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Blatant pro-alternative medicine propaganda in The Atlantic

Some of my fellow Science-Based Medicine (SBM) bloggers and I have been wondering lately what’s up with The Atlantic. It used to be one of my favorite magazines, so much so that I subscribed to it for roughly 25 years (and before that I used to read my mother’s copy). In general I enjoyed its mix of politics, culture, science, and other topics. Unfortunately, my opinion changed back in the fall of 2009, when, on the rising crest of the H1N1 pandemic, The Atlantic published what can only be described as an terrible bit of journalism lionizing the “brave maverick doctor” Tom Jefferson of the Cochrane Collaboration. The article, written by Shannon Brownlee and Jeanne Lenzer, argued, in essence, that vaccinating against H1N1 at the time was a horrendous waste of time and effort because the vaccine didn’t work. So bad was the cherry picking of data and framing of the issue as a narrative that consisted primarily of the classic lazy journalistic device of a “lone maverick” against the entire medical establishment that it earned the lovely sarcasm of our very own Mark Crislip, who wrote a complete annotated rebuttal, while I referred to the methodology presented in the article as “methodolatry.” Even public health epidemiologist Revere (who is, alas, no longer blogging but in his day provided a very balanced, science-based perspective on vaccination for influenza, complete with its shortcomings) was most definitely not pleased.

I let my subscription to The Atlantic lapse and have not to this day renewed it.

Be that as it may, last year The Atlantic published an article that wasn’t nearly as bad as the H1N1 piece but was nonetheless pretty darned annoying to us at SBM. Entitled Lies, Damned Lies, and Medical Science, by David Freedman, it was an article lionizing John Ioannidis (whom I, too, greatly admire) while largely missing the point of his work, turning it into an argument for why we shouldn’t believe most medical science. Now, Freedman’s back again, this time with a much, much, much worse story in The Atlantic in the July/August 2011 issue under the heading “Ideas” and entitled The Triumph of New Age Medicine, complete with a picture of a doctor in a lab coat in the lotus position. It appears to be the logical follow up to Freedman’s article about Ioannidis in that Freedman apparently seems to think that, if we can’t trust medical science, then there’s no reason why we shouldn’t embrace medical pseudoscience.

Basically, the whole idea behind the article appears to be that, even if most of alternative medicine is quackery (which it is, by the way, as we’ve documented ad nauseam on this very blog), it’s making patients better because of placebo effects and because its practitioners take the time to talk to patients and doctors do not. In other words, Freedman’s thesis appears to be a massive “What’s the harm?” argument coupled with a false dichotomy; that is, if real doctors don’t have the time to listen to patients and provide the human touch, then let’s let the quacks do it. Tacked on to that bad idea is a massive argumentum ad populum portraying alternative medicine as the wave of the future, in contrast to what Freedman calls the “failure” of conventional medicine.

Let’s dig in, shall we? I’ll start with the article itself, after which I’ll examine a few of the responses. I’ll also note that our very own Steve Novella, who was interviewed for Freedman’s article, has written a response to Freedman’s article that is very much worth reading as well.

CHOOSE: HARRIED UNCARING DOCTORS OR QUACKS

You know an article about medicine going to be bad, at least on the science, when it starts out with a sympathetic profile of Brian Berman after an introduction that reads:

Medicine has long decried acupuncture, homeopathy, and the like as dangerous nonsense that preys on the gullible. Again and again, carefully controlled studies have shown alternative medicine to work no better than a placebo. But now many doctors admit that alternative medicine often seems to do a better job of making patients well, and at a much lower cost, than mainstream care—and they’re trying to learn from it.

One of these “many doctors” is, apparently, Dr. Brian Berman. One also notes that nowhere in Freedman’s article is a shred of compelling evidence is presented to support the assertion that alternative medicine can do a better job of making patients well at a much lower cost. It’s all assertions and speculations by “experts” in the field. In any case, regular readers might remember Dr. Berman, who has been featured on this very blog for his advocacy of quackademic medicine, most recently after he managed to get a credulous article about acupuncture into the New England Journal of Medicine (discussed by Mark Crislip and myself). Then, not unlike the vast majority of the evidence that CAM practitioners prefer over basic science and clinical trials, Freedman segues right into an anecdote about a man named Frank Corasaniti, a 60-year-old retired firefighter who had injured his back falling down a steel staircase at a firehouse some 20 years earlier and had subsequently injured both shoulders and his neck in the line of duty. Corasaniti was suffering from chronic pain due to his old injuries and at the urging of his wife tried acupuncture at Dr. Berman’s clinic under the direction of an acupuncturist named Lixing Lao. The consultation is described thusly:

Their first visit had lasted well over an hour, Corasaniti says, time mostly spent discussing every aspect of his injuries and what seemed to ease or exacerbate them, and also other aspects of his health–he had been gaining weight, he was constipated, he was developing urinary problems. They talked at length about his diet, his physical activity, his responsibilities and how they weighed on him. Lao focused in on stress–what was causing it in Corasaniti’s life, and how did it aggravate the pain?–and they discussed the importance of finding ways to relax in everyday life.

All of which is nothing that a real doctor couldn’t or wouldn’t do and completely unobjectionable. It’s what comes next that is the problem, as Lao tells Mr. Corasiniti about how acupuncture “works”:

Then Lao had explained how acupuncture would open blocked “energy pathways” in his body, allowing a more normal flow of energy that would lessen his pain and help restore general health. While soothing music played, Lao placed needles in and around the areas where Corasaniti felt pain, and also in his hands and legs, explaining that the energy pathways affecting him ran throughout his body.

Mr. Corasaniti feels better now; therefore acupuncture works.

I wonder how closely Lao is supervised by Dr. Berman or what the formal arrangement is, because, quite frankly, from the description I see here it sure sounds as though Lao is practicing medicine without a license. What are his qualifications in nutrition? Is he a dietician? What are his qualifications as a counselor or psychologist? In the article, Lao is described as a physiologist with Dr. Berman’s center, which to me sounds as though he has no legitimate qualifications whatsoever to be discussing diet and counseling Corasaniti how to deal with his chronic injuries. Yet there he is, practicing what sound to me like dietetics, counseling, and even medicine without a license at a major academic medical center. That’s leaving aside how, by Freedman’s own report, “practitioners” like Lao, with the approval of doctors like Berman, telling patients that there is a magical life force whose flow acupuncturists can rearrange to therapeutic effect by sticking little sharp objects into their bodies. Indeed, if there’s one thing I’ve found about alt-med, it’s that the supposedly “sensible,” science-based advice about diet and exercise that it’s co-opted as somehow “alternative” and pointed to as being better than what physicians offer often turns out not to be so sensible or science-based when you look at it more closely. Fad diets, supplements, various “detox” diets are all par for the course. We’ve pointed out numerous examples right here on this very blog of pure pseudoscience in medical schools and academic medical centers—even, I hate to admit it, at my medical alma mater.

Freedman then delves into what he apparently views as the failure of scientific medicine, beginning by proclaiming that “on balance, the medical community seems to be growing more open to alternative medicine’s possibilities, not less.” Unfortunately, I can’t actually argue with this assessment; thanks to the infiltration of unscientific CAM into former bastions of SBM like the University of Maryland, quackademic medicine is indeed coming to the fore, but Freedman seems to be arguing that this is a good thing rather than a bad thing because to him scientific medicine has “failed.” This leaves Freedman making this argument as to why quackademic medicine is so popular:

That’s in large part because mainstream medicine itself is failing. “Modern medicine was formed around successes in fighting infectious disease,” says Elizabeth Blackburn, a biologist at the University of California at San Francisco and a Nobel laureate. “Infectious agents were the big sources of disease and mortality, up until the last century. We could find out what the agent was in a sick patient and attack the agent medically.” To a large degree, the medical infrastructure we have today was designed with infectious agents in mind. Physician training and practices, hospitals, the pharmaceutical industry, and health insurance all were built around the model of running tests on sick patients to determine which drug or surgical procedure would best deal with some discrete offending agent. The system works very well for that original purpose, against even the most challenging of these agents–as the taming of the AIDS virus attests.

But medicine’s triumph over infectious disease brought to the fore the so-called chronic, complex diseases–heart disease, cancer, diabetes, Alzheimer’s, and other illnesses without a clear causal agent. Now that we live longer, these typically late-developing diseases have become by far our biggest killers. Heart disease, prostate cancer, breast cancer, diabetes, obesity, and other chronic diseases now account for three-quarters of our health-care spending. “We face an entirely different set of big medical challenges today,” says Blackburn. “But we haven’t rethought the way we fight illness.” That is, the medical establishment still waits for us to develop some sign of one of these illnesses, then seeks to treat us with drugs and surgery.

This is pure piffle. Preventative medicine is part and parcel of primary care, and by definition screening programs for disease (such as mammography) are anything but “waiting for us to develop some sign of one of these illnesses). Similarly, primary prevention (treating hypertension, for instance) is all about preventing serious diseases, such as heart disease or stroke. Moreover, because of our success against infectious diseases, people are now living long enough that chronic degenerative diseases, such as heart disease and cancer, have come to the fore, and these diseases are much more difficult to deal with than infectious diseases that can be cured with the right antibiotic. Basically, when you boil it all down, Blackburn’s assessment is nothing more than the same old complaint against “reductionistic Western medicine” that CAM supporters trot out again and again. The only difference is that it’s tarted up with a “just so” story about how modern medicine supposedly evolved that bears little resemblance to reality and is not questioned. It’s also presented as though physicians haven’t advocated healthy lifestyle interventions for many decades now. In Freedman’s narrative, cribbed from Blackburn, and then placed on steroids by Freedman, in come CAM and “integrative medicine” to deal with chronic disease.

Next comes a favorite CAM trope about how the U.S. spends more on health care than any other nation and has worse outcomes:

All of these shortcomings add up to a grim reality: as a prominent 2000 study showed, America spends vastly more on health as a percentage of gross domestic product than every other country–40 percent more than France, the fourth-biggest payer. Yet while France was ranked No. 1 in health-care effectiveness and other major measures, the United States ranked 37th, near the bottom of all industrialized countries.

This observation, even though true, is utterly irrelevant to the central thesis of Freedman’s article, namely that CAM can somehow improve health care in the U.S. The reason is that France, just as much as the U.S., uses SBM, not CAM. Nor does France, as far as I have been able to tell, “integrate” quackery with its “conventional” medicine any more than the U.S. does. Yet Freedman conflates two unrelated issues in order to suggest that CAM can show us the way out of the perceived “failure” of SBM because of its emphasis on “prevention” and “wellness” and the allegedly closer, more caring relationship between provider and patient, without providing anything other than anecdotes and argumentum ad populum to demonstrate that this might be so.

The one part of the article that comes closest to making sense is when Steven Novella is quoted as saying, “Alternative practitioners have a big advantage. They can lie to patients. I can’t.” This ethical problem appears not to bother Freedman at all. So enamored is he of placebo effects due to CAM that he proceeds to use and abuse them in the same way that Mike Adams did when he was seemingly amazed enough to discover that there are placebo effects in medicine that he tried to argue in a massive tu quoque argument that “Western medicine” is every bit as much a placebo as alt-med. Freedman’s argument, stripped to its essence, is no different than Mike Adams’. Freedman even pulls out an argument that I like to call, “Your Western science can’t study my woo because it’s ‘individualized,’” an argument much favored by woo-meisters:

Randomized controlled trials, the medical world’s gold standard for assessing the efficacy of treatments, cannot really test for this effect. Such studies are perfect for testing pills and other physically administered treatments that either have a direct physical benefit or don’t. (In its simplest form, a controlled study randomly assigns patients to receive either a drug or the equivalent of a sugar pill. If the real thing doesn’t bring on more improvement than the placebo does, the drug is a washout.) But what is it that ought to be tested in a study of alternative medicine? To date, the focus has mostly been on testing the physical remedies by themselves–divorced from any other portion of a typical alternative-care visit–with studies clearly showing that the exact emplacement of needles or the undetectable presence of special ingredients in homeopathic water isn’t really having any significant physical effect on the patient.

But what’s the sham treatment for being a caring practitioner, focused on getting a patient to adopt healthier attitudes and behaviors? You can get every practitioner in each of the study groups to try to interact in exactly the same way with every patient and to say the exact same things–but that wouldn’t come close to replicating what actually goes on in alternative medicine, where one of the main points is to customize the experience to each patient and create unique bonds.

This particular argument is, of course, utter nonsense, as has been pointed out time and time again. If Freedman couldn’t find at least a few studies examining the question of how much of a treatment is due to nonspecific or placebo effects and how much is due to actual interventions themselves, he just wasn’t looking very hard. The bottom line is that Freedman’s article is built on a false dichotomy. Basically, he seems to be arguing that, because conventional doctors are constrained by our current visit-based system of reimbursement from spending a lot of time with patients to get to know them better, empathize with them more, and deal with psychosocial issues, we should cede that aspect of patient care to quacks, letting them step into the breach, so to speak. No, that’s not a straw man position; that’s really what one can reasonably conclude to be Freedman’s argument. He just wouldn’t call it “quackery.” I would in many (but not all) cases. The reason I would is because what comes in with all the caring attention to patients is often pure pseudoscience based on prescientific vitalism. That’s what homeopathy, acupuncture, reiki, and various forms of “energy healing” popular today are. There has to be another way to bring back the “personal touch” and more attentiveness to patients besides telling them that if they want that personal attentiveness they have to go to a quack, which is what Freedman, for all his denials, does, whether he realizes it or not, whether he’ll admit it or not.

THE ATLANTIC SHOWS ITS HAND

As it sometimes does for controversial issues, The Atlantic is hosting an online “debate” about Mr. Freedman’s article and alternative medicine in general, in this case entitled Fix or Fraud? You can tell from the very beginning exactly which side of the issue The Atlantic comes down on by its choice of debaters. (Hint: It’s not “fraud.”) The lineup is stacked with “heavy hitters” in the alt-med movement, all arrayed against Steve Salzberg, who appears to have agreed to take on the role of the token skeptic as he correctly entitled his rebuttal A “triumph” of hype over reality. Besides the author of The Atlantic‘s paean to alt-med, arrayed against Salzberg are:

The rest of the “panelists,” who have not yet contributed responses as of this writing, include Dean Ornish, MD, “pioneering researcher of preventative medicine”; Mimi Guarneri, MD, Founder of the Scripps Center for Integrative Medicine (who also appeared as the pro-CAM physician paired with Dr. Novella on The Dr. Oz Show nearly two months ago); Vasant Lad, director of the Ayurvedic Institute; and Reid Blackwelder, MD, Board Member of the American Academy of Family Physicians who has written credulously about CAM. A more blatantly stacked panel it’s hard to imagine, short of adding Deepak Chopra and Dr. Oz himself! It must have been a painful decision for Steve Salzberg to agree to be the token skeptic; I don’t know what I would have done in his place. Or maybe he didn’t know when he agreed to do it.

Given the wealth and length of the text produced by this team of CAM apologists, I clearly have to do something that doesn’t come natural to me and point out only a few of the most blatantly wrong and misguided arguments, nearly all of which, it should be noted, Mr. Freedman supports when he pipes in. I can also point out that Steve Novella took the time to rebut some of Mr. Freedman’s responses to complaints made by Steve and others, so that I don’t have to. It is interesting, however, to note that in these comments, Mr. Freedman “takes the gloves off,” so to speak and lets his true pique at being criticized show, even as he tries to paint his critics’ responses as emotional, “hot and bothered” knee jerk insults rather than considered responses to his plethora of logical fallacies. On his own blog, he goes on and on about how our responses are so “angry” and elsewhere even goes so far as to accuse his critics of “scienceology,” which he defines as a “quasi-religious faith in a set of closely held beliefs that are dressed up in the trappings of science and kept immune to any counter-evidence or -opinion.” As Steve pointed out, Freedman got the word wrong and didn’t need to make one up. A word already exists to describe the concept Freedman is driving at, and that word is “scientism.” Scientism, by the way, is a favorite charge of advocates of pseudoscience, be it alternative medicine, evolution denialism (i.e., creationism), or whatever. In any case, if you want a taste of how Freedman responds to criticism, here’s an excerpt from his own blog:

Those two basic arguments underlie Gorski’s particularly rabid rant, too. But if you read it, you’ll quickly find yourself buried in a detailed, apparently point-by-point refutation of virtually everything I say in my article. He goes through the article paragraph by paragraph, sentence by sentence, finding in each the logical flaw, the fallacy, the error of argument. Do I compare A and B? Then I’m a fool because A and B are different! Do I contrast C and D? Then I’m a fool, because it’s a false dichotomy! Do I assert a point about science? What do I know about science, I’m a journalist, and therefore a fool! Do I quote a Nobel Laureate? Then I’m a fool, because I’m arguing from authority! Do I point out a problem with mainstream medicine? Then, fool that I am, I’m setting up a straw man! Do I cite a study? Then I’m a fool, because that study was trash, or I’ve misinterpreted it, or it doesn’t apply here! Do I say that randomized studies, the gold standard of medical science, can’t really settle the question of whether alternative medicine might ultimately do a better job in some ways? Then I’m a fool, because any question can be settled with randomized trials, and in fact the studies have been done!

Except that I’ve never called Freedman a fool in any of my posts, either here or on my other blog, leaving me to marvel at his thin skin. Seriously. Go back and read if you don’t believe me. I’ve simply argued that he drew the wrong conclusions from his research and that he, as every writer must do, framed his presentation to support those conclusions. Apparently he can’t distinguish between criticism of his sloppy arguments and criticism of himself, although I do agree that Mr. Freedman did commit every sin of argumentation that he lists in the paragraph above, even as he frames my earlier criticism of his arguments as now a “rabid rant.” Personally, I’m more than happy for readers to compare Mr. Freedman’s own rant with my actually rather mild “rant” and decide whose is the more “rabid.” I also note that Freedman’s argument boils down to assuring us that, yes, he has done the research and that there is “no tearing apart Gorski could produce that I couldn’t in turn rip to shreds.” Trust him on that one, except that, for the umpteenth time, Mr. Freedman fails to produce any scientific evidence or examples to refute a single thing I’ve written and falls back on arguing from authority and straw men, such as claiming that I routinely assert that “alternative medicine is a purely evil and harmful thing that must be crushed.”

But enough of Freedman’s pique at having his work criticized. From now on, I’ll focus primarily on the framing of the pro-alternative medicine responses in The Atlantic “debate.” Freedman’s central thesis was that, even though he openly admits that alt-med is, by and large, placebo medicine and that many of the concepts behind its major modalities (for instance, acupuncture, homeopathy, and reiki) are pseudoscientific nonsense, alt-med still does a “better job of making patients well, and at a much lower cost.” Let’s start with Dr. Briggs and Dr. Killen, the heart of whose argument appears to be similar to Freedman’s. After pointing out that the most common problem for which people turn to CAM is chronic pain and that pharmacotherapy of chronic pain has problems, she argues:

Evidence is growing, based on carefully controlled studies, that certain non-pharmacological complementary interventions may be useful adjuncts to conventional care. For example, the pain of osteoarthritis can be lessened by acupuncture; tai chi may be helpful in reducing the pain of fibromyalgia; and massage and manipulative therapies may contribute to the relief of chronic back pain and related functional impairments. Furthermore, evidence from basic research points to ways in which such interventions use the body’s own pathways known to be involved in response to pain.

Let’s look at the latter two first. I discussed the tai chi/fibromyalgia paper when it came out. It’s nothing more than more of the classic “bait and switch,” because there is nothing unique to tai chi that can be invoked as the cause of better subjective outcomes. Basically, the study should have concluded that gentle exercise is better than, in essence, doing nothing other than talking and a bit of stretching for fibromyalgia. As I put it at the time, the “alternative” frame succeeded. The best you can say about this paper is that it showed that tai chi-style exercise for a longer period of time is better than stretching exercise and talking for a shorter period of time every day using an unblinded study. Similarly, no one argues that massage doesn’t make patients feel better or that manipulative therapies can’t help back pain. Indeed, physical therapists do manipulative therapy all the time. The difference is that they use more science-based interventions. There’s a reason I sometimes refer to chiropractors as “physical therapists with delusions of grandeur.” Physical therapists rely on the physical and don’t claim to be able to help anything not related to the musculoskeletal system. In contrast, many chiropractors infuse their craft with all sorts of woo-ful references to the “vital force” and flow of nerve impulses that have far more to do with a vitalistic, prescientific understanding of disease than with science. As for the acupuncture study, it’s certainly possible to find “positive” acupuncture studies; random noise in clinical trial results, bias, and publication bias will guarantee that. When you look at the totality of evidence for acupuncture, it is resoundingly negative for anything other than placebo or nonspecific effects.

Here’s the NCCAM leadership falls for the CAM frame and false dichotomy promoted by Freedman:

As Freedman also notes, research suggests that non-specific effects often make important contributions to the benefits patients may experience. For example, acupuncture involves a complicated interaction – including the stimulus of needles and their placement, expectancy, touch, a soothing environment, and a reassuring, supportive practitioner – that science has yet to disentangle.

Should we dismiss any benefits as mere placebo effects? Or should we explore the possibility, increasingly suggested by the science, that some complementary interventions provide powerful tools for studying the contributions of attention, touch, time, and reassurance, which are now in short supply in our health care system?

How many times does it need to be repeated that just because science doesn’t know everything doesn’t mean that you can fill in the gaps with “whatever fairy tale most appeals to you” or that it’s not necessary to study pseudoscientific, vitalistic, nonsensical health care systems based on a prescientific understanding of disease in order to determine the relative contributions of provider-patient interactions, nonspecific effects, and placebo effects versus actual benefit from medical treatments themselves? Apparently ad nauseam, because this canard keeps popping up again and again and again, Whac-A-Mole-style.

Moving on to Dr. Weil’s response, I can see from it just why he is the master of obfuscatory language in the service of CAM, as I discussed last month when I looked at his attack on evidence- and science-based medicine. Just look at the title which I’ll paraphrase: The times, they are a-changin’ and we need “smarter” doctors. Note the not-so-subtle implication that, by contrast, CAM opponents must be stupid Luddites who refuse to change with the times, a favorite framing device of CAM promoters. Then, to emphasize his mastery of language, Weil states:

Using synthetic drugs and surgery to treat health conditions was known just a few decades ago simply as “medicine.” Today, this system is increasingly being termed “conventional medicine,” and is the kind of medicine most Americans still encounter in hospitals and clinics. While often expensive and invasive, it is also extremely good for many things, such as medical and surgical emergencies. Some conventional medical approaches are scientifically validated, while others are not.

Any therapy typically excluded by conventional medicine, and that patients use instead of conventional medicine, is known by the catch-all term “alternative medicine.” Alternative therapies are generally perceived as being closer to nature, less expensive and less invasive than conventional therapies, although there are exceptions. Some alternative therapies are scientifically validated, some are not.

Note the dismissiveness towards “conventional” medicine, in particular the framing of its using only “synthetic” drugs and surgery. Never mind that many of the most commonly used drugs are every bit as much derived from natural products as anything touted by an herbalist. Sure, Dr. Weil says, SBM’s good for emergencies (I picture Dr. Weil looking down his nose as he says this, like a desert Santa Claus chastising a naughty child who won’t be getting anything for Christmas), but it’s “expensive and invasive.” Contrast this to the happy, “natural” CAM therapies that are “inexpensive” and “less invasive” than conventional therapies (except, apparently, when they’re not). And just like CAM, some of its approaches are scientifically validated and some are not! Got it? The two are equivalent! Except that Weil has constructed a false equivalency, given that the only alternative therapies that are “scientifically validated” are the ones that CAM has appropriated from SBM, such as diet and exercise, and Dr. Weil, not surprisingly, tries to use them as the proverbial Trojan Horse that I frequently reference:

Use of alternative medicine is but one component of integrative medicine. It attracts the most attention and the harshest criticism. But is nutrition counseling alternative? How about exercise recommendations? What about prescribing botanicals such as saw palmetto for benign prostatic hyperplasia or red rice yeast to lower cholesterol? There is as much or more hard science establishing the efficacy and safety of these therapies as there is behind drug interventions.

See what I mean? Notice how Dr. Weil blatantly co-opts science-based modalities, such as diet and exercise, as being somehow “alternative” when they are not and assiduously avoids any mention of the more hard core CAM modalities, such as “energy healing,” reiki, or homeopathy. Also, saw palmetto doesn’t work for prostatic hypertrophy, and the reason that red rice yeast appears to work to lower cholesterol is because it contains lovastatin, as the Mayo Clinic points out. Basically, as our very own Harriet Hall pointed out, using red rice yeast to lower cholesterol levels involves taking an uncontrolled and unregulated amount of an adulterated pharmaceutical drug. That makes it the height of chutzpah for Weil to claim that there is “as much or more hard science establishing the efficacy and safety of these therapies as there is behind drug interventions.” He can’t resist engaging in a bit of typical pharma-bashing, too.

In the end, Weil “frames” his version of “integrative medicine” not, as he should, as “integrating” quackery with science but rather as aiming to:

  1. Restore the focus of medical teaching, research, and practice on health and healing;
  2. Develop “whole person” medicine, in which the mental, emotional and spiritual dimensions of human beings are included in diagnosis and treatment, along with the physical body;
  3. Take all aspects of diet and lifestyle into account in assessing health and the root causes of disease;
  4. Protect and emphasize the practitioner/patient relationship as central to the healing process;
  5. Emphasize disease prevention and health promotion.

These are all noble ideas, but none of them requires integrating pseudoscience- and belief-based medicine with SBM; yet that is the false dichotomy that Freedman and Weil promote in their articles.

WINNING THE FUTURE OF MEDICINE

Finishing his article, Freedman looks to the future, proclaiming that the next generation of physicians will determine whether alternative medicine takes hold. Not surprisingly, Dr. Weil finishes his article the same way, proclaiming integrative medicine to be “the future of medicine and healthcare.” Meanwhile, in his responses, Freedman simply doubles down on his original article, repeating how he’s making his arguments “with the explicit support of many prominent researchers and physicians” and blithely dismissing both Steve Salzberg’s devastating retort to him, as well as inconvenient criticisms that he considers too harsh as doing away “with all pretenses of objectivity, civility, or respect for evidence and reason.” One can’t help but note that nowhere has Freedman actually been able to refute a single one of the criticisms thus far leveled against him with anything resembling sound arguments or scientific data.

Unfortunately, Weil and Freedman are probably correct about pseudoscience being the future of a disturbingly large swath of medicine. There’s a reason why promoters of unscientific medicine such as the Bravewell Collaborative are focusing so heavily on medical education and setting up “integrative medicine” programs at academic medical centers and bolstering its consortium of CAM-friendly academic medical centers. They’re playing for the long term; there’s no doubt about that. Right now, they’re succeeding, too. The infrastructure is rapidly being built to subvert science in the bastions of academia and replace it with quackademic medicine. Freedman views this as a good (or at least neutral) thing.

We at SBM do not.

Posted in: Acupuncture, Medical Academia, Medical Ethics, Nutrition, Science and the Media

Leave a Comment (59) ↓

59 thoughts on “Blatant pro-alternative medicine propaganda in The Atlantic

  1. SloFox says:

    I wonder if he really comprehends the absurdity of his argument and that he is advocating for overt fraud in healthcare. Dr. Novella’s quote about not being able to lie to patient’s hits the nail on the head. What would it be like to go to the doctor’s office and know that your physician wasn’t obligated to tell you the truth about the treatment he’s recommending.

  2. Becky Murphy says:

    I really appreciate S-BM. I am not a professional, so my comment is based on my experiences as a patient and a parent–While I appreciate the fact there are doctors who practice medicine with integrity, and are, “not able to lie to patients,” I have been lied to, misinformed and the last time this happened the doctor told a blatant lie 3x and then demanded my respect. The same “doctor” the ignored a question posed by my brother; an astrophysicist, who asked, what could we do to help my son feel safe? Reasoning, since it was a fear-driven trauma response that was causing the problem; what could be done while he was in the hospital to help him feel safe? Again, a demand that we “respect” him, followed by a statement made in a chiding tone, “Neuroleptics do not cause brain damage.” The misinformation and the lies I have been told—by “doctors” of psychiatry. The very day this last conversation with a “doctor” of psychiatry took place, I posted, http://involuntarytransformation.blogspot.com/2011/05/which-came-first-doc-brain-damage-or.html before leaving to meet with this “doctor.”

    My son was put on Risperdal in 1996, in 2001, a NIMH funded researcher, Jon McClellan, started telling me I had no say in what drugs he was giving my son, when I questioned his diagnosis, and his drugging the health, the intelligence and the personality and almost the life out of my son. My son was thirteen and he said that meant he did not have to have my permission or approval—even though my sone could not have a conversation of any substance for longer than MAYBE a minute at the time! This “lead researcher” and Medical Director told me I had no say and gave my son virtually every neuroleptic being “trialed” for use in children 2001-2005—I assure you most emphatically: NOT all doctors are compelled to follow the American Medical Association’s “Ethics Guidelines for Informed Consent,” the Hippocratic Oath or the Nuremberg Code. Whether it is willful intent, willful blindness or apathy or ignorance (relying on misinformation propagated by unethical “research” reported in “peer-reviewed” journals) doctors who fail to inform patients about what is known about how Neuroleptic drugs can cause the Parasympathetic Nervous System to become dysfunctional: and cause a wide variety of iatrogenic illnesses, leading to disability and death. Being doctors, I am sure you are aware of the risk for disability and death that is inherent in all neuroleptic drugs—being scientists, I am sure you can access the Evidence Base which would cause any one with the capacity for critical analysis to wonder: “How in the hell can the same drugs be “sleep-aids,” first-line treatment for schizophrenia(required for life), ADHD, aggressive behavior, PTSD AND also and “add-on” treatment for bi-polar?!?” Or, in my case “How in the hell can you not share these facts with a patient, or with a parent?!? The literature back in 2001 when I started researching because of how blatantly rude, evasive and disrespectful Dr. Jackass was. I had the impression that he had never been asked questions by a parent, and he definitely gave me the impression that he needed no one’s input, insight or approval but his own—He is an editor for the Journal of AACAP–he is a Professor at the U of W, Medical Director of Child Study and Treatment Center Center and on Staff at Children’s Hospital which was recently designated a Evaluation and Treatment facility to take Involuntary Commitment cases…Most significantly to me however, he is a liar, who caused my son, a victim of violent crime, with severe PTSD, an incredible amount of emotional and physical trauma when he “treated” him by using him as a guinea pig.

    Both his older brother and I are dealing with grief and loss while discovering that only bio-medical treatment is provided in the “adult” system—That drugs via “case” and “med-management” are available—but do not question if the drugs can be lowered to lessen “side-effects” or decrease the risks for harm–THAT kind of important “medical” decision is made by the “doctor” who had no problem tolerating the “side-effects” my son was complaining about; and declared them tolerable. My son the patient, had nothing to add to any treatment discussion or decision in the “doctor’s” insightful professional opinion—Later, I found out the “doctor” is also the Medical Director of the “mentally ill” Community Clinic.

    My son had an IQ of 146—he had a quick, sarcastic sense of humor and could do triple digit math in his head at six; there is little evidence of who he once was or of the intellect, creativity and attention span that enabled him to put together 1,000 piece jigsaw puzzles, give turn by turn directions to a place he had been to only once, and work on projects with his brother for hours—-the hardest thing for me to take is his awareness of and ability to articulate the loss he feels—”They stole my intelligence mom!” which was declared shortly after he asked me in agony, “How could they take so much from me, mom?” I feel a tremendous amount of guilt for not being able to stop the harm and rescue my son sooner…I know it is misplaced guilt—I really did try, and ultimately succeeded—The reality is my son should not have needed to be rescued from being used by an unethical thug in a white coat conducting federally funded drug trials in the first fucking place!

    If the Science of Medicine is to maintain it’s integrity and doctors both the trust and respect of their patients; individual doctors must abide by the codes of conduct and ethics guidelines of the profession. It’s collective membership must be diligent in their moral duty and hold members who violate these honor codes accountable: it harm patients! Worse, doctors who misinform fellow doctors causing them to harm their patients: unaware of the risks—therefore, unable to properly Inform the patient for Consent purposes. Serve and Protect the patients police yourselves!—Patient’s are NEVER to serve Medicine or the real or perceived needs of practitioners involved in clinical research! In the practice of medicine, what you are practicing is “for keeps” there is no excuse for failure to be honest and accountable, so:

    first things first: “…do no harm…” —the part everybody remembers—but just as important, is the duty implied here:

    “Whenever a doctor who cannot do good, he must be kept from doing harm.” Hippocrates

  3. salzberg says:

    David, you wrote “It must have been a painful decision for Steve Salzberg to agree to be the token skeptic; I don’t know what I would have done in his place. Or maybe he didn’t know when he agreed to do it.”

    I can answer that. They told me that Andrew Weil and Vasant Lad (the Ayurvedic promoter) would be among the panelists. I thought about it and decided I had to participate, even if I was in the minority. I didn’t realize I’d be the *only* skeptical scientist in the Forum. Here’s what I wrote to their editors when I accepted their invitation: “I’m a bit leery of being in the same forum with Andrew Weil (if he participates). He is (in my view) a fraud, and I don’t want to help him in promoting his own supplements, newsletters, and books, which he seems to be remarkably successful at. But I’m willing to participate; I always want to try to educate the public as best I can.”

    After seeing the makeup of the panel, I’ve written to the editors and asked them to include at least one other scientist who is in favor of modern medicine and is skeptical of acupuncture, homeopathy, Ayurveda, etc. I’m still hoping they’ll add someone to the otherwise heavily biased panel.

  4. David Gorski says:

    I wouldn’t hold my breath. I doubt they will add another skeptic to the panel. Meanwhile, Freedman himself chimes in after each response in order to castigate his critics and whine about just how mean we’ve all been to him.

  5. nybgrus says:

    I think this habit of equating open-mindedness with being “nice” and closed-mindedness with being “mean” is utterly false and pointless. Yet it is driven into people’s heads and obviously supported since nobody likes it when they get criticized (whether meanly or nicely) and certainly no one likes it when someone is being hostile. I experienced this when I started teaching 1st year students how to prepare for board exams. I make mistake just like everyone else but because I was behind the podium nobody wanted to call me out for it. Even after I actively told people to go ahead and tear me apart if I make a mistake, they would still hold back thinking I was lying or would get mad. After over 4 months of weekly sessions, they finally get it and have no problem pointing out my mistakes. Often they are wrong, but many times I am. Either way we learn as a group.

    If you’re argument relies on tone it is a pretty weak one. Freedman seems more interested in the tone of his criticisms than thier content. But of course, that fits in nicely with the touchy-feely woo of Weil and his ilk.

  6. Dr. Salzburg, rest assured that your challenge was not thankless — I thank you, and I know many others who feel the same way.

    On the bright side, the editors of The Atlantic have shown their hand. Their panel is so glaringly tilted that it communicates just as clearly as if they proudly announced their bias.

    Many readers and commentators will notice — it’s too absurd not to.

  7. cervantes says:

    I do believe that we need to devote more effort to understanding why all this nonsense is so appealing. Obviously, just countering with the lack of evidence for, or affirmative evidence against, the various modalities of quackery isn’t working. The attraction is unrelated to the scientific evidence for treatments. It evidently reflects a dissatisfaction that many people must feel with their experience of medical care, limited general understanding of biology and scientific reasoning, something emotionally or aesthetically attractive about wooish modalities, legitimate distrust due to flaws in the FDA approval process and dishonest marketing of drugs and devices, the high and inexorably rising cost of medicine, and no doubt other causes as well.

    I think that we really need to grapple with these problems more directly. Just arguing from within the assumptions and focal interests of biomedical science seems to me to be largely missing the point of what is going on here.

  8. I’m always game for speculating along those lines, Cervantes, but at the same time I’m not sure the appeal of alternative medicine is really all that mysterious, or that there’s any lack of serious efforts to wrap our heads around it. Many books have been written about Extraordinary Popular Delusions and the Madness of Crowds, ever since Charles Mackay’s 1841 classic.

    As a (former) massage therapist, I was constantly exposed to intense public cynicism about “mainstream medicine,” and many of my clients loved to hate doctors. It was pretty clear that, in most cases, what they really disliked was not medicine and doctors, but the huge, impersonal scale of modern institutionalized care.

  9. wales says:

    I disagree with DG’s comment that “The one part of the article that comes closest to making sense is when…(insert SN comment).” Actually, many of the article’s physician quotes made tremendous sense, though they are not mentioned in DG’s “review” of the article.

    Much of what impressed me about the Atlantic article was not even touched upon here. I found Dr. Gertz’s attitude compelling “Over the past 30 years, I’ve seen hundreds of patients who clearly feel they’ve benefited from alternative therapies. It’s not my job to tell them they shouldn’t feel better. And I wouldn’t tell patients they shouldn’t try alternative medicine if they want to—we need to follow the clues patients give us about what might help them. “

    and this

    “Gertz is among the many physicians who dismiss the lack of supportive randomized-trial data as a reason to write off alternative medicine. “The randomized trial is a very high bar,” he says. “Eighty percent of what I do here isn’t based on randomized-trial data.” Physicians routinely write “off-label” prescriptions, Gertz says—that is, prescriptions that call for drugs to treat conditions for which those drugs have not been officially approved. It’s a perfectly legal and ethical practice, and even one that physicians consider essential, accounting for about a fifth of all U.S. prescriptions. “It’s off-label not because it doesn’t work, but because there’s no good randomized-trial data on it. In the same way, we may not have great evidence that alternative medicine works, but that’s very different from saying it doesn’t work.”

    DG cites the Mayo Clinic regarding the cholesterol comment, but neglects to comment on some of the statements made by various Mayo physicians regarding alternative treatments. It’s hard to explain how a 5,000 word “review” of a 7,000 word article manages to avoid mentioning the comments of Elizabeth Blackburn and multiple Mayo Clinic physicians.

    One criticism is that the Atlantic could have done a better job of selecting their “token skeptic”. A physician skeptic might have been more convincing than Salzberg, a guy with degrees in English and Computer Science. If we are reduced to swapping anecdotes, give me the anecdotes of physicians who actually treat patients over those of a computer scientist. One thing I found curious, Freedman refers to Salzberg as a “biology researcher” (who believes in hypnosis), but I couldn’t find any evidence of training in biology. Wikipedia calls Salzberg a “biologist”, but Salzberg’s UMD biosketch mentions no degrees in biology.

    I find that I have begun to read SBM less for the content and more for the valuable reference to the “take down” target articles.

    Oh and btw, DG, we already know you canceled your subscription to the Atlantic, you have informed your readers of this multiple times. All the same, thanks for pointing out this interesting article to the rest of us nonsubscribers.

  10. David Gorski says:

    Oh and btw, DG, we already know you canceled your subscription to the Atlantic, you have informed your readers of this multiple times. All the same, thanks for pointing out this interesting article to the rest of us nonsubscribers.

    Actually, no I didn’t. I informed you that I let my subscription lapse, not that I canceled it. Apparently I need to repeat it again, because you clearly didn’t get the message. :-)

  11. Scott says:

    @ wales:

    The biggest problems I have with those quotes from Dr. Gertz are that (for the first) “we need to follow the clues patients give us about what might help them” neglects to consider the fact that such stories DON’T really give us any clues, because we know that it’s placebo effect already. And for the second, this is not a situation where there is absence of evidence, or evidence that’s not directly on-point. CAM is a situation where we HAVE the evidence, and the evidence says that it’s an elaborate placebo.

    In short, Gertz is either unaware of the evidence against CAM, or chooses to ignore it. Neither is a recommendation.

  12. Rick says:

    I think there a many things going on here IMO. The first is that while patient-centered care is important, that this is becoming patient directed care. This is something we struggle with where I work. Do we “discharge” a family that doesn’t believe in immunizations, because they put our other patients at risk when they come in to be seen? A patient disagrees with a treatment plan, they may seek a physician that will give them what they want despite evidence to the contrary or do when give them what they want?

    Next, we can give nutritional advice and do counseling in my offices, but is it worth it? At the end of the day are there enough reimbursement dollars for a physician and RN to do this? Most offices cut corners ($) and have MA’s which for the most part are unregulated doing follow up if any with patients regarding nutrition and exercise. Under the delegation of public health codes could this be what Dr. Berman is doing?

    Money is a major in primary care; however, I also see that it is a lack of training being a problem. People are referred out for mental health issue despite that most of these first appear in the primary care physician’s exam room. I bring up the idea of discussing advance directive counseling, and see fear in PCP’s eyes. We are just starting training on motivational interviewing for physicians and nurses. We’ll see how that goes. Talking to people where CAM does a better job. The joke, or sad truth is in many medical offices, if you really want to know what is going on with a patient, you should talk to the receptionist or the person who takes care of referrals.

    Lastly, the physicians have a difficult time policing their own. In the most recent Medscape survey of 10,000 physicians, it listed reporting an incompetent or impaired colleague as one of the biggest ethical dilemmas physicians face. Even when reported, the medical board has a difficult time taking that all important license away. Take the Texas Medical Board when it received information from two nurses regarding Dr. Rolando Arafiles who used olive oil to treat MRSA, and sewed part of the rubber tip from suture kit scissors to a patient’s torn, broken thumb, diagnosed hypothyroidism in 1 patient without any testing and diagnosed the same disorder in a second patient despite normal thyroid function tests, and prescribed hormone replacement therapy (HRT) for a woman whose lab work showed testosterone, estradiol, and progesterone levels within the normal range — HRT was contraindicated for the woman because of a history of deep vein thrombosis, which reoccurred after HRT was initiated. He was also was charged with witness intimidation after he listed the help of his friend the sheriff to trace the anonymous letter back the nurses. Wonder how many physicians over looked what Dr. Afafiles did?

    The TMB after all this suspended his license but stayed the suspension, meaning that Dr. Arafiles can continue to practice medicine under board monitoring. However, he must take and pass a TMB examination on laws and board rules governing medical practice within the next 12 months. Way to put the hammer down TMB.

  13. wales says:

    DG, not necessary. I think it’s precisely because you repeated it so many times that I glossed over “lapsed” vs. “canceled” distinction.

  14. David Gorski says:

    No, seriously. I think I need to repeat it again. :-)

  15. wales says:

    And while we’re discussing “harms” of alternative treatments vs. conventional medicine, check out this NY Times article which garnered almost 300 comments.

    http://www.nytimes.com/2011/06/18/health/18radiation.html?_r=1&sq=ct%20scans&st=cse&adxnnl=1&scp=2&adxnnlx=1308585677-85Y/o2nTe8TC2u36/K7/Fg

  16. wales says:

    Scott, are one-fifth of US prescriptions (off-label) also “elaborate placebos”?

  17. wales says:

    DG, nice to see you in such good humor.

  18. windriven says:

    “Their first visit had lasted well over an hour, Corasaniti says, time mostly spent discussing every aspect of his injuries and what seemed to ease or exacerbate them, and also other aspects of his health…”

    “All of which is nothing that a real doctor couldn’t or wouldn’t do and completely unobjectionable.”

    Whether or not this is realistic and factual, the perception appears to be that quacks can and will spend significant time with patients and that MDs can’t or won’t. Repeating the mantra that quackery doesn’t work won’t do much to alter that perception.

    Echoing Paul Ingraham’s comment above, the “huge, impersonal scale of institutionalized care” seems to be the agar on which quackery feeds. A number of major medical schools and hospital systems seem to have grasped the notion that there is at least the perception of an unmet need. Unfortunately, they have responded by creating departments of quackery – dabbling in acupuncture, chiropractic and other idiocies.

    The more reasoned response would be to starve that perception by using appropriate professionals and paraprofessionals to make the deep level of caring and commitment that lies at the heart of science based medicine more obvious – and more accessible – to the average patient.

  19. Scott says:

    Scott, are one-fifth of US prescriptions (off-label) also “elaborate placebos”?

    No, and that’s precisely the sort of thing I’m complaining about with Gertz. Not having robust on-point data, but biological plausibility/data in related groups/data on related disorders/etc. (i.e. good off-label use), is utterly different than having actual robust data saying that it does not work (i.e. the major CAM modalities).

    That said, some off-label prescribing DOES warrant the term. Antibiotics for a cold, for instance.

    But if you have a point to make, please make it clearly instead of asking what you clearly intend to be leading questions.

  20. wales says:

    The point is that Dr. Gertz and the other Mayo physicians mentioned in the article are Possibilians, which is not an anti-science stance, and that may be a more productive relationship for many with chronic medical conditions which have not been alleviated by science-based medicine.

  21. Scott says:

    Actually the quoted position is completely anti-science (or possibly simply ignorant). You can’t simply ignore the evidence and NOT be anti-science. I’d also love to know how ignoring the evidence is “productive” for anyone.

  22. cervantes says:

    Paul Ingram writes, “It was pretty clear that, in most cases, what they really disliked was not medicine and doctors, but the huge, impersonal scale of modern institutionalized care.”

    Well yes, that’s exactly the kind of thing I’m talking about. And the point of my comment is not that we necessarily need to spend a lot of effort studying why people are attracted to quackery and woo — I suggested several of the reasons. Rather, it’s that the mighty labors of DG and others to combat it by arguing about the scientific evidence for and against various treatments is not working, and it is not working because it’s missing the whole point of the controversy — it is not fundamentally about science or evidence of effectiveness in the first place. If the bloggers here at SBM could really grok that, they would have a chance to advance the cause more effectively.

  23. kdv says:

    Just to carve out a small piece of this long, but superb, article, I’ve always had problems with the terms “alternative” and “conventional” medicine, even (especially?) when used by those in the science camp.

    Weil is right , what was once just “Medicine” is now “Conventional Medicine”. The term was coined by the anti-science crowd to denigrate science, and thus, by the usual false dichotomy, elevate themselves, given the negativity that “conventional” holds. ( e.g. Conventional methods won’t work here, we need to be innovative! ) However it’s now so ubiquitous that all sides seemingly accept it. Let’s get back to Medicine.

    Even worse is “alternative”. If I want to go from point A to point B, then (depending on distance, geography, and so on) I might walk, cycle, or ride in a car, train, boat , or plane. Those are alternatives, because they will all get me to point B. Trying to get there on a flying carpet is not an alternative, whatever the flying carpet salesmen say.

    And, to shamelessly pinch an analogy from another topic of debate, “integrative” and “complimentary” are just “alternative” wearing shabby tuxedos.

    Shouldn’t the adjective be un(or anti)scientific?

  24. wales says:

    Scott – Actually Gertz’s comment “we need to follow the clues patients give us about what might help them” is quite scientific. Open minded and refreshing perhaps, but scientific nonetheless.

    Ciao for now.

  25. Scott says:

    Go back and reread my earlier post. It is NOT scientific to pretend that up is down, or that CAM might have some effect other than placebo, when we have robust evidence that this is not the case. It is NOT scientific to pretend that off-label prescribing (generally weaker evidence) is in any way analogous to CAM (robust evidence against).

    You seem to be advocating being so open-minded that our brains fall out. If we have strong evidence against a proposition, we can’t simply ignore it and treat the proposition as a complete unknown! Yet that is exactly what you and Gertz both do.

  26. @Cervantes, sure I can get behind that, and see that I did miss your point in my earlier reply.

    It’s all important. Many people are moved by evidence of treatment efficacy, or the lack, while many other fence sitters need to hear other issues and concerns addressed.

    Certainly I’ve often noticed — we all have — the way opponents in these debates seem to be talking past each other, as though every rebuttal is prefaced with, “Um, whatever about that, but my point …”

  27. windriven says:

    @cervantes

    “Rather, it’s that the mighty labors of DG and others to combat it by arguing about the scientific evidence for and against various treatments is not working, ”

    If the only mission of SBM is to convince the scientifically minded and the more rational fence-riders, it could be argued that it is working.

    But if the mission is to influence broader pubic policy, to improve medical care and consign quackery to the darkest shadows, then your point is well taken.

  28. Wales, you may have been “compelled” by comments from Gertz and others in Freedman’s article, but I sure wasn’t. It’s a familiar and disingenuous rhetorical tactic to act as if alt-med simply lacks RCT support because it’s such a “high bar” to clear, when in fact RCTS have been beating the crap out of every classic alt-med intervention for years. These things aren’t unstudied at all! Implying otherwise is just reality-denying propaganda.

  29. windriven says:

    @Scott-

    A am not in any way disagreeing with your argument on what is scientific and what is not but I wonder if wales’ larger point isn’t that regression to the mean and placebo effects cover a non-trivial portion of all patient recoveries and that more than a little bit of medical care is based on less than rigorous scientific evidence.

  30. Scott says:

    Trouble is, that fact provides no support at all for what Gertz is quoted as saying. There quite simply IS no way to support

    In the same way, we may not have great evidence that alternative medicine works, but that’s very different from saying it doesn’t work.

    which is about like saying “we may not have great evidence that dropped rocks fall up, but that’s very different from saying they don’t.”

  31. windriven says:

    @Scott

    I’m not sure what the antecedent to “that fact” is. If it points to something in my comment I would certainly agree with you. Gertz’s assertion is logically inept as well as being factually inaccurate; we have rather compelling evidence that quackery in fact does not work.

    Several of the commenters on this post have zoomed out a bit on the subject and observed that placebo effects and regression to the mean also play a role in medical care.

    My own contention is that we err in not recognizing that some people require a bit more hand-holding and stroking along their path to recovery. If we cede that ground to quacks, quackery will feed on it and, from a public policy perspective, will consume an increasing share of a scarce resource at the expense of science based medicine.

  32. wales says:

    If the Mayo Clinic are “quacks” then why is DG quoting them on cholesterol?

  33. wales says:

    BTW…levels of “certainty” vary quite a bit with regard to the physics of falling rocks vs. that of the biological sciences in general and the practice of medicine in particular.

    Wish I could chat more, perhaps another day.

  34. wales says:

    make that “vs. the mechanisms and treatments results” of the biological sciences and medicine.

  35. windriven says:

    @wales

    I just searched through the post and ensuing comments and if anyone called the Mayo Clinic quacks I missed it somehow.

    And don’t you see that there are differences between being a science based physician, and evidence based physician, a physician without a thorough grounding in science, and a quack? Even very bright people can hold ridiculous positions: Linus Pauling leaps to mind.

    I know you don’t mean to suggest that anything must be true if a Mayo physician asserts it. And while I don’t speak for Dr. Gorski, I don’t believe that he would argue that Dr. Gertz doesn’t know what he’s talking about on any subject simply because he holds a foolish view on this subject.

  36. Scott says:

    I’m not sure what the antecedent to “that fact” is.

    Apologies for my lack of clarity. I was referring to:

    regression to the mean and placebo effects cover a non-trivial portion of all patient recoveries and that more than a little bit of medical care is based on less than rigorous scientific evidence

    As for wales…

    BTW…levels of “certainty” vary quite a bit with regard to the physics of falling rocks vs. that of the biological sciences in general and the practice of medicine in particular.

    True. But they don’t vary anywhere near enough to change the conclusion.

  37. wales says:

    windriven: it was implied that Mayo Clinic (by virtue of its offering complementary and integrative medicine training and services) are quacks, it was not stated explicitly.

  38. Scott says:

    I can’t speak for anyone else, but IMO those at the Mayo Clinic offering CAM services and classes most certainly are quacks. As are those at Harvard, etc. doing the same. This doesn’t make the entire Clinic quacks, however.

    See: “quackademic medicine.”

  39. windriven says:

    @wales

    Alas, Mayo isn’t alone in this regard. So many first tier medical programs have allied themselves with shameless quackery it makes me choke.

    The problem we have here is not one of science alone. I suspect that it is the business of health care that is driving the embrace of quackery. We ignore that at our peril. Somehow quackery has wriggled its way from (near) universally decried snake oil to the treatment of choice for some people.

    It isn’t so much the scientists who are channeling how health care dollars get spent, it is politicians, bureaucrats, CFOs and others who may have no appreciation in particular for science based anything. When they embrace quackery they are simply trying to capitalize on what they perceive as an under-served need.

  40. SloFox says:

    @cervantes

    Your point is well-taken regarding the experience that patients have and that there should be greater efforts undertaken to both study and overhaul primary medical care in the US. I propose we use the money that NCCAM currently receives and wastes as a starting point toward that end. For those of us in medicine, however, I think it remains important to continue to emphasize the importance of remaining science-based. It is unconscionable that physicians are allowed to get away with promoting patently false therapies. I agree with windriven regarding the likely limited impact this blog will have on policy makers but the more the medical community can focus on the real issues the more likely they can lobby for the appropriate systemic corrective measure. That is my hope, at least.

    @ wales

    There is no question in my mind that there are major problems in which medicine is practiced. Your NY Times article is just the tip of the iceberg. The point of this site (as I see it) is to promote science-based medicine across the board. CAM is definitely the low hanging fruit and perhaps gets most of the attention but that doesn’t mean there aren’t non-science-based practices that are occurring.

    That being said, the more pseudo-scientific and manifestly false clinical practices invade the medical mainstream the harder it is to dismantle and police the bad practices that already exist.

    I do wish this blog focused more on the over-prescription of antibiotics, bad practices in pain management, the importance of the patient-physician relationship, overtesting, etc. but nothing irks me more that current trend of encouraging overt fraud.

  41. windriven says:

    @SloFox

    “the more the medical community can focus on the real issues the more likely they can lobby for the appropriate systemic corrective measure.”

    And the sooner the better. Perhaps medical staff at Mayo, Yale-New Haven, Duke and others have rebelled against the incursion of quackery into their programs. If so it has been a notably quiet rebellion.

    The more the medical establishment is seen to embrace quackery the easier it is for the political and health care management types to steer money into those programs at the expense of medical care and medical research.

  42. SloFox says:

    @windriven

    Unfortunately, one of the ways that Freedman is sorely mistaken is that many physicians have already succumbed to the “what’s the harm” view of alternative practices even if they believe them not to work. I used to be one of them. The rationale is quite simply that if some patients appear to benefit and there is no downside then why not go along with it. Freedman seems to think that folks like Gertz are somehow revolutionary but I think they’re much more the mainstream. They just don’t make money off of it like Gertz seems to. If Gertz gets a fraction of what the woo peddlers he supervises earn he’s essentially raking in cash without having to do any work.

    When asked about alternative therapies I would say, “it seems to work for some people. You might want to give it a try.” It wasn’t until an erudite patient started asking me some specific scientific questions that I started to realize the absurdity of these therapies and started to feel guilty for recommending something that I had not investigated simply because my assumption was these treatments were harmless. Assuming harmlessness until proven otherwise goes against the non nocere principle in medicine. Initially I found it hard to believe that I could ever have allowed myself to practice such sloppy medicine.

    When you have patients that you are having difficulty treating (especially pain, anxiety, and other subjective symptoms) it can be frustrating to not have another therapy up your sleeve. I think that’s one reason why physicians are mostly passive (at best) or supportive (at worst) of alternative therapies. It hard to say, “There’s nothing more I can do” to a patient.

    Ultimately part of the problem lies with patients and their expectations as well. I think physicians can do a better job of managing expectations but patients often do not like to hear the truth. No one wants to hear that they’ll need to take pills for the rest of their lives. No one wants to hear that while the pain can be managed it’s unlikely to be ‘cured.’ Unfortunately that’s what I need to tell them (though not always so bluntly) if that’s what the evidence shows.

    If I tell someone they should lose weight to help with their joint pain and an acupuncturist says they can deal with it by sticking needles into their foot which is the more compelling to a patient with chronic pain? My wife is suffering from some pregnancy-associated nausea and is thinking of seeing an acupuncturist. We have discussed at length why I am opposed to this but ultimately her answer is, “instead of thinking of it as acupuncture to treat nausea think of it as acupuncture so that I can hope that something will make it better.” I think that’s crazy but I know she’s far from alone and I can’t bring myself to lying to her and giving her a placebo pill as an alternative.

    This will be a tough battle to fight. I think cervantes is right that there needs to be more recognition of these sorts of limitations in medicine and the healthcare community needs to adjust appropriately. I’ll continue to push my colleagues but I often feel I’m on the losing side of this conflict. I hope I go down in flames.

  43. windriven says:

    @SloFox

    “When you have patients that you are having difficulty treating (especially pain, anxiety, and other subjective symptoms) it can be frustrating to not have another therapy up your sleeve.”

    It is here that I wonder if science based medicine can steal a march on quacks by prescribing non-traditional therapies that address underlying problems without resorting to woo. Specifically I’m thinking about massage or PT instead of chiropractic, social workers or psychiatric nurses for patients with strong craving for continuing personal attention; whatever creative therapies are appropriate and have at least a modicum of scientific plausibility that would continue to be available as palliatives when hard therapies have reached their limits.

    Is it fair to think that your wife’s statement:
    “instead of thinking of it as acupuncture to treat nausea think of it as acupuncture so that I can hope that something will make it better.”

    could be restated as:

    “medicine may have given up on solving my nausea but my nausea is debilitating so I can’t give up on it and right now acupuncture seems like the only game in town.”

    I’m just wondering if physicians can offer more potentially constructive alternatives to people like your wife without descending into the pits of woo.

  44. SloFox says:

    @windriven

    I’m with you on both counts. I fear it will remain difficult to compete with folks that aren’t bound by the constraints that the truth imposes. False hope always seems easier to sell than real hope. I don’t want to be overly negative, however. I think there are definitely ways in which the current state can be improved. I’m just skeptical that it can ever compete head-to-head with fraud. I do agree that if we can find ways of doing a better job up front we can certainly decrease some of the demand for woo.

  45. daijiyobu says:

    I’m wondering this:

    is Freedman’s article an example of a generalist wading into an area that is better served by a journalist with expertise in medicine, science, absurd claims / skepticism and such?

    In other words, is it an accidental, yet crafty, piece of slanted / biased / unbalanced proponentry simply due to unfamiliarity coupled with an enthusiasm that ‘doesn’t even know’?

    Perhaps there will be a capstone piece he’ll do after the stacked deck submits that will indicate, and what is included will be as important as what’s excluded.

    -r.c.

  46. nybgrus says:

    @slofox: keep fighting the good fight. I am just in my second year of med school and I see it amongst my colleagues already. I would almost certainly have been one of those – one of my degrees is in anthropology and I was vehemently taught (and bought into) the “evil western reductionist” model and for a long time preached that medicine was a culturally based system and that things like Ayurveda and TCM were equally as valid as American biomedicine when taken in cultural context.

    I met some good scientist friends and ultimately was turned onto this blog from them. Over time, through reading here and my own experiences and understanding I realized that most of what I was taught in my anthro degree was total garbage.

    But hey, you are living proof that it is never to late to stop being a shruggie, and I am proof that even when actively taught garbage and woo science can win out if you work at being intellectually honest. All we can do is keep reading, learning, and doing our best to hold our colleagues to the same standard.

  47. daijiyobu says:

    @nybgrus re: “all we can do is keep reading, learning, and doing our best”,

    excellent advice.

    And this is from someone who was snookered by the naturopath branch of sCAM into one of their 4-year doctorates,

    wherein sectarian medicine is falsely labeled “science” .

    I too “am proof that even when actively taught garbage and woo, science can win out if you work at being intellectually honest.”

    I stopped the ND doctorate, but never stopped thinking about it all.

    And then I also decided to whistleblow.

    -r.c.

  48. nybgrus says:

    @ daijiyobu: Then congratulations to you as well! Success stories like yours, which I think are much more profound than mine, hearten me in my endeavors. Thank you for sharing, and thank you for the compliment.

  49. SloFox says:

    @daijiyobu & nybgrus

    I think there’s something to be said for maintaining integrity. It’s hard to do and it’s all too easy to find yourself compromising your integrity without even knowing it. My purely personal, non-scientific belief living the examined life. . . the good life. . . means, possible above else, having integrity. It’s never too early and never too late to get some.

    Most people have at least a shred of it and I think it’s worth appealing to it in discussing what the basis of a good medical practice ought to be. It won’t work on charlatans like Weill or Geitz. They’re too savvy and slick. But ask your colleagues to really reflect on what’s going on with CAM and I think many will start to feel guilty. I’m not promising that people will change their practice but I’m fairly sure that most people with a conscience will start to second guess themselves if they view this as a question of integrity. Planting a seed of doubt, even if ephemoral, is still a victory for skepticism,

  50. daijiyobu says:

    @nybgrus: well, for me success was about walking away after realizing I’d been fleeced — and then living with huge debt. Yet, I did not fleece others in the manner I was to be trained in — so, yes, it was all about my integrity, or, in the words of an existentialist, since “being is doing” I did not become ‘of the slimy’.

    Presently, I train adults usually of low-income urban backgrounds in medical science and then they work for local physicians. I think I make a bigger difference towards the collective good than any sCAM proponent ever will. They’re usually just reaping the cream from the well-to-do.

    @ SBM all: up at The Atlantic, I asked Weil this regarding his contribution “Changing Times Call for Smarter Doctors”

    (see http://www.theatlantic.com/life/archive/2011/06/changing-times-call-for-smarter-doctors/240536/ ):

    “Dr. Weil, regarding ‘spiritual dimensions of human beings are [to be] included in diagnosis and treatment’ as ‘integrative medicine’ [IM], since the supernatural has so many versions already, different in so many different ways, WHICH metaphysics / figmentation-system should be employed and how? And then, if outcome measures were done well and it turned out that NO system had any advantage over any other — yet they are so different in so many different ways — and that nonsupernatural supporting systems were also equal to the supernatural ones in supportive outcome, would this rebuke the IM insistence — which I see all over, from TCM to homeopathy-naturopathy to reiki — that medicine be supernaturalized in order to truly have its patients be healthy? -r.c.”

    I don’t know if there will be an answer.

    Though the sCAM people never seem to admit so, they begin from VERY DIFFERENT assumptions regarding reality [ontology, metaphysics, epistemology].

    So, when Weil writes that the difference is “not a clash of medical philosophies but confusion over terminology”, my response is

    bullshit.

    Philosophy, to the extent that it is useful in determining reality particularly in a scientific sense, is what it is all about.

    sCAMsters wish to equate — and I hate to get philosophical in terms of terms but I have to — different epistemic types.

    Weil, like so many integrative cheerleaders, wants to equate articles of faith NOT IN EVIDENCE BY DEFINITION and basically supernatural FIGMENTATIONS

    with scientifically derived evidence and the knowledge that that yields.

    I’ve often though that ‘they want to return to the Middle Ages’, wherein warts were removed by rubbing a potato against it and then burying the potato under a rock.

    To quote the pediatric intensivist from the Frontline episode “The Vaccine Wars” from 2010,

    “we can do better than that.”

    IM is truly MEDIOCRITY.

    -r.c.

  51. Jann Bellamy says:

    ” . . . entitled The Triumph of New Age Medicine, complete with a picture of a doctor in a lab coat in the lotus position.”

    Let’s give credit where credit is due: to the unnamed Atlantic editor who wrote this headline and the art department for the illustration. While the article may try to present CAM as a legitimate option in medicine’s armamentarium, the headline tells the truth: it’s just a repackaging of the shopworn “New Age” movement of the 60′s and 70′s, itself a repackaging of earlier movements, such as Mesmerism, Christian Science, and Theosophy, which are themselves reinventions of still earlier movements. It’s like arranging two mirrors so that one appears to be looking at endless images of the same thing (usually oneself). If the Atlantic came with one of those musical greeting card features, no doubt “Aquarius” would start playing when opened to this article.

    It occurred to me that the headline and illustration were subversive editorial comments on the article itself — after all, neither the author nor those he interviewed use the term “new age.” Do I hear snickering in the back offices?

  52. David Gorski says:

    Do I hear snickering in the back offices?

    I’d love it if you were right. I fear the irony is lost on them.

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