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An open letter to NIH Director Francis Collins regarding his appearance at the Society for Integrative Oncology

Note from the editor: Since today is a holiday in the U.S., I had planned on taking the day off. Then I saw the subject of today’s post and had to respond. Also, please remember that, as always, the usual disclaimers apply. This letter represents my opinion, and my opinion alone. It does not represent the view or opinion of my university or cancer center—or anyone else, for that matter, other than me.

Francis S. Collins, MD, PhD
Director, National Institutes of Health

Dear Dr. Collins:

I am normally not one for writing open letters, but in this case I feel compelled to make an exception. This letter will have little or nothing to do with what seems to be the usual criticism leveled against you, namely your intense religious faith and claims. Personally, as a physician and scientist I don’t much care about what religion you follow and, unlike some writers such as Sam Harris, most definitely do not consider your strong Christian faith a disqualification for holding the position that you now hold. All I care about in an NIH director is how well he or she shepherds the scientific mission of the NIH and runs the organization. As a past (and hopefully future) NIH grantee, I want the NIH to fund and support only the most rigorous science and to be a well-run organization. Thus far in your tenure, I haven’t seen any anything major to worry about on that score.

Recently, however, I was very disappointed to discover that you will be the keynote speaker at the 8th International Conference of the Society of Integrative Oncology (SIO) in November. I hope that, when you agreed to accept this speaking engagement, you didn’t know just what it is that what you were accepting or what the Society for Integrative Oncology is, other than a professional society that was interested in hearing your views on faith and spirituality in cancer. In brief, it is our position that “integrative oncology” is a discipline that, at its core, is dedicated to “integrating” pseudoscience with science. No doubt you will think I am exaggerating, but I am not, as I hope to demonstrate. Worse, by agreeing to speak to the SIO, you will be providing it with the imprimatur of your position as NIH director. The NIH, as you know, is the most respected biomedical research institution in the U.S., if not the world, and that respect rubs off wherever you speak.

So, what is “integrative oncology” and why does it concern me as a cancer surgeon and researcher? I have already discussed it in considerable detail, as has my co-blogger Dr. Kimball Atwood, but I will try to summarize again. On multiple occasions, I’ve referred to “integrative oncology” as a “Trojan horse” that is allowing pseudoscience to infiltrate medical schools and academic medical centers. Here is what I mean. Whenever you see discussions of “integrative medicine” (IM) and in particular “integrative oncology,” chances are, the modalities under discussion will usually focus on various dietary changes and lifestyle interventions, such as exercise. Often recommended exercise comes in the form of yoga, tai chi, and other disciplines that tend to be infused with concepts from Eastern mysticism, such as qi (“life energy”). Other modalities featured often include herbal remedies. In other words, “integrative oncology” rebrands modalities that have no reason not to be counted as part of science-based medicine as “alternative” or “integrative” and points to them as having some promise. After all, if you strip away the Eastern mysticism from yoga and tai chi, among others, all you have left is low impact exercise, and there is no reason to consider low impact exercise to be anything “alternative” or “integrative.” Exercise and diet are within the purview of science-based medicine. Herbal remedies are nothing more than a rebranding of the perfectly science-based subdiscipline of pharmacology known as pharmacognosy. Advocates of CAM/IM then lump together pseudoscience like reiki, “therapeutic touch, acupuncture, naturopathy, and even homeopathy with sensible lifestyle interventions, such as diet and exercise, making the association that, if diet and exercise are “alternative” and work, so, too, do modalities that can at best be considered quackery, such as homeopathy.

Perhaps the best place to begin is with the SIO’s very own practice guidelines, which, I submit to you, represent a masterful package of rebranding of perfectly science-based modalities, such as lifestyle interventions and changes in diet, which are then tied to “energy healing” quackery as if there were an equivalent evidentiary basis to support them. For instance, some of the recommendations of the SIO are, as Dr. Atwood put it, embarrassingly obvious. For example:

  • Recommendation 1: Inquire about the use of complementary and alternative therapies as a routine part of initial evaluations of cancer patients. Grade of recommendation: 1C
  • Recommendation 6: The application of deep or intense pressure is not recommended near cancer lesions or enlarged lymph nodes, radiation field sites, medical devices (such as indwelling intravenous catheters), or anatomic distortions such as postoperative changes or in patients with a bleeding tendency. Grade of recommendation: 2B
  • Recommendation 7: Regular physical activities can play many positive roles in cancer care. Patients should be referred to a qualifi ed exercise specialist for guidelines on physical activity to promote basic health. Grade of recommendation: 1B (1A for breast cancer survivors post-therapy for QoL)
  • Recommendation 15: It is recommended that patients be advised regarding proper nutrition to promote basic health. Grade of recommendation: 1B

What is “alternative” about any of these recommendations? Nothing. Physicians routinely ask what supplements or “alternative” therapies their patients are using. It’s simply mind-numbingly obvious common sense not to use deep massage or pressure near cancer lesions, enlarged lymph nodes, radiation field sites, or near medical devices, such as Portacaths or other indwelling implantable devices. What physician would not recommend proper nutrition or regular physical activity, as much as the patient can tolerate, under the guidance of an exercise specialist? Then, coupled with the above sensible recommendations, we find this:

  • Recommendation 3: Mind-body modalities are recommended as part of a multidisciplinary approach to reduce anxiety, mood disturbance, chronic pain, and improve QoL. Grade of recommendation: 1B
  • Recommendation 8: Therapies based on a philosophy of bioenergy fields are safe and may provide some benefi t for reducing stress and enhancing QoL. There is limited evidence as to their effi cacy for symptom management, including reducing pain and fatigue. Grade of recommendation: 1B for reducing anxiety; 1C for pain, fatigue, and other symptom management

I find it most interesting to note what the SIO considers “1B” evidence:

Strong recommendation, moderate-quality evidence

How on earth can one reasonably make a “strong recommendation” on “moderate-quality” evidence, even assuming one agrees that the evidence is “moderate-quality”? The SIO defines “moderate quality” evidence as:

RCTs with important limitations (inconsistent results, methodological flaws, indirect, or imprecise) or exceptionally strong evidence from observational studies.

Also confusingly, the SIO makes “strong recommendations” based on “moderate” evidence (level 1B). In other places, it makes “strong recommendations” based on “low or very low quality evidence” (level 1C). Doesn’t it make you wonder why the SIO had to make up its own categories of evidence, rather than use accepted evidence-based medicine categories of evidence? Certainly, I wonder. I also wonder how the SIO could categorize instructing patients “regarding proper nutrition to promote basic health” as only category 1B.

As for other recommendations made by the SIO, rating the evidence for “energy healing” methods—or, as the SIO calls them, “therapies based on a philosophy of bioenergy fields”—as grade 1B vastly overestimates the quality and quantity of evidence in favor of “energy healing methods. Moreover these therapies are based on an unproven concept that there is an “energy field” or a “life energy” that can be manipulated for therapeutic intent. Never mind that no scientist has ever been able to measure or detect these “energy fields” or to verify that practitioners can actually manipulate them to therapeutic purpose. Never mind that the very concept is based on a vitalistic, pre-scientific understanding of how the human body works and how disease develops. I note that this includes acupuncture, whose premise is that sticking needles into the skin can somehow alter the flow of this life energy to healing effect. I also note that the totality of evidence regarding acupuncture is that it does no better than placebo when tested in well-designed randomized clinical trials. It doesn’t matter where the needles are placed or even whether the needles are placed. Indeed, even twirling toothpicks against the skin works as well as needles. Truly, as Steve Novella put it, acupuncture is the selling of nonspecific effects. Meanwhile, acupuncture apologists publish papers in which fanciful physiological mechanisms by which acupuncture allegedly works are proposed and poorly supported with evidence.

I note that the title of your talk is “Faith, Spirituality and Science in Oncology.” No doubt your intense religious faith is one reason why the SIO invited you. In actuality, in the world of “alternative” medicine,” “complementary and alternative medicine” (CAM), or IM (or whatever you want to call it), religious faith or “spirituality” is often co-opted to be the “foot in the door” for quackery in a manner very similar to how diet and exercise have been so co-opted. For example, are you familiar with reiki? It is one of the more prevalent of CAM/IM modalities, and it is currently being extensively used in cancer, even though the evidence base for it is virtually nonexistent. I have in the past referred to reiki many times as faith healing substituting Eastern mystical beliefs for Christian beliefs, and that is an accurate description. What is faith healing? It’s the belief that a healer can channel the power of God into the ill to heal them. What is reiki? Reiki involves channeling “energy” from what reiki masters call the “universal source” into the ill to heal them. Like faith healers, who assert that the power doesn’t come from them but from God, reiki masters assert that the power doesn’t come from them but rather from the “universal source.” Indeed, the founder of reiki, Dr. Mikao Usui explicitly patterned reiki on how Jesus healed:

Dr. Usui was a Christian minister in Japan, though Japanese. He was the head of a Christian Boys School in Japan. One day some of the students asked him if he believed in the miracles which Jesus did (healing, etc). Being a Christian minister he answered “Yes”. They asked if he knew how Jesus had done this, “No” he said…

With this he resolved to find the way in which Jesus had healed. This immediately set him on a journey of many years. Studying first at Christian schools in the US, for where else to learn of Jesus, but with no results. In the Christian schools the method was not known.

Dr. Usui even subjected himself to a 21 day fast on a mountain that very much resembled Jesus’ 40 days and 40 nights in the wilderness:

After a few more years of study, he felt he had come to an understanding and that to go further required serious meditation. He went to a nearby mountain declaring his intention to fast and meditate for 21 days and that if he did not come back they should come and get his body.

He went to the mountain and settled in with 21 stones with which to count the days. On the 21st day nothing had come as yet, and he turned over the last stone saying “Well, this is it, either I get the answer today or I do not”. At that moment on the horizon he could see a ball of light coming towards him. The first instinct was to get out of the way, but he realized this might just be what he was waiting for, so allowed it to hit him right in the face. As it struck him he was taken on a journey and shown bubbles of all the colors of the rainbow in which were the symbols of Reiki, the very same symbols in the writings he was studying but had been unable to understand. Now as he looked at them again, there was total understanding.

After returning from this experience he began back down the mountain and was, from this moment on, able to heal. This first day alone he healed an injured toe, his own starvation, an ailing tooth and the Abbots sickness, which was keeping him bedridden. These are known as the first four miracles.

I would respectfully submit to you as a scientist and man of faith that science- and evidence-based medicine should not be concentrating on miracles and faith healing. Yet that is what most “energy healing” modalities (reiki, therapeutic touch, and, yes, acupuncture) boil down to. It’s not for nothing that in 2009 the U.S. Conference of Catholic Bishops warned Roman Catholics to shun the eastern healing art of reiki because it lacks scientific credibility and is dangerous to Christian spiritual health. Some Christians even view reiki as a sin. Moreover, huge swaths of other CAM/IM modalities are based on similar beliefs that are rooted in faith, spirituality, and even outright magic. The common CAM/IM modality of homeopathy, for example, is based on the concepts of sympathetic magic, and naturopathy, which many SIO practitioners recommend, requires homeopathy as part of its training, which is why many naturopaths are also homeopaths.

We at SBM have criticized two institutions of the NIH for promoting and funding unscientific research, quackery even. These institutions include the National Center for Complementary and Alternative Medicine (NCCAM) and the National Cancer Institute’s (NCI) Office of Cancer Complementary and Alternative Therapy. Indeed, Dr. Atwood once wrote an open letter similar to this to NCCAM director Dr. Josephine Briggs when she agreed to speak at the annual conference of the American Association of Naturopathic Physicians last year and for the same reason that I’m writing this open letter now. The difference is that Dr. Briggs’ decision to speak to the AANP was more understandable than your decision to speak to the SIO; the reason is that, as strenuously as I and my fellow bloggers at SBM might object, NCCAM exists to study and promote “alternative” medicine. Consequently, the AANP can reasonably be considered to be within Dr. Briggs’ bailiwick. Moreover, NCCAM is but one center in the huge institution that is the NIH; her appearing at the AANP conference last year says far less about the NIH’s position with respect to unscientific “alternative medicine” modalities than your appearing in front of the SIO does.

I submit to you that SIO is trying to take advantage of your well-known religious faith in order to use your reputation as a scientist and as NIH director to claim for itself the mantle of scientific respectability that it does not merit. Instead of “bait and switch” rebranding science-based modalities such as diet and exercise as “alternative,” the SIO is rebranding religion and spirituality as somehow being “alternative medicine.” That is why I conclude by asking you most respectfully to reconsider. You represent the entire NIH, not just a single center in the NIH or an office in one institute in the NIH. Where you speak matters, and it matters a whole lot more than where Dr. Briggs chooses to speak. If you believe that we here at SBM are exaggerating or being unfair, we and others stand ready to provide you with all the supporting material you might require to be persuaded that we are not. We all strongly believe, as no doubt you do, that cancer patients deserve the best in science- and evidence-based medicine. Unfortunately, “integrative” oncology” provides nothing of the sort. It adds nothing to cancer care other than the rebranding of sensible treatments as “alternative” and the “integration” of unscientific, unproven, and potentially harmful “alternative” treatments with science-based treatments.

Cancer patients deserve better.

Finally, in these days of tight budgets resulting in even tighter paylines not seen in nearly 20 years, with no improvement in sight, please think about this one last thing. Between NCCAM and OCCAM, the NIH spends a quarter of a billion dollars a year studying and promoting a hodgepodge of modalities that range from being sensible science-based treatments, such as diet and exercise, to modalities that can only be referred to as being based on magical thinking (homeopathy, therapeutic touch, reiki, acupuncture, etc.). When budgets are this constrained, does the NIH have the luxury of spending a quarter of a billion dollars a year, or approximately 1% of the total NIH budget, half of which is nearly 3% of the NCI budget, on research that is exceedingly unlikely ever to benefit patients? For example, NCCAM has already spent over $2 billion since its inception in the 1990s and has yet to demonstrate convincingly that a single “alternative” medicine modality provides concrete benefits greater than placebo effects.

You are a man of science and faith. Your current position is a scientific one, and I have no doubt that you want to shape the NIH into a form that is dedicated to the best possible science we can get for the money and to promote that science. I hope you will realize that speaking at the SIO conference does not serve that end, nor does continuing NIH support for NCCAM and OCCAM. The division of medicine into “conventional” and “alternative,” “complementary and alternative,” or “integrative” medicine is a false dichotomy. There should be only medicine, and the scientific standards for determining what is and is not safe and effective medicine should be the same. It is my sincere hope that you, as NIH director, will not by speaking at the SIO conference support the false dichotomy that tries to foist unscientific medicine upon cancer patients as “integrative” medicine.

Sincerely

David H. Gorski, MD, PhD

Posted in: Faith Healing & Spirituality, Politics and Regulation, Science and the Media

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105 thoughts on “An open letter to NIH Director Francis Collins regarding his appearance at the Society for Integrative Oncology

  1. daijiyobu says:

    Naturopathy and naturopathy subset homeopathy is pseudoscience, quackery, magic?

    But the North American naturopathy apparatus claims the opposite, that they’re “firmly science-based”.

    Bastyr University told me so!

    Suggested search: “firmly science-based” naturopathic

    I was just on a certain ND’s site this morning, coincidentally,

    (see http://web.me.com/drham/Dr_Natalie_Ham/Homeopathy.html )

    who tells me that “homeopathy is an effective and scientific system of healing” and that NDs’ have “the same basic medical science foundation” as, well, anyone who studies medical science.

    In the end, perhaps the CAM / integrative / naturopathy movement should be nicknamed ‘a meme of superficial resemblance but not actuality’.

    The naturopath’s common Trojan Horse is that ‘nowadays rather thick-headed’ citation apparently of Hippocrates, “let your food be your medicine, and your medicine be your food.”

    What’s lost on them is how The Big H, in method and outlook, desupernaturalized / desuperstitioned / demagicked medicine, the opposite of what we see now in the integrative realm.

    As greekmedicine.net states:

    “it was Hippocrates who finally freed medicine from the shackles of magic, superstition, and the supernatural.”

    It’s the integrative meme that’s reversing that.

    -r.c.

  2. Well said, Dr. Gorski. I hope Dr. Collins responds here – I’d be interested in reading his position.

  3. David Gorski says:

    My guess is that the likelihood of that happening is slim and none, I’m afraid.

  4. Linda Rosa says:

    Thank you, Dr. Gorski, for bringing these issues to Dr. Collins’ attention. The purveyors of pseudoscience make much hay out of keynote appearances, which they can reasonably interpret as an endorsement. A speaker has a ethical duty to consider how his appearance may be exploited for good or ill.

    CAM proponents are even trying to co-opt the entire field of preventive medicine, asserting that physicians only treat symptoms and have no interest in the cause of illness.

    This is a ploy also used in nursing, where CAM proponents have now gone so far as to claim that “caring” is a CAM practice, as well as a new paradigm in nursing. What an insult to generations of nurses!

  5. rosemary says:

    “Herbal remedies are nothing more than a rebranding of the perfectly science-based subdiscipline of pharmacology known as pharmacognosy.” That is not true.

    First, most herbal “remedies” promoted by alts and the claims made about them come from herbalists such as Rosemary Gladstar who reject science. Gladstar gives lectures on botanical “remedies” for continuing ed credit to the nurses at Dartmouth College hospital. http://rosemaryjacobs.com/WellnessCenter.html Scroll down to the end for quotes from her book. Naturopaths, those licensed as “primary care physicians”, learn and practice herbalism not pharmacognosy. If you have access to old alt. forums, you can find the very low opinions alts have of Varro Tyler, who is one of 2 pharmacognosists without whose support I doubt DSHEA ever would have been passed.

    Second, pharmacognosy is a bench science. In order to scientifically evaluate botanicals for use as drugs, they have to be standardized and tested using high quality RCT. I do not know of any compelling body of evidence from such trials indicating that any of the currently promoted herbal “remedies” offers benefits. Third, herbal “remedies” is a subsection of “dietary supplements” which includes things like silver supplements. Again, almost every brand of alt in Altsville promotes and uses silver in spite of the fact that there is a huge body of evidence indicating that it is dangerous snake oil.

    But the train is moving. AM morphed into CAM which morphed into Integrative. The whole business plan is to get third parties to pay for supplements because that is where the money is. To do that the supplement industry has to get sups, including botanicals, prescribed by licensed “physicians”. Since they haven’t succeeded in getting many MDs to do that, the supplement industry is now working very hard and successfully to get NDs licensed to practice as MDs because they certainly not only prescribe and promote supplements they also sell them. It is all about money and selling placebos, both pills and “therapies” that have little risk of causing the kind of harm that can get the prescriber or salesman sued.

    This is the stop the train is at now on the west coast, http://www.oregonlive.com/health/index.ssf/2011/06/q_a_with_dr_shauna_birdsall_di.html#_login.

    Note the ND writes, “Another misconception is there are natural therapies out there that by themselves can replace conventional treatment. Naturopathic medicine can support patients but cannot support conventional cancer treatment on its own.“ Notice the ND is no longer claiming that natural therapies will cure cancer. They are simply being used to “support patients” and also NDs prevent patients from using bad remedies that will interfere with “conventional” cancer treatment.

    Unfortunately, the ND who wrote the article is not IMO really trying to give accurate info to the public. I believe that whether she knows it or not she is just trying to water down outrageous claims in the hopes of finding her niche in the mainstream health care system, the best paying one. If she were really interested in educating the public so that they could make informed decisions, she would have posted my comment,
    “Since naturopaths think that silver offers benefits and include it in their Vermont state formulary for IV use when in fact it is a heavy metal toxin, I would not trust them to know which supplements interfere with chemotherapy. 
http://rosemaryjacobs.com/naturopaths.html 
I would expect an oncologist to know this, an MD who specialized in treating people with cancer, since he would follow the scientific studies in the drug data bases, the ones that show that ingesting silver in any amount or form is all risk and no benefit. If promoters and practitioners of alternative medicine didn’t spend so much time disparaging evidence-based medicine, MDs and scientists, the general public might not be so hesitant about speaking with their MDs about supplements and other alt treatments.

  6. Harriet Hall says:

    I took David’s comment to mean that CAM is trying to lay claim to the concept of using plants for medicinal purposes, when that idea is actually one of the foundations of scientific medicine.

  7. weing says:

    Where is Flexner when we need him? Dr. Collins could do so much to rid us of superstition. Is he up to the job? As the blind man said, “We shall see.” This country is literally going to pot. It appears we are rapidly abandoning the principles that led to our scientific and technological superiority. Just like rolling back the safeguards put in place to prevent the economic catastrophe we are currently experiencing. I wonder which country will take up the torch? We don’t have the power on a state, never mind national, level to stop the waste of precious resources on nonsense. I laugh at what is going on, but it is truly sad.

  8. David Gorski says:

    I stand by my statement about pharmacognosy and see no reason to change it. With all due respect, I also think Rosemary either misunderstands or is unaware of the context and should read Harriet’s response; she beat me to it.

    Note that I am fully aware of how pharmacologists study natural compounds, having on occasion collaborated in doing research with them and having at least two prominent such researchers in my cancer institute. As I’ve pointed out elsewhere on this blog, herbalism is basically the substitution of the use of adulterated drugs from natural sources of inconsistent potency and purity for the more pharmacological approach of isolating pure active compounds in the belief that somehow “natural” is better and that there is some sort of “synergistic” effect

  9. David Gorski says:

    I took David’s comment to mean that CAM is trying to lay claim to the concept of using plants for medicinal purposes, when that idea is actually one of the foundations of scientific medicine.

    Exactly. It is a theme that has been repeated on this blog many, many times. I stand by my statement regarding pharmacognosy.

    I would point out to Rosemary that I am aware of how pharmacologists study natural compounds, having on occasion collaborated in doing research with them and having such researchers in my cancer institute. I also suspect that we probably agree on more than she realizes. As I’ve pointed out elsewhere on this blog, herbalism is basically the substitution of the use of adulterated drugs from natural sources of inconsistent potency and purity for the more pharmacological approach of isolating pure active compounds in the belief that somehow “natural” is better and that there is some sort of “synergistic” effect

  10. Chris says:

    An example of a scientist who works in the field of getting actual pharmaceuticals from herbs is listed on the right side of this page: David Kroll:

    As more than half of anticancer drugs are derived from plants, microbes, or marine organisms, Dr. Kroll has always held high regard for nature as a source of chemical diversity in the discovery of drugs for a variety of therapeutic areas and worked at one point with the co-discoverers of Taxol (paclitaxel).

  11. JPZ says:

    @rosemary

    As someone who conducts RCTs on nutritional products, I would thank you to refrain from broad generalizations about the quality of science and recommendations in this field without providing evidence on par with your overreaching statements. For example, I have never recommended silver, and I do not know any scientists in my field who have. There are many non-scientists and pseudo-scientists making irresponsible recommendations about nutritional products (to David’s point), and there is a need for a high level of caveat emptor when buying nutritional products making health-related claims. But, there is a strong core of responsible nutrition companies doing good science and selling health-promoting products.

  12. daedalus2u says:

    Those SIO guidelines really are a piece of work, a piece of work designed to be deliberately misleading (IMO). They say the guidelines are modeled after the guidelines of the American College of Chest Physicians Task Force, but they really aren’t.

    http://chestjournal.chestpubs.org/content/129/1/174.full

    It appears that they completely misrepresent the guidelines of the American College of Chest Physicians and confabulate what the different numbers and letters mean.

    In the ACCP guidelines, they use “vice versa” too, but in the context it is clear what they mean. 1C means that in the event of weak evidence that something is clearly harmful, or clearly beneficial, strong recommendations are given based on the treatment being clearly harmful or clearly beneficial.

    The SIO recommendations are deliberately worded deceptively in a bait-and-switch type manner because the rating is based on one thing but the wording of the recommendation is designed to give a different impression.

    It is because of this deliberate deception that Dr Gorski misinterpreted what the guidelines mean. If a senior cancer clinician like Dr Gorski can misinterpret the guidelines, then the guidelines are worse than useless, they are dangerously misleading and should be retracted.

    Recommendation 5, is rated 1C because a non-oncology trained massage therapist could kill the patient. Yes, there are no clinical trials showing that deep pressure applied to tumors that may be in the process of being disrupted by cancer treatment could be harmful, but the dangers are clearly there. What is left out is the recommendation of whether or not massage should be given at all. Is there any evidence massage is helpful in this context? They don’t say, they just say that if you are going to have massage it better be by an oncology-trained massage therapist. A better way to phrase would be is that massage should not be used except as recommended by the treating physician and then only with an oncology-trained massage therapist as directed and coordinated by the treating physician, and then explain why, because disrupting tumors in the process of dying could be bad. Of course they don’t say that, they deliberately use ambiguous language to give the impression that massage is recommended, you just need to use an oncology-trained massage therapist.

    Recommendation 6 should be 1C also (because of the clear but weak evidence it could be harmful), but appears to be rated 2B because there might be some conceivable circumstance where it benefits and risks might be equivocal, that is where there might be no benefits and no harm.

    Recommendation 13 is 1C because non-competent acupuncturists (isn’t that redundant?) could kill the patient by puncturing something vital or infecting them with hepatitis or HIV. It should be worded to say that acupuncture should not be done except…

    These guidelines are quite deceptive in that they make a recommendation based on how an intervention should be done (with a trained professional) where a competent professional will say there is no indication what so ever to do the intervention.

    Regarding recommendation 19, no competent, trained, professional in chemotherapy in oncology could conceivably recommend taking unknown quantities of unknown botanicals with unknown interactions with the chemotherapy and other treatments. Of course their definition of “trained professional” isn’t given. A better way to recommend it (with the same meaning but with less obfuscation) would be to recommend that botanicals be not used except as directed by the oncologist directing the treatment.

    The goal of the ACCP guidelines is explicitly stated.

    http://chestjournal.chestpubs.org/content/129/1/174/T1.expansion.html

    The goals of the SIO guidelines are to obfuscate the usefulness and reliability of CAM treatments (IMO), not to deliver “2. Simplicity and transparency for clinician consumer” as the ADDP guidelines set out to do.

  13. David Gorski says:

    I went back to look at the “vice versa” thing, and, quite frankly, I still don’t really understand what the SIO is driving at. Maybe I’m just stupid; or maybe I should remove the paragraph on “vice versa” if I misunderstood things that badly. Whatever the case, I went back to the Chest recommendations that you cite, and it uses “vice versa” in the same confusing manner. Are they saying that the recommendations are made against something “vice versa,” in other words, when the risks and harms clearly outweigh the benefits?

    In both cases, it’s a horrible way to phrase recommendations.

    I think I will remove that brief passage. It is only a distraction.

  14. daedalus2u says:

    What they are saying is that if there is weak evidence, case reports for example, for something that is either really good (reattachment of a hand), or really bad (brain transplant), even though the evidence is “weak” (because it is case reports), you still make a strong recommendation to either do it, or not do it.

    That is where the vice-versa comes in. The “strong recommendation” isn’t just in favor, it is either in favor or not in favor.

    In the SIO guidelines they use the concept very poorly and to deliberately deceive but to give themselves plausible deniability.

    “1C /strong recommendation, low-quality or very low quality evidence”

    “Benefits clearly outweigh risk and burdens, or vice versa ”

    “Observational studies or case series”

    “Strong recommendation but may change when higher quality evidence becomes available”

    The way they are wording things, they would say “to get a brain transplant, consult a trained professional”; strong recommendation 1C.

    It isn’t that the benefits of a brain transplant outweigh the risks, rather consulting a trained professional about getting a brain transplant outweighs the risks of consulting a non-trained non-professional about getting a brain transplant.

    There are no randomized trials of brain transplants, there is some animal data that suggests it would turn out badly in humans and no data that suggests it would turn out well. But rather than say that, they say consult a trained professional who (if the trained professional is competent) will tell you that a brain transplant will turn out badly and if the trained professional is ethical won’t do one.

    This is why the guidelines are deceptive. They put the onus on the patient to find a qualified trained professional.

    They define “alternative medicine” to be something that people use as an alternative to medicine and “complimentary medicine” to be something that people use in addition to medicine. Never do they try and discourage anything that falls under CAM, they just say to consult a “trained professional”, even when any competent trained professional would tell you, don’t subject yourself to nonsense, they say to ask a “trained professional” anyway, but never define the term but tell you to search the internet to find one with “values” that are compatible with your own.

    The SIO is being deliberately deceptive.

  15. pmoran says:

    The guidelines are “deceptive” as to what, exactly? The following quote from SIO president presumably explains the intent.

    Quote –

    The guidelines clearly advocate evidence-based complementary therapies that support patients through their standard anticancer treatment//B>, help reduce adverse effects, and improve their quality of life.” (My emphasis — PJM)

    Stephen M. Sagar, BSc (Hons), MBBS, MRCP, FRCR, FRCPC, DABR
    President, Society for Integrative Oncology

    – end quote.

    Their hierarchy of evidence may not be as tight or well-tuned to the intensely error averse, mechanistically focused one liked by me and the average medical skeptic, but they are perhaps thinking of practical medical outcomes for severely afflicted patients rather than purity of doctrine or subscription to any specific mechanistic model of medical interactions (although they do say they aspire to purity of science in at least cost-effectiveness terms).

    If anyone knows of some sinister, ulterior motive for their activities please advise further.

    It’s all a bit loose for us scientific purists, certainly, but why is the SIO not to be seen, to some extent as a valuable ally in the battle against cancer quackery of the Gerson/Gonzales/Burzinski/HUlda Clark ilk?

  16. pmoran says:

    Sorry, the intended emphasis –

    Quote –

    ” The guidelines clearly advocate evidence-based complementary therapies that support patients through their standard anticancer treatment, help reduce adverse effects, and improve their quality of life.” (My emphasis — PJM)

  17. GLaDOS says:

    “Energy healing” is so obviously stupid. An 8th grader proved it false years ago, as most of us here know.

    Naturopaths re-brand ADHD as Lyme Disease or adrenal fatigue or chronic candidiasis, and so put children on long-term hydrocortisone, antibiotics, and/or antifungals. If that isn’t evil, I dunno what is.

    “Integrative medicine” is just the chiros and naturopaths continuing L Ron Hubbard’s “operation sore throat.” Time to put a stop to it.

  18. JPZ says:

    @pmoran

    “It’s all a bit loose for us scientific purists, certainly, but why is the SIO not to be seen, to some extent as a valuable ally in the battle against cancer quackery of the Gerson/Gonzales/Burzinski/HUlda Clark ilk?”

    I agree. I have been unhappy with this thread for reasons I could not identify. I think it is because the perfect is becoming the enemy of the good. If NCCAM is reporting actual research on CAM in one section while putting the beliefs about CAM under a different heading, does this make them the enemy? Is it because they do not condemn reiki and homeopathy to the satisfaction of David and others? I personally would like them to call b*llsh*t more often on various unscientific practices, but they see their job as listening and testing. As long as they call b*llsh*t once the testing is done (and it isn’t endless testing), I don’t see their apparent “every idea is welcome” attitude as dangerous. It is dangerous to dismiss someone’s perspective because you disagree with them on some points but not others.

  19. GLaDOS says:

    pmoran, you admitted you wouldn’t use acupuncture yourself, although you are in favor of prescribing it to patients.

    I think that’s where you lost the game.

  20. nybgrus says:

    but they are perhaps thinking of practical medical outcomes for severely afflicted patients rather than purity of doctrine or subscription to any specific mechanistic model of medical interactions

    And therein lies the rub. “Purity of doctrine?” Even though your word choice may have been incidental it belies something deeper pmoran. The sCAMsters have long said that we have a “doctrine” and are ideologically opposed to CAM. The reality is we are attempting to enforce a single, uniform, science based standard of evidence and testing.

    I really don’t see why that is so hard for you to grasp. You on the one hand claim to be very much and evidence-based practitioner, one who would never do acupuntcure yourself, one that would rail against outlandish treatments like the Gonzalez regimen. And then on the other you use the language of the sCAMsters to espouse a need for different types of evidence or different standard of efficacy (placebo is good enough when SBM has run out of recourse). And to top it off you use pejorative language to denounce the likes of Dr. Gorski for holding a rigorous standard – one he holds himself to and one he (and many here, obviously) think all treatment should be held to.

    The issue is not that NCCAM is not calling BS enough. The issue is not that Gorski hates homeopathy and I hate acupuncture (in fact, I don’t hate either). The issue is that CAM exists and propagates by fundamentally changing the rules of evidence to suit its own needs. It is insidiously and fundamentally corrupting the system which has allowed us the breakthroughs and progress we have thus far attained (Flexner report, anyone?). The NCCAM gives legitimacy to “other ways of knowing” by not thoroughly trouncing the failed modalities (well, to be fair that would be all of them).

    It’s this post-modernist new-agey thinking where everyone gets a blue ribbon and the kids that get the answer wrong still get a lolly and a smile. There is such a thing as being wrong. And there is nothing wrong with saying so. The kid who gets the answer wrong should not be maligned or belittled for it, but neither should (s)he be coddled and told it’s OK to be wrong (tacitly or otherwise). That child will grow up thinking that equivocal results and “no better than placebo” is a perfectly good enough outcome and that “vast clinical experience” or “intuition” can be a perfectly valid rationale when lacking a mechanism.

    This is why I have long disagreed with you pmoran

  21. David Gorski says:

    It’s all a bit loose for us scientific purists, certainly, but why is the SIO not to be seen, to some extent as a valuable ally in the battle against cancer quackery of the Gerson/Gonzales/Burzinski/HUlda Clark ilk?

    I’d turn your question around: Why do you think the SIO would be a valuable ally against quackery of the Gerson/Gonzales/Burzinski/Hulda Clark ilk? There’s no reason I have yet been able to discern to think it would be, particularly when the very field of “integrative” oncology buys into the same sorts of concepts upon which Gerson, Gonzales, Burzinski, and Hulda Clark base their quackery. Once science is abandoned as the primary criteria upon which therapies are judged, almost anything is possible.

  22. …why is the SIO not to be seen, to some extent as a valuable ally in the battle against cancer quackery of the Gerson/Gonzales/Burzinski/HUlda Clark ilk?

    Peter,

    I know what you mean, in the sense that the SIO (or at least some of the officers, especially Barrie Cassileth of Sloan-Kettering) goes to great pains to distinguish “alternative” from “complementary” methods, and would like to view itself as a way to, er, woo patients away from refusing effective treatments.

    Nevertheless, the organization promotes harmful practices even if it doesn’t recognize this. In my own post, linked above, I mentioned its touting of the NCI “Best Case Series” program, which as you know was both flawed and the official rationale for the Gonzalez trial. Its promotion of “acupuncture…as a complementary therapy when pain is poorly controlled” seems to me to be a perfect prescription to delay adequate pain control. In a paragraph that contradicts both itself and the SIO’s previously stated stance on “alternative” vs. “complementary” methods,

    Recommendation 16: In cancer patients who either fail or decline antitumor therapies, it is recommended that use of botanical agents occur only in the context of clinical trials, recognized nutritional guidelines, or clinical evaluation of the risk/benefit ratio based upon available evidence. Referral to a qualified expert in CAM modality, such as a Doctor of Naturopathy (ND) who is board certified in naturopathic oncology, may be considered. Grade of recommendation: 1C

    I find other aspects of the SIO stance objectionable, but I admit that these considerations are more a matter of taste than anything else. Its overall message of “CAM” advocacy is exactly that: it promotes woo to patients, rather than merely serves as a resource for practitioners who must respond to patient’s questions or statements. Such advocacy, similar to “Intelligent Design” advocacy, also promotes a continuation of the American-as-apple-pie tradition of anti-intellectualism and its current most pernicious element, science denial. The SIO’s pretense to be able to guide the naive patient away from bad woo and toward good woo is both presumptuous and nauseatingly paternalistic: today it might be Barrie Cassileth doing the guiding, but tomorrow it’ll be the closet laetrile pushers (see my post) or the “board certified naturopathic oncologist” (who, by the way, ought to be licensed in every state, no? After all, the legitimate MDs at the SIO think so, as, apparently, does the Director of the NIH).

    The SIO is playing with fire and doesn’t even know it. Who decides which woo is OK and which isn’t? I agree with David: “Once science is abandoned…”

  23. Clearly Dr. Gorski has not done balanced research on integrative and alternative medical treatment and its effectiveness. He seems to be parroting the official line of “anything other than what we prescribe doesn’t work,” and even worse, “anything that we can’t measure doesn’t exist.”

    There are many holistic alternative cancer therapies that work – and that work, in fact, MORE effectively than the poisonous chemotherapy and radiation that is prescribed as a matter of course. However, once a successful therapy is released, all too often the therapy is blasted, the doctor discredited, and then, occasionally, a pharmaceutical company will patent the same thing. For an example of how a therapy was discredited that works far more effectively than the official treatment line, watch The Beautiful Truth – this documentary is available on youtube, in parts.

    And simply using the argument that if we can’t currently measure it, then it doesn’t exist, where other energetic healing modalities are concerned, is simply incorrect (research Heart Math) and also naive – that would mean that we’ve already discovered all there is to discover, and that would not bode well for advancements in research.

    How are new things discovered? People think outside of the box, come up with ideas, and TEST THEM. Squashing anything not already tested and proven stagnates the industry and destroys any new, improved developments – the author would do well to remember this.

    Charis Brown Malloy, M.S.

  24. wales says:

    Huh?

    DG, you cite a reference which states that Reiki lacks scientific credibility, yet the same reference states that “the Holy Spirit sometimes gives to certain human beings “a special charism of healing so as to make manifest the power of the grace of the risen Lord.” Is this a scientifically credible reference or not? Is your citation not cherry picking? Do you agree with all of the statements of your reference or just that one item?

    It then appears that you try to cover all the bases: reiki does not just lack scientific credibility, it is even “sinful”! Double whammy with this one! ”Some Christians even view reiki as a sin.” What on earth does this have to do with science based medicine? Is this an attempt to influence Francis Collins by guilting him into canceling his speaking engagement in order to avoid contamination with “sinful” practices? Wow, congrats. High score for entertainment value.

  25. David Gorski says:

    There are many holistic alternative cancer therapies that work – and that work, in fact, MORE effectively than the poisonous chemotherapy and radiation that is prescribed as a matter of course.

    If there are so many holistic alternative cancer therapies that work “more effectively than the poisonous chemotherapy and radiation that is prescribed as a matter of course,” then I’m sure that Mr. Malloy will have no problem burying me in examples, including the scientific evidence that shows that these modalities work better than standard science-based treatments for cancer. I’d be very interested in learning of these therapies.

    I’ll wait.

    How are new things discovered? People think outside of the box, come up with ideas, and TEST THEM. Squashing anything not already tested and proven stagnates the industry and destroys any new, improved developments – the author would do well to remember this.

    Most “alternative” therapies have already been tested over and over again. They don’t work; they are indistinguishable from placebo.

  26. WilliamLawrenceUtridge says:

    There are many holistic alternative cancer therapies that work – and that work, in fact, MORE effectively than the poisonous chemotherapy and radiation that is prescribed as a matter of course.

    Really? Prove it. Prove it in a well-controlled study. If they are as effective as you claim, then it should be easy, indeed trivial, to demonstrate it. The funny thing is, when something like the Gonzalez regimen is tested, people die faster than chemotherapy. Even if the Gonzalez regimen is effective in some tiny way, it’s still less effective than standard treatment.

    However, once a successful therapy is released, all too often the therapy is blasted, the doctor discredited, and then, occasionally, a pharmaceutical company will patent the same thing. For an example of how a therapy was discredited that works far more effectively than the official treatment line, watch The Beautiful Truth – this documentary is available on youtube, in parts.

    Oh, well then. A youtube video. I’m convinced. They don’t let just anyone post a video on youtube.

    And simply using the argument that if we can’t currently measure it, then it doesn’t exist, where other energetic healing modalities are concerned, is simply incorrect (research Heart Math) and also naive – that would mean that we’ve already discovered all there is to discover, and that would not bode well for advancements in research.

    Do you know what’s naïve? The assumption that you can’t measure an effect. A true effect will show up in the numbers, irrespective controls, blinding, placebos, etc.

    Heart math seems to be little more than emotion-focussed coping and stress management. You know we can measure the effectiveness of these techniques, right? And what does it have to do with energy healing? Isn’t it just stress reduction? A search on pubmed turns up 14 studies, the most recent 4 being published in the same journal. A 2010 one links to a shoddily-designed pilot program without a control group of either no intervention or alternative intervention (http://www.ncbi.nlm.nih.gov/pubmed/20653295). A 2002 study was another pilot project that looked at only 14 subjects, again without a control group (http://www.ncbi.nlm.nih.gov/pubmed/12417824). This is energy medicine? It just looks like community building, stress reduction, all interventions that are already considered mainstream, if somewhat complex and difficult to ensure compliance once you’re out of a hospital (or cult in-group) setting. The only thing I see here is that CAM tends to produce shoddy research published in journals with low standards. Then people demand respect for a house built on a foundation of slogans and obstinance.

    How are new things discovered? People think outside of the box, come up with ideas, and TEST THEM. Squashing anything not already tested and proven stagnates the industry and destroys any new, improved developments – the author would do well to remember this.

    Refusing to discard disproven theories is how ideas become CAM. Refusing to accept alternative explanations is another way. Citing jingles and cookie-cutter straw man criticisms of actual medicine is another way. The whole point of this blog is that these methods have been tested, and most fail. Those that pass become “medicine”, often discarding the worthless parts (i.e. tai chi is exercise; ditch the qi because it is about as useful as prayer – it’s a story that is packaged with what actually carries the benefit).

    CAM practitioners aren’t thinking outside the box. They’re locking themselves in the box, demanding everyone else be crammed into the same box, demanding that their box be respected (and funded), claiming their box can’t be measured and never, ever, ever leaving their own box and damn the science.

    Wales:

    Dr. Gorski’s point is that an institution that is explicitly spiritual rejects reiki, but more than that – Dr. Collins is not justified in accepting reiki on both scientific grounds as a doctor and “spiritual” grounds as a Christian. Dr. Gorski’s is asking for consistency over special pleading. Either accept science or reject it, but don’t accept it when it’s convenience. B

  27. wales says:

    You’ve covered his roles as “doctor” and “christian” but Collins is also a scientist, and perhaps as such he is a possibilian rather than a probabilian (as in probably not).

  28. Scott says:

    He seems to be parroting the official line of “anything other than what we prescribe doesn’t work,” and even worse, “anything that we can’t measure doesn’t exist.”

    Keep in mind that “cures cancer” is a concrete, measurable effect. Anything which can do that is therefore measurable. Which means pleading that your magic is non-measurable is tantamount to admitting that it doesn’t actually do anything.

  29. WilliamLawrenceUtridge says:

    wales, ideally “doctor” and “scientist” should go together. This whole blog is kinda about that concept.

  30. aeauooo says:

    “I submit to you that SIO is trying to take advantage of your well-known religious faith…”

    A strategy that may well backfire.

    As an evangelical Christian, Collins must, on the whole, reject the veracity of faiths other than Christianity.

    I won’t claim to have anything other than an anecdotal familiarity with the spirituality of proponents of complimentary and alternative medicine, but if much of their belief systems are based on Eastern religions and beliefs, then an insistence that one must accept Christ as Lord and savior may not sit well with a lot of them.

  31. JPZ says:

    @nybgrus

    “The NCCAM gives legitimacy to “other ways of knowing” by not thoroughly trouncing the failed modalities (well, to be fair that would be all of them).”

    Isn’t this the perfect being the enemy of the good? NCCAM separates out what practitioners believe from what science says. Could they draw more scientific conclusions rather than neutrally presenting information? Certainly! Does this make them the enemy? Only if you can’t tolerate relative neutrality. Their congressionally mandated job is to scientifically examine CAM (http://www.nih.gov/about/almanac/organization/NCCAM.htm), but I too wish they would call BS more often.

    @David Gorski

    “Once science is abandoned as the primary criteria upon which therapies are judged, almost anything is possible.”

    You mean like off-label uses of drugs or novel surgical procedures? I’m just teasing you – I know what you meant. ;)

  32. nybgrus says:

    @JPZ: I can tolerate relative neutrality when it is warranted. For example I recenly did search forthis exact Cochrane review since we are covering schizophrenia in class right now. The conclusion is:

    The combination of antipsychotics and antidepressants may be effective in treating negative symptoms of schizophrenia, but the amount of information is currently too limited to allow any firm conclusions. Large, pragmatic, well-designed and reported long term trials are justified.

    That is a reasonable conclusion – we know the antipsychotics work for the positive symptoms and that the negative symptoms resemeble depression, therefore antidepressants should work on the same principle, but since the combination is novel and the disease is different, we need more studies to determine it and it may or may not work.

    However, if you look at a Cochrane review on homeopathy for dementia you find a similar conclusion:

    In view of the absence of evidence it is not possible to comment on the use of homeopathy in treating dementia. The extent of homeopathic prescribing for people with dementia is not clear and so it is difficult to comment on the importance of conducting trials in this area.

    That is an unacceptable conclusion. The a priori probability of homeopathy working is nil. Therefore we need no empirical evidence of homeopathy working specifically for dementia since we know it cannot, by definition, “work” at all.

    IMO, this sort of conclusion is made possible by the lack of critical thinking I spoke of in my previous post. One that is promulgated by the NCCAM when they offer that:

    Most analyses of the research on homeopathy have concluded that there is little evidence to support homeopathy as an effective treatment for any specific condition, and that many of the studies have been flawed. However, there are some individual observational studies, randomized placebo-controlled trials, and laboratory research that report positive effects or unique physical and chemical properties of homeopathic remedies.

    (Emphasis mine).

    Really NCCAM? There are reports of unique physical and chemical properties of homeopathic remedies?

    And then the NCCAM discusses the “controversy” of homeopathy:

    Homeopathy is a controversial area of CAM because a number of its key concepts are not consistent with established laws of science (particularly chemistry and physics). Critics think it is implausible that a remedy containing a miniscule amount of an active ingredient (sometimes not a single molecule of the original compound) can have any biological effect—beneficial or otherwise. For these reasons, critics argue that continuing the scientific study of homeopathy is not worthwhile. Others point to observational and anecdotal evidence that homeopathy does work and argue that it should not be rejected just because science has not been able to explain it.

    Did the creationists help them edit their website? I mean really, “teach the controversy” is the stance they take?

    NCCAM does not take a “relative neutrality” in their stance. They offer false equivalence. As I said in my post above, it is possible to be wrong. Homeopathy is wrong, and it is OK to say so. The NCCAM after evaluating the data and looking at the science (they are supposed to be doing science, right?) should look at it and say something to the effect of:

    “Homeopathy has been evaluated and shows, on occasion, equivocal results and some positive effects. Since the basis upon which homeopathy relies is completely contrary to established and well known basic scientific principles, and the results are scattered and only mildly positive at best, it is reasonable to conclude that homeopathy is nothing more than a placebo effect combined with a positive patient-practitioner experience. As such, the NCCAM cannot reccomend homeopathy as a valid medical practice and feels compelled to sternly admonish against its use for serious or life-threatening ailments.”

    The statements they currently make espouse the notion that there actually is some controversy in the science itself, and offer a platform by which a homeopath can point and say, “Look see! The NCCAM, your own scientific body testing our modalities, say that there could be something there and your science simply hasn’t been able to test it yet!” And it allows for Cochrane conclusions to say that it can’t comment on the efficacy of homeopathy lest specific trials are done.

    This, I think, is the fundamental crux of Dr. Gorski’s letter to Dr. Collins (forgive me Dr. Gorski, I have been speaking for you too much, but I hope I am not too off base) – namely that his speaking at an integrative medicine symposium would allow yet another thing for sCAM apologists to point at to try and claim legitimacy; a way of distracting further from the fact that there is no actual science to support their claims. Even if Collins said nothing positive at all about any specifics of the integrative claims, can you not imagine a sCAMster pointing out that he didn’t say anything negative either?

    CAM is fighting a battle of PR and politics – it obviously has no science to back it up. Giving it better PR, especially from someone as important to science as Collins, gives it ammo and offers it more opportunity to gloss over and distract from the science.

    (I’ll include a link to the NCCAM quotes in a separate post, just so it doesn’t get snagged in the filter)

  33. JPZ says:

    @nybgrus

    I agree that NCCAM should present more conclusions and not just information. I do not agree that failing to condemn homeopathy is equivalent to supporting it. That smacks of the purity tests that US political candidates are subjected to every election, e.g. pro/anti abortion, death penalty, etc. The NCCAM webpage on homeopathy notes the unscientific and unproven aspects of homeopathy while acknowledging that not everyone agrees. I don’t see any real support for homeopathy other than an apparent openess to continue testing. And, I would imagine that they acknowledge disagreement to appease some members of Congress who support homeopathy. It is a hard job to work for the government in the US.

  34. nybgrus says:

    This is where you and I may have to agree to disagree. I don’t think they are not only not condemning it, they are giving creedence on a scientific level for a controversy that does not exist.

    “and laboratory research that report positive effects or unique physical and chemical properties of homeopathic remedies.”

    +

    “Others point to observational and anecdotal evidence that homeopathy does work and argue that it should not be rejected just because science has not been able to explain it.”

    =

    implicit recognition that there may indeed be scientific basis to the efficacy of homeopathy. That isn’t just “not bashing” homeopathy – that is giving it a false equivalence that it does not deserve. And doing so gives footing for homeopaths to continue making their claims.

    Acknowledging that “not everyone agrees” is a journalistic tenet that is completely misleading and inapplicable to science and medicine writing. “Not everyone agrees” that evolution is the most valid explanation of the diversity of life on earth – does that mean that the National Academy of Sciences would be right to include such a clause in their official stance on it? Or do you think they are right to either not mention it or to do so only to denounce the notion as incorrect? Or should the American College of Pediatricians include that “not everyone agrees” that vaccines don’t cause autism?

    I think that as a supposedly scientific research body, it is the duty of entities like the NIH and NCCAM to actually take a stance on things like that, not lend false equivalence and mention nebulous “studies” which demonstrate the “unique phsyical and chemical properties of homeopathic remedies” as there are definitively no such unique properties.

    Perhaps their Congressional charge is not in line with that. I would argue that it should be. And just because it is hard to work for the US gov’t doesn’t mean we should be content with such false equivocacy and “teach the controversy” style of science.

  35. pmoran says:

    I appreciate the responses, both positive (LPZ found better words for some of what I wanted to say) and negative..

    The negatives are all variants of the slippery slope argument, one that itself might merit a little of our legendary critical thinking. In some version it verges on nonsense, such as when it is suggested that medical science is under serious threat from — well, any form of CAM or quackery. Has medical science stalled in those countries with major ongoing traditions of homeopathy? .

    Kimball, you were the voice of reason itself until the “once science is abandoned — ” comment. Don’t you just hate it when people mischaracterize positions to that degree?

    I also feel uneasy when sometimes the argument is about “the science”, but when the weaknesses of that position are shown up and it is pointed out that useful patient outcomes may be at stake it is suddenly all about the ethics.

    It suggests that something might not have been fully thought through, or at least not well enough to support the level of hostility sometimes displayed to those who think they may have found a better compromise within all the inevitably conflicting impulses that direct our dealings with our patients.

    For your consideration I suggest that even most of the public already understands that things like acupuncture, energy medicine, mind-body approaches and possibly even the cancer quack belong to a special category of less certain medical resources that are optional resorts when there are no other options, or the otherwise available ones are proving unsatisfactory. They do differentiate CAM from “proper” medicine.

    That is a very influential community resource that can be built upon, but the people have to be able to understand our position.

    One thing they cannot ever comprehend is why we would not be prepared to put the patient first, always, and in all things. If some reasonably harmless activity can make our patients feel better why would we ever violently oppose it, not being preapred to give it the least benefit of the doubt?

    Notice the difference between how the scientist, concerned with near-absolute truths, might look at the matter, and how a compassionate person might. You had better have some compelling examples of that slippery slope in action.

    Anticipating the usual responses to “what’s the harm?”, I suggest that it is not necessary, efficient or even very effective to base a strategy for keeping the public safer on an all-out attack on pseudoscience, that most people cannot follow and couldn’t care less about. There are other options.

  36. Harriet Hall says:

    @pmoran

    Harmless treatments that make people feel better: OK.
    Ripping off suffering patients with marketing hype, fairy tales, and false hopes: not OK.
    Using such treatments instead of effective treatments for life-threatening diseases: not OK.

    This is not a slippery slope argument, it’s a statement of what happens on a regular basis. I’m not so much afraid of what might happen as appalled at what does happen, even if it only happens to a small percentage of patients.

    How can we be compassionate and at the same time prevent unnecessary deaths and victimization? Any concrete proposals?

  37. nybgrus says:

    <I also feel uneasy when sometimes the argument is about “the science”, but when the weaknesses of that position are shown up and it is pointed out that useful patient outcomes may be at stake it is suddenly all about the ethics.

    That is much to simplistic pmoran. It is always about the science AND the ethics. You cannot separate the two. It about the science always, and when the science becomes equivocal and doesn’t have a clear cut answer then the ethics takes precedence. I’m always surprised at your black-and-white thinking, especially since you accuse me of the same thing.

    I also agree that most people think that CAM is pseudoscience baloney. But a LOT of people don’t realize it (ever look at how much money is actually spent on BS alternative treatments and supplements??). But more to the point, it is not a slippery slope because the public will have to make a choice. It is a slippery slope because medical students in medical schools are being taught the wrong things. They are being taught to be credulous – they are being lectured at Yale that the rules of evidence should be “revised.” THAT is the slippery slope

    One thing they cannot ever comprehend is why we would not be prepared to put the patient first, always, and in all things.

    The very framing of that statement is facetious and pejorative. It is the classic “Are you still beating your wife” question. You seem to think that doing anything and everything, regardless of placebo, science, ethics, etc that can somehow make the patient feel “better” is the only way to “put the patient first.” By your assessment then, parents who don’t give in to their child’s every whim and punish them for bad behavior or deny them candies and sweets whenever they wish are not “putting their child first, always, and in all things.” Sometimes parents know better, just as sometimes physicians/scientists know better. Yes, that does smack of paternalism and we have decided that strong paternalism is unacceptable in the medical profession. However, there is a difference between paternalism and listening to expert opinion. Would it be paternalistic for a lawyer to tell you not to drink drive? Or for a rocket scientist to tell you how to build a rocket? No, those are just expert opinions.

    So I would say your argument is fundamentally flawed – the goal is to put the patient first, always. But that involves NOT bowing to woo and pre- or pseudo-scientific thinking.

    Notice the difference between how the scientist, concerned with near-absolute truths, might look at the matter, and how a compassionate person might.

    I see no difference.

  38. Kimball, you were the voice of reason itself until the “once science is abandoned — ” comment. Don’t you just hate it when people mischaracterize positions to that degree?

    Not sure what you meant there; I thought I stated my reasons for that opinion fairly clearly. No?

    If some reasonably harmless activity can make our patients feel better why would we ever violently oppose it, not being prepared to give it the least benefit of the doubt?

    Peter, Peter, PETER! We’ve had this discussion several times before (speaking of mischaracterizing positions), and each time I’ve stressed that it is not patients to whom I direct my opposition (“violent” is an exaggeration), but the practitioners who promote, rather than merely provide consultation about, such “activities.” The SIO promotes.

  39. JPZ says:

    @Harriet Hall

    As for concrete suggestions, I think NCCAM is trying to educate patients in a constructive manner. The “true believers” are not going to change their minds (and some of them might consider NCCAM a traitor), but patients searching the internet can find NCCAM’s set of recommendations that don’t dismiss or attack their curiousity about homeopathy, et al. Attacking a half-formed belief tends to make people stronger believers. And what message do they walk away with after reading NCCAM’s view on homeopathy? Homeopathy is not supported by most research (annoying caveats aside), it is contrary to physical laws, don’t get ripped off by false claims/bad products (if you insist on using it), and tell your physician. NCCAM’s neutral style of discussing CAM needs a big can of Moxie so it can call BS more often, but it does give more measured and careful advice than irresponsible folks claiming wonderous efficacy and superiority to conventional medical treatments.

  40. daedalus2u says:

    JPZ, no! Patients can only demand what providers are able and willing to provide. If making patients feel better was so important, that can be done pharmacologically quite easily. It is my understanding that cocaine plus opiates make people feel really good, much better than any placebo. As natural and generic products they are (or could be) quite cheap.

    MDs are not allowed to prescribe cocaine plus opiates. There is plenty of patient demand for such treatments, demand that persists in the face of strict regulation and criminalization of such treatments.

    If something as effective at making people feel good as cocaine and opiates can be effectively regulated, why can’t the much less effective things like the magic water of homeopathy, the magic arm waving of reiki, or the magic poking of acupuncture be effectively regulated?

    Patients wouldn’t demand magic water, magic arm waving or magic poking if those treatment modalities were not misrepresented as being science based, safe and effective.

    Why are promoters and sellers of magic crap given a free pass to exploit the vulnerable? It is not scientific purity about efficacy, cocaine plus opiates is more effective at making people feel good than any placebo.

    It is false balance to amplify the dangers of opiate addiction in terminal patients for the essentially completely effective opiates for pain relief while emphasizing the safety of the ineffective magic water, magic arm waving and magic poking.

    If CAM proponents didn’t market CAM treatments (AKA lying to patients about how effective they are), patients wouldn’t be asking for them to complement the evidence based treatments they are receiving.

    It is disingenuous and dishonest to allow CAM marketers to lie to patients and then expect patients to make an informed decision about their health care. It can’t be an informed decision if patients are lied to.

  41. JPZ says:

    @d2u

    OK, you lost me on that one. NCCAM doesn’t market CAM treatments. I don’t think they lie to patients beyond not taking a stand (which, as I said, I wish they would do more often). In fact, compared to actual CAM marketers, they give mighty reasonable advice, e.g. tell your doctor. I haven’t seen (i.e. show me and I will see) active encouragement from NCCAM for people to seek CAM treatments. The perfect is the enemy of the good if talking about CAM without actively supporting or condemning it is demonized – especially if there is a real effort to discuss facts and separate them from beliefs on their part.

    You and I agree that physicians should make it clear to patients what is proven and what is unproven. I believe dangerous delusions must be dispelled and unsafe practices must be stopped. But, I also believe that scolding patients about CAM is counterproductive and leads to them hiding essential facts from their caregivers. If trust is garnered through saying, “I have never seen that homeopathic remedy work, but you are welcome to try it as long as you stay on your prescribed treatment” – I am OK with that.

  42. Linda Rosa says:

    Kim Atwood wrote: “Once science is abandoned as the primary criteria upon which therapies are judged, almost anything is possible.”

    Dr. Atwood is so right. A horrifying example of this is a brutal and unvalidated psychotherapy called “Attachment (Holding) Therapy.” Practitioners claim that the actual torture of adopted children is therapeutic. This has resulted in numerous high profile criminal child abuse and death cases. But the practice is still popular and enjoys public funding.

    http://www.childrenintherapy.org/videos.html

  43. pmoran says:

    “Once science is abandoned as the primary criteria upon which therapies are judged, almost anything is possible

    I was annoyed at what I referred to as this “mischaracterisation” because hardly anyone within CAM, and certainly none of those within integrative medicine, is anywhere near “abandoning science” or scientific medicine. This is one more for the list of skeptical doctrines that could use bit of critical reappraisal.

    Some certainly like to interpret “the science” to their advantage (or that of their patients) but hardly anyone can claim to be never guilty of that.

    As evidence I tender that that the very worst of quacks like to create the appearance of being involved in a scientific endeavour. That is a compliment to science, reflecting how deeply entrenched and respected scientific approaches are within the general public.

    This is one of the reasons why I think it is ridiculous to worry that CAM is a serious threat to medical science.

    Now I agree that it is not easy to know where to draw the lines, but I have suggestions on that too.

  44. pmoran says:

    Linda, nothing I have in mind stops us speaking out about dangerous or cruel CAM practices.

    Attachment therapy is both, before one even considers its lack of scientific merit and inherent implausibility.

  45. David Gorski says:

    One thing they cannot ever comprehend is why we would not be prepared to put the patient first, always, and in all things.

    As a physician and fellow cancer surgeon, I find your remark nothing short of insulting.

    You seem to be not-so-subtly implying that, by contrast, proponents of SBM don’t put the patient first. Your statement is also a false dichotomy nearly as outrageous as the ones promoted by CAM proponents, namely that we as physicians can’t be truly “patient-centered” unless we accept quackery. As Kimball Atwood pointed out, it’s not as though we haven’t addressed this issue dozens, if not hundreds, of times before over the three and a half years of this blog’s existence, coming at it from a number of different angles at different times.

  46. David Gorski says:

    But, I also believe that scolding patients about CAM is counterproductive and leads to them hiding essential facts from their caregivers. If trust is garnered through saying, “I have never seen that homeopathic remedy work, but you are welcome to try it as long as you stay on your prescribed treatment” – I am OK with that.

    I challenge you to find even a single post here where any of us has advocated “scolding” patients about their CAM use. You won’t find it. My policy with individual patients is very similar to what you say above, except that I would be a bit stronger in what I say about quackery like homeopathy, perhaps something along the lines of, “There’s no convincing scientific evidence that homeopathy works and a lot of scientific evidence that it doesn’t.” There is a difference between what we say on a blog, which is meant for a general audience and meant to argue for science and against pseudoscience, and what we say to our patients in the privacy of the exam room; context matters.

    For example:

    http://www.sciencebasedmedicine.org/index.php/how-not-to-win-friends-and-influence-people
    http://www.sciencebasedmedicine.org/index.php/how-should-we-discuss-quackery-with-innocents-and-the-not-so-innocent

  47. I was annoyed at what I referred to as this “mischaracterisation” because hardly anyone within CAM, and certainly none of those within integrative medicine, is anywhere near “abandoning science” or scientific medicine.

    Well, most people within “CAM,” if by that you mean “CAM” practitioners, never embraced science in the first place (other than, as you concede, “to interpret ‘the science’ to their advantage”), even if many of them would seek legitimate treatments for serious illnesses. They recognize at some level that real medicine works, but they don’t quite understand why or how it came to be. To them, science is merely a way to garner ‘privileging.’

    But now I understand what you were trying to say: that real doctors who are flirting with “CAM,” such as those in the SIO, are not abandoning science or scientific medicine. I get it, but that isn’t the point that I (actually David Gorski, whom I was quoting) was trying to make. The point was that those MDs have chosen to selectively ignore science in their promotion of “CAM.” This is playing with fire, because they’ve positioned themselves as the arbiters of distinguishing “good CAM” from “bad CAM.” People in general can’t be expected to make such delicate distinctions (ie, they see advocacy, period), and even within the SIO there will be substantial disagreement that, in some cases, will likely lead to harm. I cited a couple of examples.

    Let me offer an (admittedly flawed) analogy: I’d rather be subject to a government of laws than to a government of men. Substitute “science” for laws and “SIO members” for men, and you get the idea, I hope.

    Note to others: yeah, yeah, I get the flaws in that analogy, and it ain’t ‘scienceology,’ so spare me.

    Back to Peter: yesterday there was an article in the Wall Street Journal lamenting the NIH’s inadequate funding for Alzheimer’s research, which the authors cited as 2% of the total budget. They asserted that this is a shame because 85 year-olds (who are increasingly common) have a >30% risk of developing AD. Consider that re-allocating NIH “CAM research” funding to Alzheimer’s research would more than double the latter. Yeah, “CAM” can reasonably be viewed as a serious threat to medical science even if it doesn’t threaten the entire project.

  48. David Gorski says:

    But now I understand what you were trying to say: that real doctors who are flirting with “CAM,” such as those in the SIO, are not abandoning science or scientific medicine. I get it, but that isn’t the point that I (actually David Gorski, whom I was quoting) was trying to make. The point was that those MDs have chosen to selectively ignore science in their promotion of “CAM.”

    Indeed, but they’re doing more than that, whether they realize it or not, whether they admit it or not. Whenever they have a CAM modality that they like that science utterly disproves (i.e., homeopathy), they try to twist the science and evidence either to support it or, at the very least, not to refute it. David Katz represents an excellent example of this:

    http://scienceblogs.com/insolence/2008/05/integrative_medicine_at_yale_a_more_flui.php

    Money quote from Dr. Katz:

    I think we have to look beyond the results of RCTs in order to address patient needs today, and to do that I’ve arrived at the concept of a more fluid form of evidence than many of us have imbibed from our medical educations…[Referring to a patient anecdote, Dr. Katz went on.] Now, we don’t want you on narcotics anymore than you want to be on narcotics. We initiated a course of acupuncture and over the next two to three months weaned him off narcotics. He was pain-free on acupuncture and subsequently transitioned into homeopathy. Now, I don’t care to get into a discussion of how or even whether homeopathy even works, but this guy had tried everything.

    In other words, if rigorous scientific evidence in the form of everything from physics, chemistry, and biology to RCTs shows that a modality like homeopathy doesn’t work but Dr. Katz believes it can work, then throw out physics, chemistry, biology, and RCTs and use a more “fluid” form of evidence! Use anecdotal evidence instead! Dr. Atwood’s point about how “integrative” medicine makes humans, not science, the arbiter of what is a “good” CAM therapy is spot on.

    I stand by my statement. Promoting CAM like homeopathy or acupuncture necessitates either rejecting or misinterpreting science. Oh, those who promote CAM won’t admit it, and they try desperately to co-opt the language of science to paint their position as being supported by science, but in the end they are rejecting science. Worse, as promoters of quackademic medicine infiltrate medical schools, medical students are being taught to think the same way.

    BTW, Dr. Atwood has also discussed David Katz:

    http://www.sciencebasedmedicine.org/index.php/science-reason-ethics-and-modern-medicine-part-2-the-tortured-logic-of-david-katz/
    http://www.sciencebasedmedicine.org/index.php/the-2nd-yale-research-symposium-on-complementary-and-integrative-medicine-part-ii/

  49. GLaDOS says:

    CAM sucks time and energy from smart people who could be doing better things.

    Every day I have to counter some dodgy therapy promoted by people who look sciency, and the number of these therapies is ever increasing.

    Recent case: the heartbroken father of a beautiful young teen s/p TBI due to MVA went to a brain injury conference where an MD “and herbalist” promoted huperzine. Huperzine is an anticholinesterase sold as a supplement for “boosting brain function.”

    Long story short: no positive controlled trials. In my book that means the public should be outraged and should insist upon good studies before going near the product. If companies can make bank without doing the research, they’ll never get around to it.

    Furthermore, an anticholinesterase should have immediate effects, like within minutes to an hour or so. But my patient’s father had been taking huperzine for over a year without any signs of benefit. The family felt, “if it does no harm but it might help, we should use it.” Somehow they’d been led to believe that huperzine might help slowly over the long term. However, it is my impression that an anticholinesterase should produce effects within minutes to an hour or so after ingestion.

    Just one example of CAM crap that eats up time I don’t have every single friggin’ day.

    And even worse: the socially awkward moment when I must contradict a physician the patient admires. Those moments usually damage my relationship with the patient just a little.

    So please, you CAM promoters, consider killing yourselves. Thanks.

  50. GLaDOS says:

    Crap a crazy typo. Not my patient’s father has been taking, but my patient’s father had been giving huperzine to his daughter for over a year.

  51. GLaDOS says:

    NCCAM doesn’t market CAM treatments.

    Obviously you are wrong. NCCAM is Harkin’s gift back to Herbalife and the chiropractic profession that has long supported him.

    Notice that all the research out of NCCAM is meh. Not one good therapy discovered.

    A sensible America would shut NCCAM down and move on. But it continues to exist because the mere fact that the NIH is studying something is a major marketing win.

  52. daedalus2u says:

    I have made arrangements to be at TAM. What I would like to do is meet with those who are available off-line (i.e. not at the panel discussion on the placebo effect) and discuss my view of the placebo effect, which is consistent with all the data that everyone here is familiar with.

    How I see the placebo effect is a part of physiology that regulates the “top-down” allocation of resources, so that when you are running from a bear, you don’t waste ATP healing the boo-boo that you got on your little finger yesterday. Your physiology shuts down the healing of minor boo-boos so those substrates can be diverted and held ready to give an extra step or two to escape from the bear.

    That physiology has to be from the top-down because threat recognition has to be from the top-down. The physiology has to have systemic effects because substrate used anywhere is substrate that can’t be used for running from a bear.

    In my conceptualization, psychogenic stress is what activates the anti-placebo effect, AKA the “fight-or-flight” state. When fight-or-flight is activated, resources are diverted away from healing via a top-down mechanism (which is not well understood). The placebo effect is a top-down psychogenic process that redirects substrates toward healing. When that diversion is complete, there is nothing more that physiology can do.

    I think that my bacteria will trigger the placebo effect pharmacologically because the archetypal stress response is to lower NO levels systemically. If that is correct, then my bacteria should trigger a placebo effect (a better term might be an anti-fight-or-flight effect) better than any psychogenic placebo.

    If that hypothesis is correct, then there is a way to use the NCCAM to remove the respectability of CAM treatments. I think, that in any trial of my bacteria against any CAM placebo, that my bacteria will provide better results. If ammonia oxidizing bacteria (AOB) are shown to be better than acupuncture for condition xyz, then it becomes unethical to use acupuncture instead of AOB to treat condition xyz.

    I think if you go down the list of CAM treatments, the ones that have effects only through the psychogenic placebo effect, that AOB will beat every single one in a head-to-head clinical trial.

    How to get there from where I am now is what I would like to discuss at TAM with anyone who is interested.

  53. JPZ says:

    @GLaDOS

    Obviously, thank you for sharing your opinions. A sensible America thanks you too. ;)

    @David Gorski

    Thanks for sharing the links. As always, they made for informative reading. I can’t imagine what the job description for a “scolding advocate” looks like! LOL

    From your linked post, I can see that you are very thoughtful about how to respond to different audiences. A patient coming to the exam room with NCCAM printouts is taking a very different approach to managing their health compared to a patient already taking inappropriate dietary supplements and quoting irresponsible marketing. I would think that the patient reading NCCAM material has a more neutral opinion about CAM efficacy and might be easier to educate. Some of the people posting on this topic take issue with neutrality about CAM efficacy. “Scolding” was perhaps too strong of a word, but a patient can still clam up and hold tighter to their CAM beliefs if their physician can’t tone down their disdain appropriately. Again, based on your linked post, I am sure you think about this topic often and have well-practiced approaches to putting your patients at ease.

  54. nybgrus says:

    As evidence I tender that that the very worst of quacks like to create the appearance of being involved in a scientific endeavour. That is a compliment to science, reflecting how deeply entrenched and respected scientific approaches are within the general public.

    That’s exactly the danger pmoran! If they completely eschewed even just the trappings of science, they would be much less succesful (but not defunct – just look at the millions faith healers like Peter Popoff). The fact that they wear the cloak of science, albiet very poorly fitting and always falling off, makes them appear legitimate. It is not a nod to science and SBM and therefore a positive. It is a way of infilitrating and subverting.

    The wolf in sheep’s clothing was not complimenting how deeply entrenched wool is in the general sheep population.

    @GLaDOS:

    I agree. I haven’t been there myself (yet), but I can certainly see how being forced to contradict another physician peddling woo would be difficult and likely strain a patient-doctor relationship.

    @JPZ:

    What Dr. Gorski says is also the ideal I hope to live up to. The tone, content, and demeanor of what you say can and must be tempered to your audience. I do, at times, write with vitriol. But I would never do so with a patient. In fact, I just wrote up a presentation I am to give tomorrow discussing how to assess what your (hypothetical) patient knows about topic X and then how to frame your response based upon that in order to ensure the patient realizes you are on his/her side while educating them sufficiently to let them make the decision him/herself. As I said above, I have yet to engage an actual patient in such a manner. However, a friend of my girlfriend’s is a ballerina, pilates instructor, vegetarian and almost stereotypical “crunchy granola” type. She was certain acupuncture worked and made a comment to me once that she uses it. I didn’t shove my opinion down her throat – she noticed my slight grimace and asked me if I disagreed. I explained to her a number of reasons why I thought it did not work, a little history on acupuncture itself, and a few examples of the dangers of it. I finished with something like, “I don’t think it is the worst thing ever, but I certainly think it really doesn’t work and the financial cost and potential risks, even though they are unlikely, just don’t make it worthwhile to me.” She has since never used acupuncture and we are actually quite good friends and she asks me about various CAM modalities she comes across. She made the decision herself – I did not tell her she needed to stop. That is the sort of rapport I would like to have with as many of my future patients as possible.

  55. nybgrus says:

    oops – that should be “look at the millions faith healers like Peter Popoff make

    and just to be clear when I say “engage a patient in such a manner” I mean “engage a patient in a discussion about CAM in a professional setting” – I have engaged many patients before and my manner has always been courteous and professional. I just haven’t yet had the need to discuss a specific CAM modality with a patient in an actual professional capacity

  56. daedalus2u says:

    The magic 8 ball technique that Dr Hall discusses in the other thread is the same as what NCCAM is doing. They are trying to put the trappings of science onto non-science without understanding what science is. They are doing cargo-cult science (at best).

    The electronic 8 ball technique could just as easily be done with tea leaves, entrails, a crystal ball or by taking pulses.

  57. JPZ says:

    @d2u and GLaDOS

    May I ask you to provide examples to support your broad generalizations about NCCAM?

    If your complaint is that NCCAM does not denounce CAM loudly enough for your tastes, then you need to come to grips with your Nirvana fallacy (now with 100% less Kurt Cobain!). Also, I happen to agree that they should call BS more often on CAM that fails scientific testing (but being a government agency, I understand that it is not easy for them to take bold stands). If your complaint is that they simply exist and this is independent of what they actually do, I am not sure if that would qualify as science-based decision making. If you are bothered by the fact that they present CAM information and the related scientific evidence neutrally, I think that is another Nirvana fallacy.

  58. pmoran says:

    ”One thing they cannot ever comprehend is why we would not be prepared to put the patient first, always, and in all things.”

    David :As a physician and fellow cancer surgeon, I find your remark nothing short of insulting.
    You seem to be not-so-subtly implying that, by contrast, proponents of SBM don’t put the patient first. Your statement is also a false dichotomy nearly as outrageous as the ones promoted by CAM proponents —

    ————————–

    The context makes it clear that I was referring to how our insistence upon strict scientific standards and our apparent rejection of anything less can be perceived by the public as often working against patient interests — most starkly whenever the mainstream itself has little better to offer.

    I admit to lamenting elsewhere that the standards we have chosen do limit our ability to exploit the psychological potential of medical interactions . That is a defendable scientific proposition.

    This is the full context —

    That is a very influential community resource that can be built upon, but the people have to be able to understand our position.

    One thing they cannot ever comprehend is why we would not be prepared to put the patient first, always, and in all things. If some reasonably harmless activity can make our patients feel better why would we ever violently oppose it, not being prepared to give it the least benefit of the doubt?

    Notice the difference between how the scientist, concerned with near-absolute truths, might look at the matter, and how a compassionate person might. You had better have some compelling examples of that slippery slope in action.

    -end quote.

    So our priorities can look warped. We should choose our words carefully.

    Making matters worse, there are constant reminders to the public as to how arbitrary our standards seem to be in practice. Among other things, even 20% of mainstream treatment choices not being supported by high standards of evidence undermines the scientific authority we are trying to assert over CAM.

    Kimball objects to the “violently” in the above, but I suggest that does not exaggerate the implications of much skeptical rhetoric, even if it is not the underlying intent.

    We will be judged by our extremes, just as we habitually judge and react to CAM’ by its extremes.

  59. David Gorski says:

    The context makes it clear that I was referring to how our insistence upon strict scientific standards and our apparent rejection of anything less can be perceived by the public as often working against patient interests — most starkly whenever the mainstream itself has little better to offer.

    Please don’t insult my intelligence, Peter.

    The context, including the context of your previous comments, also makes it crystal clear where your sympathies lie, and that’s not with us, whom you incorrectly and unfairly paint as rigid, dogmatic, and uncaring about patients. Rather, your sympathy is clearly with the “public” that in your view looks at supporters of SBM as not putting the patient first out of some sort of dogmatic, unthinking dedication to scientific “purity” or “purity of doctrine” (your words, not mine, and, tellingly, not used in the context of describing what you perceive to be the public’s viewpoint).

    In fact, your choice of words in your comments over the last several months makes it very clear that you—not the public, whose viewpoint you claim to be describing, but you—view science-based medicine far more as an an inflexible ideology or dogma than what it is: An ideal in which we advocate one standard for all medicine based on science. By throwing around terms like “purity of doctrine” or “purity of science” so freely, you skate perilously close to a favorite attack used by CAM advocates themselves, namely the claim that science is a religion and resistance to unscientific quackery is based on dogma, not science.

  60. GLaDOS says:

    I’m not insisting patients think like scientists. I’m insisting MDs resist the temptation to promote bullsh_t in our medical schools and to the public at large.

    Does this make me a bad person?

  61. David Gorski says:

    Peter certainly seems to think so, I’m afraid. Or, at the very least, Peter behaves as though that makes you hopelessly dogmatic, a slave to “purity of science” and “purity of doctrine.”

  62. GLaDOS says:

    May I ask you to provide examples to support your broad generalizations about NCCAM?

    Go to any moonbat alt med web site and search for “NCCAM.” You will find the mere fact that the NCCAM has taken interest in some crazy nonsense used to imply that there must be something to it else NIH wouldn’t bother with it.

  63. pmoran says:

    David: In fact, your choice of words in your comments over the last several months makes it very clear that you—not the public, whose viewpoint you claim to be describing, but you—view science-based medicine far more as an an inflexible ideology or dogma than what it is: An ideal in which we advocate one standard for all medicine based on science. By throwing around terms like “purity of doctrine” or “purity of science” so freely, you skate perilously close to a favorite attack used by CAM advocates themselves, namely the claim that science is a religion and resistance to unscientific quackery is based on dogma, not science.

    I know it is difficult for you to see what I am getting at and I apologize if poor communication skills are conveying total distortions of what I actually believe.

    Let me say first that if we want to be judged by what we aspire to and by the very best of us, then I think we should to some extent be prepared to extend the same courtesy to others.

    So, why cannot the Integrative medicine doctors be first and foremost be regarded as respectable colleagues, having similar objectives, who may be able to offer valuable help to cancer sufferers with little risk — and then, with sadness rather than righteous glee, look at areas where we think we have a strong scientific case against what they propose?

    Let’s get concrete. If their employment of acupuncture should eventually be shown to reduce the need for mind-numbing opiates in cancer patients, which is certainly possible, why would we not be ready to regard that as a wholly good thing? Or would we quibble about the lack of blinding in such studies?

    I sincerely fear that through underestimating such possibilities we risk finding ourselves clinging to the end of a very precarious limb.

    We are in effect stretching highly arguable scientific and ethical scruples to their very limits. The full case for and against a little flexibility on these matters is never considered here. When I submit studies that should be a warning as to what is possible they are ignored. Why is that?

    IM can be an ally. I know I would like to be able to say to those who do think we are dogmatic, unfeeling, venal pricks — “well look at these doctors — they are pretty open-minded about a lot of “alternative” methods, but they also see conventional cancer treatments as offering cancer sufferers the best chance of cure and palliation.”

    And that should be our main message. It is not CAM that is so dangerous, it is the rejection of proper care.

    And we are part of the public face of “proper care”. We should be analysing carefully what messages we send.

  64. daedalus2u says:

    JPZ, if you look at the director’s page:

    http://nccam.nih.gov/about/offices/od/director.htm

    She says “Some critics dismiss the benefits from these interventions as placebo effects, but I agree with Freedman’s Atlantic commentary that the term ‘placebo’ can distract us from more important issues. As Freedman notes, the time, attention, and reassurance given by alternative medicine practitioners almost certainly contributes to any benefit from the therapy. The research supports this. With acupuncture, for example, a number of studies have shown clear benefit for pain management when compared to conventional care, but only marginal benefit when the control group receives equal attention from a health care provider and a sham intervention that looks and feels like acupuncture. Should we dismiss this as a ‘placebo’ or acknowledge this source of benefit for patients? A difficult question for which there will not be a single answer.”

    Calling it a placebo isn’t “dismissing” it, it is using accurate and precise terminology. What is more important than using terminology that is accurate and precise? I presume using terminology that tricks patients into believing the treatment they are receiving is better than a “sham intervention” when it isn’t.

    Changing the ways that clinical trials are used to evaluate treatments so as to render treatments equivalent to sham to be acceptable therapeutics is to destroy EBM and SBM. What is the standard if equivalence to sham in double blind clinical trials means it is acceptable? Worse than sham? Something has to be actively harmful to be unacceptable to the NCCAM?

    It is being a “purist” to want treatments to be better than not actively harmful?

    She says “As Freedman describes, the benefits being observed with complementary and alternative therapies may yield important lessons for our health care system: the time, attention, and reassuring touch traditionally provided by caring health care providers is in short supply and is a highly important commodity.”

    The only reason “time, attention, and reassuring touch” is in short supply is because of low reimbursement rates for “conventional” medicine. No magic is needed to change that, only different reimbursement rates.

    NCCAM is comprised of people and was generated due to the lobbying of stakeholders in CAM, and those stakeholders (the practitioners of the various magic therapies) certainly do lie, to themselves, to prospective patients and to patients.

    NCCAM was generated to give respectability to the lies of CAM. Has a single CAM practice been validated by NCCAM? Has a single CAM practice been invalidated by NCCAM? Has any work funded by NCCAM changed any CAM practices?

    If NCCAM is not funding research that has any applicability in the practice of CAM or of medicine, or in the understanding of physiology or science, or anything, what exactly is the money NCCAM spending doing?

    If medicine is going to be improved, such that medicine of the future can treat more diseases earlier and with better outcomes, the path by which that improvement is going to happen will be via science and not via magic. If NCCAM is unable to distinguish between magic and science, they are unable to help advance any understanding of physiology or the treatment of any disease.

    The goal of NCCAM is not to improve medicine, it is not to improve the health of patients, it is not to improve outcomes of treatments. It is to make CAM respectable so it can be used more so that the practitioners of CAM can have their egos puffed up and make more money from gullible patients.

    If you look at what NCCAM says about red yeast rice

    http://nccam.nih.gov/research/results/spotlight/071709.htm

    They say that red yeast rice can lower cholesterol as an alternative to statins. This is nonsense and not correct. Red yeast rice is effective at lowering cholesterol because it contains a statin. The wikipedia page on red yeast rice is a lot better than the NCCAM page.

    In her statement on childhood vaccines, Josephine Briggs is pretty positive on vaccination and says that all health provider organizations should support the CDC vaccine schedule. She could have gone one step further and said that “any CAM provider or CAM provider organization that discourages adherence to the CDC childhood vaccination guidelines should be avoided”, but she didn’t. She has a bully pulpit and decided to not use it.

  65. GLaDOS says:

    pmoran, you make vague appeals for tolerance toward CAM generally, but when pressed you stand up for acupuncture specifically. Acupuncture acupuncture acupuncture.

    It’s like the word “CAM” is a euphemism for acupuncture in your world.

    Don’t be hatin’ on acupuncture ya big SBM meanies!

    Do you have any conflicts of interest you might like to mention? Like maybe a close friend or family member invested up to their eyeballs in some pro-acupuncture cult?

  66. GLaDOS says:

    Culties like acupuncture a lot because graduates of acupuncture programs get to put “doctor” in front of their names.

  67. JPZ says:

    @d2u

    I appreciate your in depth commentary! Really! The red yeast rice stuff is seriously missing the point – thanks for sharing that with me, I had not read that before. I’ll point you to some equivalently misleading NIAAA stuff some time, just for giggles (not that it makes NCCAM comments better, but it does illustrate how government institutions do science). And, as for the new Director (I knew Paul Coates better), didn’t she say that doing something other than acupunture has the equivalent benefit? She has to deal with the political consequences of damning a treatment some government offical finds wonderful. She tried to do it without being false, but you damn her for lack of ideological purity. Welcome to the Nirvana fallacy.

    @GLaDOS

    Seriously? The fact that unscientific websites have cited NCCAM makes them worthy of your rancor? That remarkably unscientific and undiscerning attitude has now led me to question your insight – at least for the moment. Shall we consult Reddit to determine how you treat your next patient? Maybe Facebook can help your next diagnosis be less subject to a lawsuit. Get it together and debate for real. I appreciate a strong opinion, but not your fluff support.

  68. JPZ says:

    @GLaDOS

    Are you seriously going all “argumentum ad hominem” on pmoran? I don’t always agree with pmoran, but attacking him personally demonstrates unpleasant things about you. Please try to keep your personal attacks in control.

  69. GLaDOS says:

    It’s not a personal attack. It’s an attempt to understand his motivated reasoning.

    Alt med people use NCCAM fool patients into thinking their dodgy alt med treatment is legit. That is a f_cking fact. NCCAM can pretend that’s not their problem. But herp. And also, derp.

  70. JPZ says:

    @GLaDOS

    The CAM folks throw a lot of “facts” around as well. It is unfortunate that you don’t wish to support your “facts” about NCCAM. My impression is that you are more willing to express your opinion than you are to seek facts. That discredits you. Please return to reason.

  71. kdv says:

    DG: Personally, as a physician and scientist I don’t much care about what religion you follow and, unlike some writers such as Sam Harris, most definitely do not consider your strong Christian faith a disqualification for holding the position that you now hold.

    Dr Gorski, as always, your article made me grind my teeth. That’s a complement, though. It’s the issues you discuss that get the teeth-grinding going, and the fact that you address them so well aggravates the damage.

    However, I feel that you do an injustice to Sam Harris in the above sentence. Just following the link you gave reveals that Mr Harris neither advocates that Dr. Collins should be “disqualified”, and nor does he give the general position that a “strong Christian faith” is in itself the problem. ( He expands these thoughts on the longer article on his website ).

    Rather, he give a number of specific examples of talks and writings by Dr Collins which express firm opinions which may ( I repeat, may ) conflict with the position he holds. Mr. Harris specifically recognises Dr Collins’ expertise and experience, but says that the specific examples he discusses make him “uncomfortable”.

    Dr. Collins’ very adamant, non-scientific, beliefs probably don’t conflict with his work on the genome project. I can see, however, that his dogmatic insistence that mankind chose to ‘sin’ might well raise eyebrows amongst the neuroscientists trying to find a reason for pathological behaviour.

    I suspect that most surgeons might have an issue to discuss if Dr. Collins was a Jehovah’s Witness, say, given their views on blood transfusion. It would not be a discussion about the general issue of religious belief. It would be a specific issue which gave concern.

    Likewise Mr. Harris, except that the issues are multiple.

    ( p.s. ) I’m in no way an advocate for Mr. Harris. I often disagree with him. But in this case, I’m afraid, I have to agree with him. )

  72. GLaDOS says:

    So JPZ, you don’t think NCCAM adds legitimacy to homeopathy and acupuncture simply by taking these things seriously?

  73. nybgrus says:

    @d2u:

    The only thing I would add (which I think is implicit in your writings) is that the only way medicine can improve is by definitively saying “This doesn’t work” or “That is not worth pursuing further.” If you never discard the chaff, you’ll simply never get to the wheat. And that is exactly what the NCCAM does – it never manages to get to the point where it says, “Maybe more research will show something but it really isn’t worth pursuing any further. Lets move on.”

  74. pmoran says:

    Glados, I have no ulterior motives.

    I tred to explain here I am coming from in a previous post–

    “What is wrong with me, David? I will try and explain once and for all, for any who care.

    I differ from the average skeptic only in that I am perhaps more prepared to allow that CAM-based medical activity may have a beneficial role in some people’s lives.

    Even in my earlier, more “skeptically correct” days, I was always a little uncomfortable with the complete dismissal of some types of quite dramatic CAM testimonial. They seemed consistent with the influence of placebo and other non-specific effects of medical attentions. I knew from my own practice how simple reassurance can terminate some kinds of illnesses, and how powerful suggestion can be.

    So it was always reasonable to believe that charismatic CAM practitioners, free of many of the constraints upon normal medical practitioners, might better exploit such influences on patient outcomes. CAM use could be of particular help to some who have not found satisfaction within conventional medical care for a number of likely reasons, or for those for whom there are simply no entirely suitable EBM-endorsed treatments.

    There is nothing very unusual in that belief — Harriet seems to share it to some extent. It is not clear what others here think.

    But for a long time I didn’t want to give an inch to CAM. I simply found the pseudoscience and the fraud intolerable. I happily went along with those reassured by the views of Goetsche et Al and Hrobjartsson et Al, whose studies seemed to suggest that placebos don’t really do that much. CAM then had one less place to hide. The testimonials were obviously mainly illusion, or people just making things up, we thought.
    .
    It’s not so clear now. Study of the placebo over the last decade or so seems to be permitting much stronger and more “real” effects (with subjective complaints and psychosomatic conditions — not usually underlying disease processes).

    How to resolve this contradiction?

    My AHA! moment came when I twigged to the fact that the Goetsche and Hrobjartsson studies weren’t really showing what was claimed. Their data was derived from studies the design of which is calculated to inhibit placebo and non-specific influences. It told us nothing at all about what might be possible under more favorable conditions.

    Wow! The big surprise, and a somewhat transforming experience for me, was not so much that my first instincts might best fit the facts after all, but that so many skeptics including myself were so biased against CAM as to be overlooking a bleeding obvious flaw in our own self-justifications!

    Nevertheless, there remained over-riding reasons for an uncompromising, blanket opposition to CAM, — didn’t there?

    Well, to my further surprise, as I applied fresh, less biased thinking to previously unquestioned skeptical wisdom, I found I had to question much of it.

    Some seemed to be utter tosh, such as the suggestion that medical science could actually crumble under the supposed assault of pseudoscience. More often it was a matter of degree: unscientific dogmatism, overgeneralizations and over simplifications. (Of course medicine is such a complex field that every time we open our mouths we will be guilty of at least one of these. But we could do better).

    Mainly, the issues resolve into this: once you accept that CAM-based activity (note not usually the specific CAM modalities) may have non-zero benefits the cost/risk/benefit equations that determine medical decision-making have to be recalculated, and separately for a wide variety of different clinical and public health settings and also possibly for some individual medical needs. -

    OK, “no worries”; we now say, no one really needs CAM. Doctors will be able to harness the same influences. I regret having to say, for my allegiance is still very strongly with the mainstream, that for now this is probably another self-reassuring skeptical fantasy. If you look at Harriet’s recent (incomplete) list of factors which might encourage non-specific responses to medical care within CAM,
    http://www.sciencebasedmedicine.org/?p=12523
    very few of them can operate without some form of deception, or the recruitment of our own mainly-placebo therapeutic rituals (e.g. massage for back pain, although preferably something a little more mysterious or dramatic). So the usual ethical considerations will forbid them.

    So what is wrong with me? You decide”

    1. Harriet Hall says:

      “Harriet seems to share it to some extent”
      I’d like to clarify. I sympathize with pmoran’s frustration on the front lines of primary care where things are seldom black and white and where we may not have effective science-based treatments to offer. If a patient thinks he is getting a benefit from CAM, I have no desire to take that away from him as long as no harm is involved. If a patient asks me about CAM, honesty compels me to say what I think; but humanity compels me to suit my words to the occasion and sometimes to bend the rules a bit and even commit the sin of omission when I feel it is kinder. I might say (in simpler words) “From reading the scientific evidence I think any perceived effect from X is likely due to placebo responses or other nonspecific factors, but some patients do think it has helped them, and if you believe in it or want to try it “just in case” or because you hope for a placebo effect, that’s fine with me.” In some circumstances, with some patients, I might omit the information about the lack of evidence and just say it was OK with me if they wanted to try it. If the patient had not brought up the subject, I would not feel comfortable recommending a CAM treatment. Instead, I would try to think of something more I could suggest in the way of comfort measures or distractions that didn’t involve false claims of efficacy or mumbo jumbo about imaginary things like qi or subluxations or energy fields. When all else fails, the answer is not to foist the patient off on a naturopath or an acupuncturist. When a doctor can’t offer a cure, he can always offer sympathy, understanding, and emotional support. Just taking time, listening, and caring are important. There is always hope, but we may have to settle for limited hopes that are realistic.

  75. nybgrus says:

    what’s wrong is that, quite simply, the answer is not to justify and enable the use of CAM but to scientifically research those “non-specific effects” and see about possibly incorporating them into actual medical practice.

    Just because you have noticed some non-zero benefit does not mean the calculus changes to include the side-by-side implementation of magical and pseudoscientific thinking in some non-overlapping magisteria of medical worlds. Just as science and religion are indeed mutually exclusive, so is the notion of magical thinking based (MTB) medicine with EBM/SBM.

    Nothing you said was factually incorrect (at least I think not). But the application is one of either giving up on EBM or saying MTB is “good enough.”

    If there is no “entirely suitable” treatment within EBM then there is no need to “compliment” that with magical thinking. Care and compassion, consistently applied and genuine, are all you need.

    If there is absolutely no treatment at all, then most certainly magical thinking is not the way to go. It erodes the fundamental progress humanity has made.

    You may indeed be right that medical science as a whole will never entirely crumble. I do seriously doubt we will suddenly find ourselves living in a society that has (metaphorically) burned all the books and goes to shamans and medicine men for ritual chants instead of chemotherapy. But I can see a schism forming, with those that think in woo like Chopra and Weil on one side and the Gorski’s and Novella’s (and me if they’ll have me :-)) on the other. No, medical science won’t disappear. But it will erode and many a student will be mislead, be taught incorrectly, and many patients will suffer harm at the clash. It is already happening now with integrative medicine being taught in medical schools (you always seem to neglect the fact that your supposedly infallable bastion of scientific medicine is actually teaching these thing credulously) and in the community at large (at the ER where I worked, a level 1 trauma facility with top of the line facilities “therapeutic touch” was a valid option to be checked off as intervention for pain relief). What happens when this become even MORE pervasive, which it is?

    And why on earth SHOULD we give CAM an inch? Because we can’t cure and treat and fix EVERYTHING at the moment? Really Dr. Moran?

    Give a mouse a cookie…..

  76. pmoran says:

    D2: “ Calling it a placebo isn’t “dismissing” it, it is using accurate and precise terminology. What is more important than using terminology that is accurate and precise?

    Agreed. Nevertheless there is nothing in the least precise in terms of patient care about the placebo.

    In the usual double-blinded placebo-controlled clinical trial “working better than placebo” simply means that, assuming the trial was performed well, which is never a certainty, that conclusion has a certain probability after applying an arbitrarily selected statistical rule of thumb.

    Even then, you know nothing about what impact the placebo treatment ritual might have had within the placebo group, or what it might achieve under different conditions.

    Then, of course, there is plenty of evidence that some placebos perform better than others. . All it takes is a little more attention to the patient, or any other means of tweaking of patient expectations.

    Take also into account that designated “placebos” (meaning all non-specific aspects of medical care) can seemingly produce effect sizes comparable to that of some pharmaceuticals, even within clinical studies with designs that would be inclined to suppress many such influences. What does that mean for medical practice?

    Then there is the extreme difficulty of designing an adequate placebo control for some interventions e.g. Chopra’s meditations. How can you blind such a study, so as to determine whether “placebo meditation” works as well? I am not sure that you can.

    So “working better than placebo” simply creates a large grey area, whenever we are dealing dealing with patient outcomes that are susceptible to psychological influences.

  77. pmoran says:

    Nybgrus, nothing is more hostile to the pseudoscientific aspect of CAM than my understanding that that so far as we can tell it “works”, to the extent that it works at all, via the psychological, supportive, nurturing aspects of medical interactions, not via any unique physiological activity of any of the modalties employed.

    Having decided upon that, I can try to dodge being to harsh on those areas where patients may be deriving benefits at little risk, while condemning medial claims that do seriously defraud, or put patients at serious risk.

    One personal benefit is that I now don’t get my knickers in as much of twist and my BP up so high about “the science”, because I understand that that has little bearing on the needs that drive patients to seek CAM or the motives of many of those who choose to offer it to them.

    My basic message for prospective CAM users is this ” these methods may help you feel better but they should not be relied upon exclusively for serious illnesses.”

  78. DevoutCatalyst says:

    @pmoran

    What do you see as the pitfalls of your stance? CAM comes with some serious baggage, as it is dispensed today, in my experience as a former client of CAM.

  79. GLaDOS says:

    I think there is something wrong with you, pmoran, because you continually re-frame opposition to CAM promotion by NCCAM, medical school faculty, and other MDs as intolerance toward patients who want to try some unproven treatment that is likely harmless. These two issues are entirely separate.

    For an MD to promote CAM, he has to bend the rules of evidence in the same way that a biology teacher would have to bend the rules of evidence to promote intelligent design in his classroom.

    The public need someone who is capable of sorting fact from fiction in an expert manner. They may indulge in wishful thinking much of the time. On an individual, case-by-case basis, we can live with a lot of childish thinking in ourselves and others. But when the chips are down, people need to know who to count on for good science.

    Right now patients can’t tell what’s CAM and what’s actual medicine. It was an MD “brain injury expert” that promoted huperzine in the example I gave recently.

    Soon much of the medical profession itself will fail to appreciate the distinction between CAM and medicine. In fact that’s what the US Federal government wants. That is why the NIH director is rubbing elbows with the alternative cancer treatment nutters. That’s why every medical school and most hospitals now have departments of integrative medicine. That’s why the teaching of integrative medicine is now a mandatory part of medical education.

    If you think BigPharma is dangerous now…

  80. daedalus2u says:

    To expand on what nybgrus said, when it is observed that certain things cause a medical benefit, SBM tries to understand what is going on, couple the observed medical benefit with the rest of the SMB understanding of reality and then try to expand and extrapolate the use of what ever it is that caused the medical benefit. If this type of heuristic is not followed, then we would still be eating bark instead of having purified and synthetic bark in the form of aspirin.

    If something has a real medical benefit, that real benefit can only derive from something real happening via real physiology. If we understand what is really going on, that real physiology can be better invoked. If we don’t understand what is going on, it doesn’t mean that nothing is going on, it just means that we don’t understand it.

    That heuristic is not what NCCAM is doing. They are still keeping the CAM interventions at the magic stage. Reiki is magic. It is called an “energy therapy” because people found that waving their arms around without touching the patient made some patients feel better and perhaps even heal better and made up the idea of “energy” because it sounded sciencey. There is no data or physics theory to suggest that there is any actual type of energy field that can be subject to manipulation and which can then affect physiology by the coupling physiology has to that supposed energy field. All data suggests that there is no such energy field.

    SBM looks at the data of reiki “working” and tries to understand the physics and physiology behind it so the limits and utility of that physics and physiology can be utilized more reliably in patient care. NCCAM doesn’t want to look at or try to understand the underlying physics and physiology, they want to keep it as “magic”, and not try to understand it or look to closely at it for fear that the effect will go away. They are afraid the effect will go away because that is what they observe. When careful and blinded trials are done, the results are equivalent to sham treatments. Placebos work as well as active CAM treatment.

    If placebos have effects, they can only have those effects through physiology. If we understood the physiology of the placebo effect, such that we could invoke the placebo effect at will, that would be an enormously powerful treatment modality.

    The armamentarium of CAM consists mostly of elaborate procedures that invoke placebo effects to different degrees.

    SBM looks at the “successes” of CAM (positive patient results from CAM treatments) and tries to understand the physics and physiology that couples what the CAM practitioner did and the positive result that the patient achieved.

    That coupling of placebos and physiology is what I am working on, to trigger the placebo effect pharmacologically. I think this is what I have with my bacteria, a treatment that lowers the threshold for triggering the placebo effect. If the threshold is low enough, and the placebo effect is triggered strongly enough, there is nothing left to trigger. No placebo can have any additional effect once the placebo effect is maximally triggered.

  81. Scott says:

    Take also into account that designated “placebos” (meaning all non-specific aspects of medical care) can seemingly produce effect sizes comparable to that of some pharmaceuticals, even within clinical studies with designs that would be inclined to suppress many such influences. What does that mean for medical practice?

    This seems overstated to me. In some limited cases, placebo effects can be comparable to pharmaceutical effects (e.g. pain, mild depression). But not in general (e.g. antibiotics, vaccines, thyroid hormones just to name a few; I’m sure you can list dozens/hundreds more than my layman’s knowledge). Accordingly, I’d say the import for medical practice is fairly limited.

    I don’t doubt you’re aware of this, but I think it’s important to keep in perspective just how limited a range of applicability placebos have.

  82. daedalus2u says:

    Scott, I don’t think it is overstated, I think it is understated.

    Yes, placebos don’t work so well (or at all) as replacements for antibiotics. Antibiotics don’t work so well as replacements for insulin and insulin doesn’t work so well as a replacement for antibiotics, and neither works as well as immobilization for a broken bone. That doesn’t mean that antibiotics and insulin are not both useful treatment modalities for the conditions they are indicated for. Matching what a treatment does with what a condition needs is what medicine is all about.

    What does it mean for SBM? What it means is that there is this whole area of the coupling of psychology and physiology which is not well (or at all) understood. An entire new area that is ripe for investigation and understanding. An entire new area of potential treatments that address completely different degrees of freedom. All we have to do is understand the physiology behind them, learn how to trigger and control that physiology, and medicine will have a whole new range of treatment options.

    What the data says is that there are modes of treatment with no known physics or chemistry, or physiology behind them (acupuncture and sham acupuncture) that make patients seem better compared to standard treatment. The data is the data. The conclusions that CAM practitioners make, that magic needles stuck in magic places by a magically trained acupuncturist works and that mundane toothpicks poked in random places by untrained toothpick pokers works too! Is an example of magical thinking and post hoc ergo prompter hoc. He/she concludes “I can’t do anything differently or it might not work, the magic might go away.”

    The SBM practitioner concludes “I don’t understand what is going on, I must investigate it until I do understand. Then maybe I can use this effect more reliably and for more interventions, for prevention as well as treatment. Since prevention is always easier than treatment, maybe I can use this understanding to prevent some of those conditions like fibromyalgia, CFS, Morgellons, depression, chronic pain, that people flock to CAM for.”

    NCCAM is looking at CAM as a magic spell that needs to be followed a certain way and they don’t know what that certain way is, so they try different magical perturbations, just like Cargo Cult scientists.

    SBM tries to understand what is going on and fit it with the rest of science.

    CAM doesn’t want SBM to investigate CAM because SBM can strip away everything that is useless and bogus and focus on the core physiology and make that core physiology work better in ways that CAM can’t appreciate because CAM only has magical ways of thinking. SBM has the capacity to take everything that works and is good out of CAM and leave nothing behind except useless and bogus magical thinking.

  83. Scott says:

    The only way that could possibly be understated would be if you care to claim that placebos could replace ALL medication. Your argument seems to be that the placebo effect exists. Sure, nobody denies that. Sure, it may be possible to harness it to some extent. That’s a far cry from claiming that it’s equivalent to/a replacement for pharmaceuticals in general, which is what pmoran’s comment tends to imply (perhaps inadvertently).

  84. David Gorski says:

    I think there is something wrong with you, pmoran, because you continually re-frame opposition to CAM promotion by NCCAM, medical school faculty, and other MDs as intolerance toward patients who want to try some unproven treatment that is likely harmless. These two issues are entirely separate.

    Exactly.

    Note Peter’s choice of language. It’s liberally sprinkled with words and terms designed to paint SBM and opposition to the promotion of CAM as ideological or religious dogma: purity of science; purity of doctrine; a reference to Peter’s past days of being more “skeptically correct” (a take-off on the term “politically correct”); unscientific dogmatism; another “skeptical fantasy”; suggesting that we advocate “scolding” patients for CAM use; and painting SBM advocates as hewing to “near-absolute truths” compared to “compassionate” people and how they might look at CAM. (That last one really irks me; it’s another false dichotomy, as if you can’t be an advocate of SBM and be a compassionate person as well.) This is language custom-designed to facilitate the dismissal of the skeptical viewpoint as being rigid, dogmatic, and more akin to religion than to science and the above examples by Peter were found just in this comment thread alone.

    I don’t know if Peter is doing this on purpose or not, but he’s doing it nonetheless. It’s particularly irritating because, while he’s peppering his posts with the liberal use of derogatory terms for skeptics and skepticism designed to make the SBM viewpoint seem unreasoningly dogmatic, Peter is near-constantly lecturing us skeptics and SBM supporters for—you guessed it—using harsh, uncompromising language about the infiltration of pseudoscience into medicine and medical academia.

  85. JPZ says:

    @nybgrus

    I couldn’t agree more. I wish NCCAM would reach some conclusions and “move on” on certain areas of CAM.

    @GLaDOS

    I do not think NCCAM promotes CAM by studying it. I am open to the theory that NCCAM does little to close out failed areas of CAM by not reaching conclusions based on sufficient scientific evidence. I have offered my opinion as to why they don’t reach conclusions (i.e. government agency and their mission).

    @d2u

    I am not sure how you fit all the pieces of this argument into one post and came to the opposite conclusion:

    “Reiki is magic. It is called an “energy therapy” because people found that waving their arms around without touching the patient made some patients feel better and perhaps even heal better and made up the idea of “energy” because it sounded sciencey.”

    “If something has a real medical benefit, that real benefit can only derive from something real happening via real physiology.”

    “There is no data or physics theory to suggest that there is any actual type of energy field that can be subject to manipulation and which can then affect physiology by the coupling physiology has to that supposed energy field.”

    “If we don’t understand what is going on, it doesn’t mean that nothing is going on, it just means that we don’t understand it. ”

    I know I changed the order and thus the intent, but I think I presented them in the same context. You probably didn’t mean for your ideas to be taken in this order, so it is probably silly to bring it up. ;)

  86. daedalus2u says:

    JPZ, those fit together perfectly to me. Reiki can have real effects, but those real effects are not mediated through a non-existent energy field. Those effects are mediated through the placebo effect which triggers the physiology of the patient via psychological mechanisms.

    Whatever Reiki is doing, it is a multi-step process, all the “important” steps of which are inside the patient and are due to the patients physiology. Where and how the waving hands gets transduced into an ultimate physiological effect is uncertain, but it does not involve a non-existent energy field. Where the multi-step process does involve physiology, there are opportunities to mediate the same physiology via another mechanism.

    That is what I want to do with my bacteria, mediate the placebo effect via another mechanism. I think I have a mechanism that will be stronger and more reliable than the waving of hands and tricking the patient into thinking there is some non-existent energy field that is being manipulated.

    I think that once the placebo effect is invoked stronger and more reliably, that there will be nothing left for reiki to invoke. Reiki will have no additional effect because my bacteria have already maximally triggered the placebo effect.

  87. GLaDOS says:

    I do not think NCCAM promotes CAM by studying it.

    Well why would all those serious scientists study something totally crazy, something that boils down to nothing more than magic? Surely they wouldn’t do that.

  88. daedalus2u says:

    PM, the first principle of medical ethics and practice is primum non nocere “first do no harm”.

    To expand on Kimball’s analogy of law and science, remember what Thomas More said about the law in A man for all seasons, that he would give the Devil himself the benefit of the law, not to protect the Devil, but to protect himself.

    Part of the reason doctors use science is to protect themselves from doing harm. If you don’t understand what you are doing, the chance of harming someone is much larger. There are two aspects to harm, the harm from doing something actively harmful, or the harm of inducing someone to not do something else that is more helpful than what you are inducing them to do. Harms of action and harms of omission.

    As I understand medical ethics, it is not possible to ethically treat someone without having an understanding of what the treatment is doing and how it is supposed to function. Non-scientific understandings as in acupuncture, homeopathy and the Gonzalez protocol for pancreatic cancer have great opportunity for harm because the “understanding” they are derived from is in fact wrong and delusional. A false understanding, for example reiki, is not an acceptable basis for treatment.

    Prior to any treatment, the medical professional must receive informed consent from the patient. Informed consent means informing the patient as to the potential benefits and potential harms of the treatment and the basis for the understanding of how those potential benefits and potential harms derive.

    I think that what PM is doing is saying that it is ok for patients to want and use CAM if they think it helps them.

    What DG, KA, I, and the others are saying is that it is not ok for a health care provider to offer bogus CAM treatments because any benefit is uncertain, there are real harms from relying on the magical thinking that CAM requires, and there may be uncertain harms that outweigh any benefits. A SBM health care provider can’t know about all the harms of CAM because they have not been subjected to the kinds of examinations that medicine has been subjected to.

    CAM providers may think they are doing something non-magical with their magical treatments, but their theoretical explanations don’t fit with reality as we know it. SBM clinicians are left with recognizing that either the CAM clinicians are lying (know that their treatment theories are bogus but use them anyway), or are out of touch with reality (actually believe their bogus treatment theories are correct). No SBM clinician can ethically defer to a practitioner that the clinician believes is either lying about treatments or is deluded about treatments.

    As I see it, as long as CAM practitioners are either lying about the theoretical basis of their treatments, or are deluded as to the theoretical basis of their treatments, SBM can’t use CAM practitioners as part of a treatment team.

    I think this is the dilemma. How can SBM clinicians get their patients to achieve the modest and small but positive health effects of a good placebo response without lying to them or unethically referring them to someone who either will lie to them or is deluded? My solution is to use a treatment that will invoke the placebo effect pharmacologically. It isn’t really a “placebo” because it has pharmacological effects, but it isn’t really a “drug” because it has no effects other than placebo.

  89. pmoran says:

    I think there is something wrong with you, pmoran, because you continually re-frame opposition to CAM promotion by NCCAM, medical school faculty, and other MDs as intolerance toward patients who want to try some unproven treatment that is likely harmless. These two issues are entirely separate.

    This is sheer self-delusion and hypocrisy –it confuses everyone if attitudes in both settings are not being governed by the same understanding of the clinically relevant science, and the same understanding of potential patient benefits.

    My approach (“these methods may help you feel better but they won’t cure you of X”) would be consistent over these and all other relevant interfaces — political, educational, everywhere.

    I have listed other advantages elsewhere, but have said enough for now.

  90. pmoran says:

    D2. I accept that the ethical argument against mainstream doctors using probable placebos has merit. There is actually a clash of ethical obligations, some of which require the doctor to use ALL his professional knowledge and experience for the benefit of each individual patient, and others that inhibit him from doing that fully.

    When trying dubious treatments is the only way left of helping a patient then i cannot see asking them “would you like to try X (a dubious treatment that appears to safely help patients when compared to “normal care” in comparative studies)?” as an awful ethical transgression.

    It is not fair for remote and highly theoretical risks to become that patient’s burden.

  91. GLaDOS says:

    …it confuses everyone if attitudes in both settings are not being governed by the same understanding of the clinically relevant science, and the same understanding of potential patient benefits.

    Agreed. An evidential double standard is wrong. That’s why I would not want a medical school instructor telling medical students that acupuncture is an effective treatment for pain, in comparison to nonspecific interventions such as reassurance and social attention.

    And that’s why I think doctors should not tell patients that acupuncture is an effective treatment for pain, in comparison to nonspecific interventions.

    However, I realize that rules sometimes are not adequate guides in challenging situations. So I’m ready to forgive a doctor who nods in favor of acupuncture in certain situations, which I cannot describe. If I could describe those situations, I’d make a rule for them. But then I’d just need to create another fudge factor, so I’m not going there.

  92. Harriet Hall says:

    @pmoran,

    “When trying dubious treatments is the only way left of helping a patient.”

    I don’t accept that dubious treatments are “the only way left.” You can listen, be understanding and sympathetic, validate their suffering, help them accept the reality of a bad prognosis and make the best of it, help them deal with uncertainty, provide support, and suggest comfort measures that do not claim to cure or depend on a mythical rationale. Sending them to the acupuncturist is a cop-out.

  93. daedalus2u says:

    I completely agree with Dr Hall, sending a patient to a CAM practitioner because you can’t help them is a cop-out and a dereliction of the clinicians’ duty of care. Referring them to an EBM or SBM based practitioner who has a better bedside manner and can invoke superior non-specific effects than you can is not an abdication of the clinicians’ duty of care.

  94. pmoran says:

    @pmoran

    What do you see as the pitfalls of your stance? CAM comes with some serious baggage, as it is dispensed today, in my experience as a former client of CAM.

    Good question. I can see the same theoretical and actual risks as others, while feeling they are exaggerated and amenable to more direct approaches than ethereal attacks on pseudoscience (not that they do not have their place).

    I see my stance as aligning me more closely with ALL the science relating to medical interactions, with the way most patients and the public approach medical problems, and also with justifiable expectations of the medical profession.

    If that does not work better in regaining the public trust that is the key factor in all this, than what we have been trying so far, I will be surprised.

    At minimum it has created a more comfortable space for me amidst a lot of otherwise conflicting considerations.

  95. pmoran says:

    Harriet: “When trying dubious treatments is the only way left of helping a patient.”

    I don’t accept that dubious treatments are “the only way left.” You can listen, be understanding and sympathetic, validate their suffering, help them accept the reality of a bad prognosis and make the best of it, help them deal with uncertainty, provide support, and suggest comfort measures that do not claim to cure or depend on a mythical rationale. Sending them to the acupuncturist is a cop-out.

    Yes, that was badly put of me, though I submit that I was referring to consulting the patient about further treatment options that they might be interested in, not “sending” them off anywhere, and not so much advocating that as an entirely desirable thing as saying that it was not “an awful ethical transgression” to do this.

    I suppose took it for granted that doctors will also try to do what you suggest as best they can under present conditions. Whether that will have much effect on CAM use is a another matter. We both understand the difficulties, such as even maintaining contact with patients when there is nothing very active going on.

  96. GLaDOS says:

    One big pitfall: what’s CAM?

    For a lot of patients I see, the CAM is prescribed by MDs. The patients don’t know it’s CAM. They think it’s medicine.

  97. Harriet Hall says:

    @pmoran,

    “consulting the patient about further treatment options that they might be interested in” ?

    If there are no further treatments available except dubious ones, why not help the patient accept that no further treatments are available and work together on trying to improve the patient’s quality of life? Helping a patient face reality is arguably kinder than raising false hopes and pursuing a wild goose chase.

  98. nybgrus says:

    When trying dubious treatments is the only way left of helping a patient then i cannot see asking them “would you like to try X (a dubious treatment that appears to safely help patients when compared to “normal care” in comparative studies)?” as an awful ethical transgression.

    Except that, as in the case of acupuncture, it is packaged with mysticism and BS, coupled with real risk. The issue is you are saying that the non-specific effects of the dubious treatment can help them… yet you are left holding the bag offering such a treatment that isn’t inextricably intertwined with pseudoscientific hokum. With acupuncture, take away the meridians, the qi, the life force, the needles, and what are you left with? Exactly what Dr. Hall is advocating we do as physicians… have a genuine and caring patient encounter.

    Sending the patient off to an acupuncturist for that is not only a cop-out on your part as a physician, but unethical because you know the acupuncturist will claim all the meridian, qi, life force garbage is doing the work.

  99. daedalus2u says:

    Referring the patient to a psychotherapist is another option.

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