decided some time ago to lead by example. That is why I say “let korea do what it wants.” The idea being that the ultimate goal is reform and SBM acceptance in MY sphere of influence which would act as a model and beacon for others to follow. It is a slow change, but I see no other effective model. The adjunct to that is of course to encourage others who are in my similar position but in different parts of the US and then the world to espouse similar ideals and hold the standard of SBM, but concerning myself with the immediate effect this would have on Korea in addition to (or even instead of) the US would be, IMHO, fruitless.

  95. Ben Kavoussi says:

    @ nybgrus

    It amazes me in retrospect how much of this false dichotomy bunk and absolute reverence for cultural relativism I was required to know and believe in to graduate

    Great point.

    Indeed, this is related to what Edward Said calls “Orientalism” — meaning “a style of thought based upon an ontological and epistemological distinction made between the Orient’ and (most of the time) ‘the Occident’.”

    Orientalism and cultural relativism are at the very core of the ICTM nonsense.

  96. nybgrus says:

    @Ben:

    Indeed. I distinctly remember professors ANGRILY stating that Western medical practitioners were to “reductionist” to understand how such modalities as acupuncture, chi gong, or ayurveda worked. It was drilled into me that medicine is a “culture bound” practice and that one medical system was entirely equivalent to another (i.e. Vietnamese hot/cold vs Western Biomedicine) because it was what was most relevant to the culture in which it was practiced. Furthermore, as an example, I was taught that even Western Biomedicine was practiced differently in different parts of the world – I wish I could remember the book we read to illustrate how high blood pressure in Germany was defined differently than the US and how the French believed in spa treatments and “holistic” care and homeopathy (yes, I was taught homeopathy was a valid modality!) and that was a perfect example of how the “same” medicine is practiced equally effectively based upon the cultural expression of the medical practice (the ‘French Paradox’). Don’t worry – I now know what that all REALLY means, but at the time…. And of course, I had to read and understand “The Spirit Catches You and You Fall Down.” Makes me shudder thinking about it all. And now that I think about it makes me think I know why I got passed up for med school the first couple of rounds despite my two degrees, honors, and an excellent MCAT score. My personal statements reflected this belief and ideology.

    At least I have seen the light. Many others haven’t. And BTW, I can understand why – this s**t is hard! I am studying for my boards and I sometimes wish I could just pull magic water out of my hat and wave my hands over people and say I cured them! But the responsibility of knowing (and NOT knowing and thus missing something important) is very serious and, quite frankly, daunting.

  97. Dr Benway says:

    Postmodernism is such fail. When you claim that reality results from social agreement, period, you are one step away from madness.

    Used to be mostly college hipsters reading Jean-François Lyotard, Michel Foucault, Baudrillard, etc., pressing the pomo thing, probably because when you’re in your early 20s your sense of self can shift as you move between different social settings. In your 20s getting everyone to agree that you are pretty cool seems just as good as actually being pretty cool.

    In the 1980s it wasn’t hard to ignore the crowd talking vague incomprehensible nonsense, and the French. But then the hippies grew up and got rich, and with their narcissistic super powers combined they spawned an Oprah, who then infected everyone with the meme virus known as “the Secret,” resulting in a widespread encephalopathy characterized by the Four Agreements.

    The New Thought tribe wants agreement. It wants you to click this Facebook link if you agree. The more agreement the more real.

    The tribe is peaceful and pleasant toward outsiders provided that they signal sufficient elasticity in their relationship to reality. The hard-headed, rule-bound thinkers are marked as sources of counter-intention, negativity, and suppression.

    Yesterday I visited a number of mental health websites and was disturbed to read sentences beginning with, “We believe…” The New Age creep into medicine appears to be moving right along. I see no challenges or complaints to the authority of “we believe.”

  98. US says:

    @Ben

    Wait, you mean to tell me that, in the unregulated trade journal of a professional association that a member of that association may have glorified her own position, making both herself, her organization, and her profession more important / influential than she / they are!?! You’re kidding!

    In case the sarcasm is not evident, let me explain. I would tend to assume that, in a comparison between the information put out by WHO and an interview done with a local woman by the organization SHE IS PRESIDENT OF, that the information from WHO might be more trustworthy and less prone to bias. Maybe that’s just me.

    Also, I don’t think I would be writing a blog post now (2011) getting all riled up about a trade association interview that was done (according to your notes?) in 2006.

    However, let me point out AGAIN that the ICTM project didn’t launch until 2010. Therefore, IT DID NOT EXIST in 2006. That project, the WHO International Standard Terminologies in the WPRO Region may have had the working title of ICTM, but that doesn’t change the fact that the ICTM project currently being worked on by WHO and to be in ICD is NOT the same thing that Ms (Dr?) Kang was interviewed about nor you are writing about.

    Do you, as the author, or anyone else posting on this thread even care that the information you provided as a foundation is fundamentally incorrect?

    @Alison

    I don’t know about the origins of the idea that milk was toxic come from, nor do I know anything about origins of the idea in TCM. What I do know, however, is that college biology class talked about how the human body was not initially designed to consume the milk of other animals, but that most people can effectively build a tolerance to it. Prof also suggested that if humans stopped drinking cow’s milk for an extended period of time and then started again, it is likely that the person would (at least initially) show signs of lactose intolerance. I don’t have a reference on this, have never looked it up, and have never tried the experiment personally, but it might be something you are interested in.

    Also, I know that any vocalist in the world can tell you that milk is mucus / phlegm producing, and that you never consume dairy before going out to perform. Whether or not the origins are in TCM, that part is true enough. This one I do know personally.

  99. US says:

    There are a few other comments which seem to not bear up under scrutiny, but this is just me being generally skeptical, and not particularly looking to start fights. . .

    One person commented that we should make a distincting between unproven (CAM) and proven (non-CAM) treatments. This distinction doesn’t work, however, as there is some evidence for the effectiveness of:

    - Artemisia annua for the treatment of Malaria, (http://www.cdc.gov/malaria/about/facts.html)
    - willow bark as a analgesic (http://report.nih.gov/NIHfactsheets/ViewFactSheet.aspx?csid=57)
    - Valerian root as a sleep aid (http://www.nlm.nih.gov/medlineplus/druginfo/natural/870.html)

    Not to mention atropine, codeine, L-dopa, ephedrine, morphine, quinine, and hundreds of other medicines which were all derived from plants and are still considered CAM among many populations in the world, even if they have also been adopted by non-CAM medical doctors.

    Another person has suggested that a responsible doctor faced with a patient who wants to try CAM should just tell them “It doesn’t work”. My question is, how do you know that it doesn’t work? I freely admit that I expect that there is a lot of worthless, possibly even dangerous stuff in CAM treatment, but the truth is that there is a distinct lack of evidence on the subject. This applies both to a lack of evidence proving that it works, and to a lack of evidence proving that it doesn’t. Therefore, a CAMmer who says that their treatment works and a doctor who says that it doesn’t are in the same position in one respect, they are both making statements based on their personal opinions and personal experience. Yes, a doctor who saw someone with a punctured lung from acupuncture will be keenly aware of the dangers of acupuncture, but how is this different from the CAMmer who happens to see a patient who had a botched back surgery? Not to be profane, but sh*t happens. Maybe it happens a greater percentage of time with CAM treatment, but I would love to see the data proving it. (Seriously, I think the medical profession has a responsibility to collect this data!)

    Another individual suggested, if I understood correctly, that the CAMmers need to prove that they can keep medical records before they can be considered for inclusion in ICD. Um, how are they supposed to do this without a statistical classification? ICD appears to be one of the foundational components to record keeping, and this, to me, suggests that lack of an equivalent in CAM might be one of the reasons their records are inconsistent. Maybe no, but does this not seem like a reasonable possibility? And therefore a reasonable justification of an ICD-equivalent for CAM?

    Last, our distinguished author stated that “Orientalism and cultural relativism are at the very core of the ICTM nonsense.”. I would suggest that, since he clearly has incorrect information about what the ICTM project is, that he really wouldn’t know.

  100. Harriet Hall says:

    @US,

    Maybe any vocalist can tell you milk is mucous producing, but scientific studies show that they are wrong.

    http://www.ncbi.nlm.nih.gov/pubmed/16373954
    http://www.ncbi.nlm.nih.gov/pubmed/2154152

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