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CAM and Evidenced-Based Medicine

Mark Tonelli, MD has problems with evidence-based medicine (EBM). He has published a few articles detailing his issues, and he makes some legitimate points. We at science-based medicine (SBM) have a few issues with the execution of EBM as well, so I am sympathetic to constructive criticism.

In an article titled: Integrating evidence into clinical practice: an alternative to evidence-based approaches. The abstract states:

Evidence-based medicine (EBM) has thus far failed to adequately account for the appropriate incorporation of other potential warrants for medical decision making into clinical practice. In particular, EBM has struggled with the value and integration of other kinds of medical knowledge, such as those derived from clinical experience or based on pathophysiologic rationale. The general priority given to empirical evidence derived from clinical research in all EBM approaches is not epistemically tenable. A casuistic alternative to EBM approaches recognizes that five distinct topics, 1) empirical evidence, 2) experiential evidence, 3) pathophysiologic rationale, 4) patient goals and values, and 5) system features are potentially relevant to any clinical decision. No single topic has a general priority over any other and the relative importance of a topic will depend upon the circumstances of the particular case. The skilled clinician must weigh these potentially conflicting evidentiary and non-evidentiary warrants for action, employing both practical and theoretical reasoning, in order to arrive at the best choice for an individual patient.

I certainly agree that clinical evidence (what he he referring to by “empirical” evidence above) is not, and should not be, the sole type of knowledge that is incorporated into clinical decision-making. However, I think this criticism is a bit of a straw man, at least with regard to items 2, 4, and 5. The goals and values of the patient are definitely part of clinical decision-making, even in a rigorously evidence-based practice. We are, after all, treating people, not diseases. When I was in medical school this was called the biopsychosocial model of medicine. Now it is also not uncommon for quality of life measures and overall satisfaction to be incorporated as outcome measures in clinical trials, blurring the lines between empiricism and personal goals and values.

So while I agree that patient values and goals absolutely need to be taken into consideration when practicing medicine, I don’t see this as a new idea or one that is at odds with EBM, nor entirely distinct from empiricism. By including this as he does, however, there is the implication that EBM excludes such considerations, and I do not believe that is fair.

Where we likely mostly agree is on number 3 – pathophysiological rationale. I could expand this to include all of basic science – medical practices should be plausible. I also think he has a legitimate point in that EBM gives too much emphasis to clinical science and shortchanges basic science. But it is interesting to note that the EBM grading system for recommendations do allow for extrapolation (i.e grade B=.consistent level 2 or 3 studies or extrapolations from level 1 studies). Extrapolation involves considering pathophysiology and mechanism of action. While extrapolation (rather than direct evidence) downgrades the recommendation by one category (which is appropriate) it does not exclude it altogether.

Further, I think the real problem with failing to consider pathophysiology is not for support of a plausible treatment, but to be extra cautious about an implausible treatment. When the basic science dictates that a proposed treatment is highly implausible, the bar for clinical evidence should be raised proportionately.  I don’t think this is what Tonelli had in mind, however, as we will see.

Item #2- Experiential evidence, is highly problematic. While experience is great for some things, like recognizing diagnoses, being sensitive to the subtleties of history taking, and interfacing with patients – it is highly misleading when it comes to determining safety and efficacy. The simple fact is that personal experience is too limited, quirky, and uncontrolled, and is overwhelmingly likely to simply confirm our biases than actually lead us in the direction of truth.

In another related article (actually published in 2001, earlier than the 2006 paper above), Tonelli clarifies:

Empirical evidence, when it exists, is viewed as the “best” evidence on which to make a clinical decision, superseding clinical experience and physiologic rationale. But these latter forms of medical knowledge differ in kind, not degree, from empirical evidence and do not belong on a graded hierarchy.

He is partly correct here – these other forms of evidence are not necessarily below, but are tangential to, empirical evidence. But I think Tonelli is missing the context of EBM. EBM is not a method for solely determining clinical practice (clinical decision-making) but for determining safety and efficacy, which is one factor that informs practice. Values, the system, and the human side of medicine also go into clinical practice, but they should not be used to determine efficacy. So it seems his criticism is based upon a straw man constructed of his own confusion.

I might have been inclined to give Tonelli some benefit of the doubt, were it not for this:

The methods for obtaining knowledge in a healing art must be coherent with that art’s underlying understanding and theory of illness. Thus, the method of EBM and the knowledge gained from population-based studies may not be the best way to assess certain CAM practices, which view illness and healing within the context of a particular individual only. In addition, many alternative approaches center on the notion of non-measurable but perceptible aspects of illness and health (e.g., Qi) that preclude study within the current framework of controlled clinical trials. Still, the methods of developing knowledge within CAM currently have limitations and are subject to bias and varied interpretation. CAM must develop and defend a rational and coherent method for assessing causality and efficacy, though not necessarily one based on the results of controlled clinical trials. Orthodox medicine should consider abandoning demands that CAM become evidence-based, at least as “evidence” is currently narrowly defined, but insist instead upon a more complete and coherent description and defense of the alternative epistemic methods and tools of these disciplines.

This casts a new light on all of Tonelli’s other publications. It seems he is making an elaborate argument for the inclusion of other kinds of evidence (other than rigorous, controlled, clinical studies) as support for fanciful but ideologically appealing treatments.

This is a refrain that is becoming common in the CAM community -  that we need to redefine “evidence”, not restrict ourselves to narrow definitions of evidence, and that CAM modalities cannot be properly studied by traditional scientific methods. There is always a flavor that CAM must free itself from the tyranny of scientific evidence.

What is it, exactly, about scientific methods that they feel is incompatible with CAM methods – being thorough, counting all the data, controlling for variables, minimizing the effects of bias, carefully defining terms and outcomes, or being statistically rigorous?  Even individualized treatments can be studied rigorously – so that is an insufficient excuse. In the end, the call to expand the definition of evidence is just a deceptive way of asking for sloppy methods of research, because CAM modalities generally do not hold up under rigorous standards.

We don’t need to redefine or expand the methods of science – we need to return common sense to medicine.

Posted in: Science and Medicine

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80 thoughts on “CAM and Evidenced-Based Medicine

  1. windriven says:

    Dr. Novella, it is plain that Dr. Torelli has it right. Look at the huge list of diseases and maladies that CAM has cured and “orthodox” medicine hasn’t:
    1.
    2.
    3.
    4.
    5.
    6.
    7.
    8.
    I could go on but for the constraints of space and time.

    ***

    I think Dr. Torelli should outfit himself with a dictionary. Casuistic does not mean what he apparently believes it to mean.

  2. Scott says:

    The killer sentence for me was

    many alternative approaches center on the notion of non-measurable but perceptible aspects of illness and health

    Which is a dead giveaway of someone who either doesn’t have a clue how science works, or is declining (deliberately or not) to actually apply that knowledge.

    If it is perceptible, it is measurable. The measurement may have varying precision depending, but ANY perception can be used as a measurement. The ONLY way to avoid the effects being measurable is to assert that the patient can’t tell whether they feel better. Which implicitly means that there is no meaningful effect.

    That’s right – anytime a quack (and Tonelli is clearly either a quack or a supporter of quacks) makes a claim like this, they are actually admitting that their woo does nothing.

  3. Scott beat me to it. What on earth is “perceptible but not measurable” supposed to mean? Does he elaborate on it anywhere?

  4. Jan Willem Nienhuys says:

    certain CAM practices, which view illness and healing within the context of a particular individual only

    This is what Tonelli parrots from CAM practitioners. But is is not what they do. I will give the example of homeopathy.

    A patient comes to the homeopath. The homeopath spends an hour with the patient asking all kinds of details. The American homeopath Kent gives examples of the questions that are asked:

    How do you feel befoire, during and after a thunderstorm? What position do like or not like (i.e. standing, sitting, lying down)? Can you stand warm baths? How do feel at the sea side / in high mountains? What time do you wake up? what side doe you sleep on? Are you afraid of burglars? And so on. There are also many questions about the illness itself. Does it become worse or better in the morning, the afternoon, the evening, befor or after eating?

    Then the homeopath takes a thick book in which a summary is listed of symptoms of different substances such as sand, chalk from oyster shells, mercury chloride, arsenic, ground up bees, Spanish fly, various poisonous and not so poisonous plants, vegetable and animal coal, table salt, elemental sulfur, and maybe even ‘north magnetism’. These symptoms are either derived from case reports of poisoning or from giving ‘healthy’ people the stuff in a 1 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 000 -fold dilution, usually telling then what it is and what to expect, and then writing down all remarkable things that happen afterwards. So one finds ‘romantic feelings in the moonlight’ listed, and ‘itch on the right hand’, sometimes many days after the substance is taken. Of course ‘death and all limbs of the corpse where luminescent’ as a consequence of taking ‘phosphorus’ is probably not caused by one zillionth of a dram of the stuff. The book contains a thousand remedies, and some remedies have over a thousand of the ‘symptoms’. Highly diluted table salt has 1349 ‘symptoms’, but petroleum has 776 symptoms (nr. 775 is ‘profuse night sweat after 6 days’).

    On the basis of the entire story of the patient the homeopath tries to find one remedy that has symptoms that resemble those of the patient. So the patient is reduced to a set of ‘symptoms’ most of them quite irrelevant. The basic tenet of homeopathy is that disease is some kind of mysterious disturbance of the life force ofd which we only know the ‘symptoms’ (in homeopathy symptoms are also the general constitution of the patient such as being a blond woman who cries easily, likes fresh air and prefers tepid drinks – give her pulsatilla whatever her complaints). Curing means: make the symptoms go away. In some cases the symptoms in these books are symptoms that went away after giving a sick person a remedy.

    After chosing a remedy the homeopath thinks up a dilution (no relation with the dilution that was used to obtain the symptoms in the book).

    If this doen’t work after two weeks, the process is repeated to get another simillimum.

    Alternatively the homeopath may try to arrive at an ordinary medical diagnosis, say ‘premenstrual syndrome’ and prescribe an OTC homeopathic preparation composed of a alcohol and water (i.e. a mixture of several highly diluted remedies).

    So summarizing, in the homeopath’s office the patients is merely a bunch of irrelevent symptoms. It is a lie that illness is seen in the context of the patient. On the contrary, his or her symptoms are seen in the context of a mishmash of unrelated 19th century nocebo symptoms.

  5. windriven says:

    @Jan Willem Nienhuys

    “prescribe an OTC homeopathic preparation composed of a alcohol and water”

    I have found an OTC preparation (though not homeopathic) of alcohol and water to have quite salutary effects ;-)

  6. Steve says:

    “Orthodox medicine should consider abandoning demands that CAM become evidence-based, at least as “evidence” is currently narrowly defined, but insist instead upon a more complete and coherent description and defense of the alternative epistemic methods and tools of these disciplines.
    In other words lower the bar so less effective strategies waste our resources.
    Yea thats what we should do.
    My favorite part of this type of thinking is the “Mulligan” attitude related to CAM. I know all the evidence says it does not work but we should really, really, check to make sure that it totally doesn’t work. Finite resources people. You can dig for gold in your back yard and maybe find it but it is lot more profitable to actually use evidence to narrow the search.

  7. Alison Cummins

    “Scott beat me to it. What on earth is “perceptible but not measurable” supposed to mean? Does he elaborate on it anywhere?”

    I was assuming he meant subjective, meaning, people perceive a difference but the differences reported may vary erratically so that the results can’t be measure or that they are too hard to controll for…maybe that’s not right though. Sounds strange when I say it.

  8. SN “that we need to redefine “evidence”, not restrict ourselves to narrow definitions of evidence, and that CAM modalities cannot be properly studied by traditional scientific methods.”

    Well many things can’t really be properly studied by traditional scientific methods. Art, Poetry, Music…

    But then I haven’t meet any artists, poet or musicians that think science should revise their “narrow definitions of evidence” to provide evidence that their art, poetry or music is good.

    So here it is loud and clear for the CAM folks, ‘You don’t get to be an artist (Healing or otherwise) AND claim that the quality of your work is supported by evidence’. End of story, they can join the rest of us wishy washy, “I know it when I see it and I’ll buy it if it looks good over my sofa” professionals who services are NOT covered by health insurance.

    Does that make sense, probably not. Coffee shortage.

  9. Mark Crislip says:

    “N-rays center on the notion of non-measurable but perceptible aspects of radiation…Orthodox physics should consider abandoning demands that N-rays become evidence-based, at least as “evidence” is currently narrowly defined, but insist instead upon a more complete and coherent description and defense of the alternative epistemic methods and tools of these disciplines.” ~ Prosper-René Blondlot

    It’s N-rays all the way down.

  10. Joe says:

    @micheleinmichigan on 23 Mar 2011 at 10:53 am. Tonelli may just be elaborating a word salad; but I think you may be right in your interpretation of “perceptible but not measurable” meaning subjective. Pain is one of those things that can’t be measured; but it can be reported by the patient on a scale of 1-10. Those numbers may vary quite a bit- if the pain could be measured one might find that two people with the ‘same’ pain report it as 7 and 5 respectively. However, with 2,000 people in a study one hopes to cancel that variability and find significant differences (or not).

  11. “CAM must develop and defend a rational and coherent method for assessing causality and efficacy, though not necessarily one based on the results of controlled clinical trials.”

    CAM should first develop and defend rational and coherent models for the plausibility of the various “CAM” practices.

    Let’s establish the plausibility of the tooth fairly before we devise ways to determine how effective she is.

    Let’s also not work backwards from the assumption that the tooth fairy is real and effective, and cherry pick ways to support that position.

    When I was in high school, the way we wrote “research” papers was to establish a position, then find support for that position rather than do the research and see to what conclusion the facts lead us.

    The high school research paper method of studying tooth fairy science is neither research nor science.

  12. Although, to be honest, “perceptible but not measurable” is a lovely phrase. I think I’ll steal it for my work.

  13. tmac57 says:

    @Jan Willem Nienhuys- That whole scenario sounded like it could have been from a witchcraft handbook.

  14. Scott says:

    I was assuming he meant subjective, meaning, people perceive a difference but the differences reported may vary erratically so that the results can’t be measure or that they are too hard to controll for…maybe that’s not right though. Sounds strange when I say it.

    Subjectivity isn’t a problem for measurement. The 10-point scale Joe mentions IS a measurement. A measurement subject to some systematic uncertainties, but a measurement nonetheless.

    Either he’s just wrong, or he’s deliberately claiming “can’t be measured” expressly to avoid scrutiny while knowing it’s false.

  15. # Scotton 23 Mar 2011 at 11:43 am

    I was assuming he meant subjective, meaning, people perceive a difference but the differences reported may vary erratically so that the results can’t be measure or that they are too hard to controll for…maybe that’s not right though. Sounds strange when I say it.

    Subjectivity isn’t a problem for measurement. The 10-point scale Joe mentions IS a measurement. A measurement subject to some systematic uncertainties, but a measurement nonetheless.

    Just for the sake of argument, so I can understand this better. I think pain is too easy to measure when it comes to subjectivity. Let’s use, the funniness Mark Chrislip.

    Hypothetically*, get everyone’s ratings here on SBM (1-10), then pop over to AoA and get their ratings. Then pop over too, I don’t know, some automotive blog and get their ratings. You’ll end up with a measurement, but I suspect the results will be kinda meaningless…so skewed by the participants frame of reference and expectations that you will never really be able to measure how funny Mark Chrislip is (although you may suspect the answer is, very funny.)

    so kinda perceptible, but kinda immeasurable.

    *Don’t really rate MC, that would probably be rude.

  16. typo – the funniness OF Mark Chrislip, makes more sense.

  17. Zetetic says:

    Dr Tonelli is from the University of Washington Medical Center and they are very much in bed with Bastyr University. Bastyr self proclaims themselves as “…internationally recognized as a pioneer in natural medicine” on their web site.

  18. If he is just talking about subjective symptoms, then again – already done. Many studies attempt to quantify things that cannot me measured – pain just being the easiest example.

    What CAM proponents want is to be able to claim that an effect exists, but cannot be measured. This is the same as saying that ghosts exist, and you can see them, but they don’t show up on film.

    It’s special pleading to explain away evidence for lack of efficacy. It’s BS.

  19. “This is the same as saying that ghosts exist, and you can see them, but they don’t show up on film. ”

    Actually, it’s closer to saying that ghosts exist, I can see them, but you can’t (or they don’t show up when you’re around), and they don’t show up on film, but any artifacts (if any) that happen to occur in a photo I take are the effects of ghosts.

    ANY evidence in support is supposedly persuasive, and ANY evidence against (or any lack of evidence for) is invalid. Heads I win, tails you loose. The deck is already stacked, and Tonelli is looking for a better and more compelling way of stacking the deck in the future.

  20. rork says:

    The many other commentaries on that Tonelli article in the same issue are more serious, and I could use help trying to understand what they are really saying in some cases, and what folks I trust better think. The overview by Miles, Polychronis, and Grey for example, left me head scratching a bit. That other evidence besides empirical (think trials) is “different in kind” seems to license them to mix evidence from various sources any way they want – they don’t clearly say what they want. They blame EBM for failing to know how to combine this information, but they didn’t seem to have any model themselves. Doesn’t the logic of each individual doctor for each patient thereby become unquestionable? None of the discussion seemed to use much of decision theory language, but rather seems to think it’s all philosophy, and use a language that makes it very hard for me to follow (Doctors, sheesh).
    I was tending toward the radicals (so detested by Miles and crew) who think you do only what empirical evidence supports, otherwise it is research on human subjects and should be conducted as such. Maybe I can soften a bit, but I’m not sure how to do so safely.
    Just to be sure it is clear, I am as appalled by the last Tonelli quote as the rest of you.

  21. S.C. former shruggie says:

    Alison Cummins @3

    Scott beat me to it. What on earth is “perceptible but not measurable” supposed to mean?

    I think I know what it means. It’s like those times when I was a kid, and I’d done my homework, but I can’t find it and I’m not turning it in.

    In wikipedia, it’s called “I’ve totally got evidence.” [citation needed.]

  22. Scott says:

    @ michelle:

    Depends what you want to use the measurement for. Comparing the relative merit of the writers? Probably not. Tracking trends for each over time? Sure, no problem.

    All measurements have uncertainties. These uncertainties are of different sizes and natures for different measurements. It’s key to understand the uncertainties in the measurements one is using for a particular purpose, but that in no way renders them non-measurable.

  23. daijiyobu says:

    Re Tonelli’s “many alternative approaches center on the notion of non-measurable but perceptible aspects of illness and health.”

    Not measurable but perceptible, in other contexts, might be called delusions or knowledge on the order of revelation / figmentation.

    I appreciate the unintended humor. Reminds me of the movie Mystery Men, where all the characters had forth-rate superpowers, particularly the Invisible Boy, ‘who can become invisible, but only when no one, including himself, is looking’.

    -r.c.

  24. Heh. Yeah, I remember finding this guy’s stuff about 10 years ago when I was first looking to see if anyone other than Wally Sampson was writing about the objections to EBM that we’ve explained here. At first glance, it looked like he might have something, but after a blink it was clear that he was just making rationalizations for BS.

  25. pmoran says:

    If there is a problem with EBM, it is not solved by weakening the evidence base. A better argument might go like this –.

    The EBM/SBM stance in relation to CAM is based upon the assumption that we can establish a clear hierarchy of treatment usefulness via quality RCTs (randomised controlled trials), with inert treatments serving as a (presumed) baseline for ineffectiveness.

    Yet this is a bit like Newtonian physics — valid much of the time, but fully descriptive of only one subset of medical reality. It may be inclusive of the most important aspects of medicine, where life and limb are at stake and where the guiding logic is unchallengeable, yet it excludes many common medical problems.

    Medicine assumes its “relativistic mode” when the therapeutic questions are to do with subjective symptoms, vague illness and ubiquitous psychosomatic complaints, where it seems there can be a dissociation between clinical outcomes and the intrinsic activity of any treatment methods adopted. The practitioner’s soothing, reassuring voice can be the main determinant of outcomes.

    It is within that zone that CAM has some claim to legitimacy, so long as it is not making unsupportable therapeutic claims. Both zones are entirely compatible with current scientific knowledge.

  26. @Scott “A measurement subject to some systematic uncertainties, but a measurement nonetheless.”

    as well as Steven Novella regarding subjectivity -

    Okay, yes, I see what you both mean now. I re-read the quote and must have missed the “eg Qi” reference the first time around. That definitely sounds more like your readings than my “subjective” take.

    Call me an idiot though, but I don’t see how Qi is perceptible.

  27. pmoran “Medicine assumes its “relativistic mode” when the therapeutic questions are to do with subjective symptoms, vague illness and ubiquitous psychosomatic complaints, where it seems there can be a dissociation between clinical outcomes and the intrinsic activity of any treatment methods adopted. The practitioner’s soothing, reassuring voice can be the main determinant of outcomes. ”

    Sorry to jump on you pmoran, but this one got to me.

    If SBM does not currently have a good answer for people with psychosomatic complaints and vague illness (oh, I can relate to that, I had one of those “vague illnesses for years), Maybe SBM should seek to find better answers, not just foist off those unfortunate patients on “sympathetic” CAM practitioners who are either shysters or don’t have an accurate handle on how their therapy is working.

    Your statement just sounds a little too much like “Look, they don’t have a “real” illness, so they don’t need a “real” treatment.

    It’s seems to me that they do need a real treatment. One that can help them overcome their real disease, not just become dependent upon some sympathetic acupuncturist.

    Maybe that real therapy could start with not letting the folks with vague illnesses fall through the diagnostic cracks or maybe the therapy is SSRIs, or CBT or DBT or maybe we need more research for something better.

    But, providing a placebo that is basically enabling either sloppy medical care or a dysfunctional psychiatric process seems like a cope out to me.

  28. Scott says:

    Qi itself might not be considered perceptible (though normally the practitioners do claim they can perceive it), but its effects must be, or there’s nothing to discuss. If it has no perceptible effects, that necessarily includes that it doesn’t do anything useful for the subject.

  29. pmoran says:

    Michelle: “ Maybe SBM should seek to find better answers, not just foist off those unfortunate patients on “sympathetic” CAM practitioners who are either shysters or don’t have an accurate handle on how their therapy is working.

    Unquestionably. Yet CAM is in this respect holding up a mirror to the mainstream, one which reveals how well current mainstream medical practice serves such patients. Some medical systems make it very difficult for patients to change doctors when dissatisfied.,

    Remember, too, that CAM doesn’t only apply to those with “vague illnesses and psychosomatic states”. We don’t have good answers for a lot of defined pathological states. Those patients also deserve any small additional relief of symptoms or sense of well-being.

    So the question is whether it is a good thing that dissatisfied patients are able to resort to CAM or an unequivocally bad thing. Or, perhaps more realistically, something that we can force ourselves to tolerate because it could be, on balance, in the best interests of some of our public and there is no clear basis upon which we can assert hegemony over areas of medicine thatwe are not very good at (not to imply that CAM is better in any major respect.). .

    And one highly annoying facet to this is that there is no theoretical reason why shysters and crackpots cannot help some of their clients. They usually have adoring clients telling us just that, and we cannot with any scientific certainty say otherwise. All we can say is that their signature methods almost certainly don’t “work” in the manner claimed.

  30. nybgrus says:

    “Homeopathy is a symptom of the failings of modern medicine”

    Ergo, fix the failings.

    “And one highly annoying facet to this is that there is no theoretical reason why shysters and crackpots cannot help some of their clients. They usually have adoring clients telling us just that, and we cannot with any scientific certainty say otherwise. All we can say is that their signature methods almost certainly don’t “work” in the manner claimed.”

    And indeed, “there is no theoretical reason why” my highly abusive father who used to beat me with metal coat hangers till I bled and punch me in the face could not help me learn some useful and positive life lessons. And in fact, he did. Some of my work ethic, my reverence for science and knowledge, and my avid reading stem directly from him. In fact, he was a physician, and I am sure he is responsible for planting the seed that got me to medical school right now. He has (and does) claim that his methods achieved the intended goals – I am (reasonably) well adjusted, quite successful in my endeavours and have a loving and wonderful girlfriend. I cannot say “with any scientific certainty otherwise.” Yet, I’m not about to raise my (future) children that way. Nor would I recommend that just because there are some “adoring” children of such families that we all adopt such an “alternative” method of child-rearing. Even though, quite frankly, the reason why I am so quick thinking on my feet and my brain is so chock full of esoteria is because if my father ever called upon me for something I had to think fast and spout off fact or get beaten. That is certainly something that the vast majority of my classmates growing up and even to this day are inferior in. I could argue quite eloquently (a la ‘A Modest Proposal’ – Jonathan Swift) for establishing a “tolerance” for such parenting on the basis that “it could be, on balance, in the best interests of some of our public and there is no clear basis upon which we can assert hegemony over areas of [parenting] that we are not very good at” as evidenced by the amazingly poor performance of Americans in essentially all fields of education. Yes, it is a “highly annoying” fact that pretty much nothing is entirely black and white and that even the worst situations and practices can (and do) have some benefits.

    And yes, that is a true story, and yes, I am a bit tired of pmoran’s assertions of leaving those scant good bits to the sCAMsters.

  31. daedalus2u says:

    Nybgrus, if you have PTSD (how could you not with that story), I have something that will help.

  32. nybgrus says:

    daedalus: Thank you for the kindness, but indeed, I do not suffer any ill effects currently. I have no flashbacks, no nightmares, etc. In my undergrad years I went to a very effective (for me) counselor for a period of a bit over a year and over time. There are still some remnants of my old bad habits and I do occasionally suffer from some self-esteem issues and will often find myself seeking approval for doing good things from others. However, I recognize these things and manage to work with them and keep them minimized.

    The true point of my story was to illustrate a very poignant example to pmoran as to the fallacy of his argument, as I see it. Continually citing these bits and pieces of CAM that are good and have demonstrably positive (however small or large) effects is entirely missing the point and putting the focus for correction in the wrong place. I managed to grow up and become a productive well-adjusted member of society. My father’s way of teaching me has lead to me thinking faster and knowing more random bist of knowledge that most people I meet. But there are many more people who were in my situation that did not have such a positive outcome. Just as there are many people for whom those scant postitve effects do not outweigh the negatives (financial or health-wise). Focusing on the subset of people who get positive results (which is itself a subset of the population seeking medical care) simply misses the point entirely.

  33. nybgrus says:

    *a bit over a year of time*

  34. tanha says:

    Who is Mark Tonelli, MD and why is HE being quoted?

  35. pmoran says:

    Nybgrus: “Continually citing these bits and pieces of CAM that are good and have demonstrably positive (however small or large) effects is entirely missing the point and putting the focus for correction in the wrong place.

    I agree that CAM would die back into an irreducible grumbling undercurrent of folk medicine and kookery, once the mainstream came up with entirely effective and safe solutions for all medical needs — if that is what you mean.

    It is not decrying the effort put into achieving that to point out that is not going to happen in our lifetimes and possibly not even in the next millennium.

    Recent experiences with Vioxx and HRT demonstrate how most of the time we are straining for small advances that are dangerously close to the potential for ill-effects that just about any active medical agent possesses. We are also left with the more difficult challenges.

    Also, nothing I have said precludes opposition to dangerous or abusive practices (even to animals).

  36. pmoran,

    We do tolerate both CAM and “alternative” forms of parenting. We do. So there’s no point in arguing that maybe we should consider tolerating them. Making that argument is a little like saying that maybe we as a society should consider forcing ourselves to tolerate refined sugar.

    Presumably when you propose that we “force ourselves to tolerate” CAM you don’t mean that at all. What you really mean is “teach CAM in medical school and define acupuncture as a medical treatment performed by doctors.” If that’s what you mean, then please say so.

    I think that generally, complex human societies are wonderful at tolerating a wide range of practices, including child abuse, folk remedies and empty calories. We try to intervene to limit the worst of the damage, but that’s it.

  37. nybgrus,

    I’m so sorry. Thanks for sharing.

  38. daedalus2u says:

    nybgrus not to be preachy or anything, you seem to have a pretty good handle on your trauma issues, better than I did. But before you have children of your own, you should consider spending considerable time with children the age you were when you were abused. There is something about one’s own children that brings stuff out.

  39. LMAO says:

    non-measurable but perceptible aspects of illness and health (e.g., Qi) that preclude study within the current framework of controlled clinical trials

    HHHhhhmmm… reminds me a bit of the invisible, incorporeal, floating dragon who spits heatless fire that was living in Carl Sagan’s garage… :D

  40. pmoran “And one highly annoying facet to this is that there is no theoretical reason why shysters and crackpots cannot help some of their clients. They usually have adoring clients telling us just that, and we cannot with any scientific certainty say otherwise. All we can say is that their signature methods almost certainly don’t “work” in the manner claimed.”

    Okay, you’re the doctor. Let people chose CAM, if they like their shyster crackpot doctor.

    Do you propose any consumer protections? Or are Nauropaths and Chiropractors prescribing oxycontin and radiation treatments, cool?

    Who do you propose pay for the CAM treatments, patient, private insurance, public insurance?

    If insurance pays, what are the criteria for payment, since we can’t have scientific evidence of efficiency, then what?

    If payment is proposed, then how much do you think premiums will rise?

    Or do you see ways that we could cut back on healthcare to make room for CAM payment?

    Will the government pay for my retail therapy…, cause there’s a pair of Betsey Johnson earrings that I’m sure will give me the confidence to overcome my social anxiety. New earrings are so much easier than CBT and more natural than Paxil.

    It’s easy to say “Those patients also deserve any small additional relief of symptoms or sense of well-being.” But the devil is in the details. I want details.

  41. nybgrus – That su@ks and I’m sorry your dad is an a&*hole.

    I admire your openness. I think you make a good point. Even the worst harms can have some benefit to the victim. But we don’t just accept those harms. We try to protect people from victimization and seek ethical, constructive ways to offer benefits.

  42. pmoran says:

    Michele:”Do you propose any consumer protections? Or are Nauropaths and Chiropractors prescribing oxycontin and radiation treatments, cool?

    Of course. I am entirely against these being regarded as PCPs (primary care providers). Well-trained doctors can make more than enough mistakes, and it seems dangerous to introduce lower standards.

    Having said that, as America has found, great deal of everyday medical care can be carried on by paramedical personnel if under the supervision of a doctor. This is one way of reducing medical costs while expensive PCP skills are directed where they are most useful. A sensible CAM practitioner (one who knows his limitations) could certainly perform the same function.

    One of the features of my approach is that it focuses ruthlessly on the limitations of CAM. It says to CAM practitioners “we know what you can do and what you can’t do”. It might also help delineate standards by which the law courts and Reigstration boards can judge reasonable behaviour by CAM practitioners.

    Who do you propose pay for the CAM treatments, patient, private insurance, public insurance?

    If insurance pays, what are the criteria for payment, since we can’t have scientific evidence of efficiency, then what?

    If payment is proposed, then how much do you think premiums will rise?

    The patient should pay, the reason being that in any communally funded health care system there will always be better ways to spending the money. The point you make about where to draw the line is also valid.

    But I am not claiming to have any fully-fledged policy on CAM. I just think that we have often approached the problem CAM clumsily and sometimes unscientifically. (Note the “we”, those who are easily offended.)

  43. nybgrus says:

    Alison, daedalus, michele: A sincere thanks for your kind words. It was tough growing up with my father was tough. My sister had a hard time of it as well. Don’t misunderstand though – he was not like those caricatures of an abusive father who is just a drunk loser that beats on his wife and kids all the time (though he did occasionally do exactly that). Often it was his form of punishment for times when we actually did do something wrong – it was just excessive and gratiuitous. Also, it was reserved for whenever he felt we had “failed” in some way. If we got a B instead of an A in a class, for example. Or if I couldn’t remember all the details of what he had taught me the day or week before (he started teaching me Einsteinian relativity when I was in the 3rd grade, my summer’s between years were spent doing science projects and math, etc). This is why I say his methodology was very effective – I was literally deathly afraid of getting something wrong. By the end of 3rd grade I had all my times tables memorized, could do 4 number long division in my head, could explain relativity to you, knew how an internal combustion engine worked, and according to my standardized tests read at a 12th grade level and my math skills were at a college level (I knew exponents). By the 6th grade I was taking night classes at the local community college and getting all A’s and B’s (physics, biology, mathematics, etc). My motivation was to placate my father. That is why I say, that in a sense, his methodology worked extremely well.

    That is why, however, I have managed to get over it. My family (mother and sister) managed to remain strong and successful after finally leaving my father when I was 17. I honestly harbor no ill will or residual anger. I recognize it for what it was, and understand that he really didnt have a choice in the matter – he grew up in Soviet Russia and his mother was even more abusive. That doesn’t excuse it, of course, and since he will not admit he has done anything untoward I haven’t spoken to him in almost 11 years. When my girlfriend found out all these things she was absolutely shocked that I was so well adjusted and kind hearted.

    Daedalus – the abuse from my father was from as young as I can remember till I last spoke with him when I was 17 so in regards to being around children that encompasses a wide range. However, my sister has two children, aged 7 & 3, and I love them dearly. I spend as much time as I can with them and have no problems reacting appropriately when they, inevitably, require some discipline. My sister as well – they have an extremely well adjusted family dynamic. I don’t think you are being preachy – it seems we are indeed the exception. Getting there, however, did take immense amounts of work and intentionally recognizing and correcting faults. Perhaps that also goes part-in-parcel with my scientific nature – I understand that failure is inevitable and that outlooks should change based on evidence. But steady progress can be made as long as you are dedicated and follow good evidence. It is the same with my personal life.

    As for pmoran: you seem to continually talk in circles. You claim that perhaps acupuncture (to use your own specific reference) should be administered by “proper doctors” but then have no idea where to draw the line. You don’t want sCAMsters to be PCPs and assert they should be reigned in via knowing their limitations but you seem to fail to understand that is exactly what they are bucking against. They are diligently working to legitimize their stance at every turn, claiming efficacy of their modalities, claiming special pleading for evidence, and fighting for licensure! And yes, being taught in medical schools, being part of “integrative medicine” gives legitimacy to CAM! They use this as well as argumentum ad populum to justify broadening their scope and privilege. And yes, we do admit ” what you [CAM} can do and what you can’t do” – there is no secret that we in the scientific and medical community openly recognize that there is a patient/practitioner interaction effect, a placebo effect, even perhaps some very small specific effects, and of course your non-specific comfort effect. And it is obvious we openly recognize what they can’t do – namely anything else. They are not content leaving it at that. Their claim, and vociferous it is, is that indeed they do much more than that. They rail constantly for recognition of that. The seek licensure to legitimately work side by side with physicians in the active treatment of cancer patients (naturapaths) as “different but equal.”

    Your arguments fail, Dr. Moran. And you are commenting as if you are telling us something we didn’t know or think of. But worse than that, after all your preaching and chiding us (and me) for our approach to CAM, and after all your claims about the “non-specific” role that CAM must indeed play in our society you finally admit:

    But I am not claiming to have any fully-fledged policy on CAM. I just think that we have often approached the problem CAM clumsily and sometimes unscientifically

    So essentially, all of your admonishments, comments, arguments, are essentially summed up as “I don’t know what to do about CAM but I’m going to armchair coach and say continually you are doing it wrong. But I have no useful advice on how to do it right.”

    And before you claim you do, I will ask you to think carefully and realize that every time you have come close to saying something concrete it has been pounced upon and dismembered by Alison and Michele long before even I or Gorski or Daedalus have a chance to.

    I agree that CAM would die back into an irreducible grumbling undercurrent of folk medicine and kookery, once the mainstream came up with entirely effective and safe solutions for all medical needs — if that is what you mean.

    So perfect medicine is the only way to get rid of them? I disagree. Better education and understanding by the population at large should pretty much suffice. And I (nor anyone here) has claimed that we believe it will ever actually go away entirely, especially in our lifetimes. But set that as the goal, and work towards it constantly to actually achieve something. You’ve been called out numerous times for what appears to be throwing up your hands and letting it continue. That is simply unacceptable to us here. If this is the best you can come up with, then that is fine. But don’t try and tell us we are doing things poorly without anything to back you up or alternative suggestions for improvement.

    In other words, put up or shut up.

  44. pmoran on the role of providers of baseless therapies in a health care system:

    “A great deal of everyday medical care can be carried on by paramedical personnel if under the supervision of a doctor. A sensible CAM practitioner (one who knows his limitations) could certainly perform the same function.”

    “The patient should pay, the reason being that in any communally funded health care system there will always be better ways to spending the money.”

    I’m getting more and more confused. If people who practice baseless therapies are paramedical personnel providing everyday medical care, why wouldn’t they be reimbursed?

    I don’t need a doctor to change a dressing, take my blood pressure, teach me how to manage my diabetes or show me exercises to help me get me back on my feet after an injury. The people who do this today are reimbursed by the public system. If an enlightened public system engages homeopaths and acupuncturists to provide these services, why wouldn’t they be reimbursed too?

    Or is that not what you mean by “everyday medical care provided by paramedical personnel under the supervision of a doctor”? Perhaps what you mean by “everyday medical care” is “relatively harmless things that make you feel better for a little while.” It’s a novel definition of medical care, but I’ll go with it. The obvious question becomes, why introduce doctors into it? Currently I don’t involve a doctor when I take aspirin for cramps, get a massage, go for a walk, see a psychotherapist, take a hot bath… or see an acupuncturist. Are you suggesting that in the enlightened public system that all these things will need to be done under the supervision of a doctor? I’m not liking the sounds of this.

    I can see making a case for reimbursing acupuncturists for treating chronic pain. That would give power to limit an acupuncturist’s services and claims. Either they promote vaccination and don’t claim to offer fertility treatments and are reimbursed for a very limited set of services, or they are not reimbursable at all. I really don’t see how one could hope to control what they do without control over money.

    I’m not saying I would accept this case, but it has the merit of being rational and internally consistent.

    If you could be a little more specific, perhaps I would understand better.

  45. micheleinmichigan on reimbursement:

    “So here it is loud and clear for the CAM folks, ‘You don’t get to be an artist (Healing or otherwise) AND claim that the quality of your work is supported by evidence’. End of story, they can join the rest of us wishy washy, “I know it when I see it and I’ll buy it if it looks good over my sofa” professionals who services are NOT covered by health insurance.”

    Also internally consistent, and a case I am more likely to buy.

  46. Anthro says:

    I have been doing allergy shots for almost two years. At the last physician visit (every six months) I asked if I’d get re-tested to see if it was working. She said they don’t do that. I asked how I would know if the immunotherapy is working. She said that I would “know” by whether or not things still bothered me. Well, here’s the trouble with that: My dog still “seems” to cause me some problems, although they “seem” a little less bothersome than a year ago. How much better? How much “less” is the dog bothering me?

    I complained about this attitude and she told me that “that’s how medicine is in practice; if the patient feels better, then he is better”.

    I was amazed by this, but had no immediate snappy comeback. This article gets to the crux of this so I think I will send it to the doc in question.

    Do any of you, especially docs, have any opinions about the scientific validity of immunotherapy? Am I just wasting a lot of time and money–I suddenly feel that what I am doing is less valid than acupuncture.

  47. pmoran says:

    :“A great deal of everyday medical care can be carried on by paramedical personnel if under the supervision of a doctor. A sensible CAM practitioner (one who knows his limitations) could certainly perform the same function.”
    “The patient should pay, the reason being that in any communally funded health care system there will always be better ways to spending the money.”

    Allison: I’m getting more and more confused. If people who practice baseless therapies are paramedical personnel providing everyday medical care, why wouldn’t they be reimbursed?
    If an enlightened public system engages homeopaths and acupuncturists to provide these services, why wouldn’t they be reimbursed too?

    Public systems will be so strapped for cash for critical patient care over the foreseeable future that it would be ridiculous for them to be “engaging” such practitioners in any major way. It would also send a message that I am not prepared to support.

    However, at least one Australian Private health Insurer offers to partially reimburse the patient for their use
    a wide range of “alternatives”, presumably feeling that the risks of doing so are acceptable. This web page indicates the wide range of modalities supported and how they accredit providers.

    http://www.medibank.com.au/Health-Covers/Information-For-Health-Care-Providers/Ancillary-Provider-Recognition.aspx

    Within most systems there have already been minor trends towards de facto amalgamation of CM and CAM, for example, integrative medical centres, group medical practices in many countries wanting to include a CAM practioner, or doctors using elements of CAM in theri own practices. It is too early to say whether this will be a passing fad.

    I must be coming across as “pushing” CAM, probably through my having to apply limited writing skills and brain power to an extremely messy subject.

    I see myself more as trying to understand the REAL reasons why CAM has proliferated in recent years, and what the emerging science of therapeutic interactions allows us to say about it.

    If people don’t have somewhat contradictory impulses concerning CAM, they probably haven’t studied it enough.

  48. Thanks pmoran.

    So in your vision, insurers will become so strapped for cash that the entire domain of “everyday medical care” will be deemed uninsurable, and any service provided by a non-MD will need to be paid for out of pocket by the patient?

    Or insurers will continue to pay nurses for wound care but simply won’t pay acupuncturists for wound care, even if they are providing the identical service?

  49. nybgrus says:

    Alison: This is basically what I have been getting out of my extensive discussions with pmoran. It seems that he doesn’t really have anything to say except “CAM is bad, but not that bad sometimes, and sometimes we can use CAM, but we really shouldn’t use CAM, its just that I don’t think CAM will ever go away, and since our efforts to make it go away haven’t worked, maybe we should just figure out someway to work with CAM, but I don’t really have any good ideas on how that may be implemented or where to draw any meaningful lines, but clearly the science shows us we aren’t exactly right in asserting CAM is useless and so therefore we should change our tack since people will be using CAM regardless of what we say.”

    In other words, he is saying…. nothing…

  50. pmoran says:

    Allison:So in your vision, insurers will become so strapped for cash that the entire domain of “everyday medical care” will be deemed uninsurable, and any service provided by a non-MD will need to be paid for out of pocket by the patient?

    No, I said public (i.e. tax funded) health care systems will be so strapped for cash that they cannot afford to pay for CAM in any major way. Private insurers are only able to pay for CAM by charging higher premiums to those who choose to be covered for it. That is fair enough, I guess. They presumably see that as commercially viable, and I am they would soon stop if it proved unsafe.

    Nurse practitioners are a way of saving money within the mainstream, so obviously they should be paid for their “everyday medical care”. CAM, in contrast, is nearly always an add-on to standard medical care, so paying for it can only double-up on costs with diminishing returns.

    I regret mentioning that CAM practitioners are able to perform many of the functions of PCPs because that has been interpreted as a recommendation. It is merely a statement of fact — part of present-day medical reality that skeptics may be unwise to ignore.

    There have actually been prospective studies that suggest very similar or better outcomes for ordinary doctors and CAM practitioners with everyday medical problems (when more or less within an overall mainstream environment) , so I am not talking through my hat here.

    This is feasible for the same reasons that practice nurses can serve similar roles especially with minor and self-limiting illnesses and in supportive roles.

    OTOH free-range CAM practitioners would necessarily be less safe because of the lack of direct medical supervision and varying awareness of their personal limitations .

    Nybgrus, when you deal directly to my arguments and insights we can talk. I am not interested in trying to score points over you, or responding to general bluster about my undoubted failings, or the implication that you must be right because others think the same (purportedly).

  51. nybgrus says:

    pmoran: we have talked. A lot. I have addressed your specific arguments. A lot. You continue to say the same vague ideas over and over with the random tidbit of change which only serves to confuse more. To say I haven’t learned anything from you would be a lie – so would saying that I have learned much.

    I am not trying to say I am right, nor that I have the answer. I have been trying to say that you are not addressing the topic well, have no concrete ideas, and are simply touting confusing and vague mumblings that certainly come off as “shruggie” and “tone troll” in nature. I have cited the fact that pretty much everyone else here is confused by your comments and also feels exasperated at your continued vagueness as evidence not that I am right but that these critiques of you and your rhetoric are not merely a failing on my part to understand what you are putting forth. In other words, I am not missing the point – you are simply not delivering one.

    I could care less about “points” and I am not here to try and say how I am better than some “Dr. Peter Moran” whom I don’t know and at best I can guess is an orthopedist in Australia. My purpose is to try and see if you have anything meaningful to say that will actually help with the CAM situation and the harm caused by it. Repeatedly you have failed to do so.

    Your musing and “out-of-the-box” thinking on CAM is indeed perfectly fine. But when you continually fail to assert the validity of your musings it is either time to change the musings or stop trying to claim them valid.

  52. pmoran on the delivery of everyday medical care:

    “There have actually been prospective studies that suggest very similar or better outcomes for ordinary doctors and CAM practitioners with everyday medical problems (when more or less within an overall mainstream environment) , so I am not talking through my hat here.

    This is feasible for the same reasons that practice nurses can serve similar roles especially with minor and self-limiting illnesses and in supportive roles.”

    Everyday medical problems meaning… what, exactly? I have proposed wound care and diabetes education as examples of everyday medical care, and you haven’t said this isn’t what you mean, so I take it that it is. If wound care and diabetes education can be appropriately handled by an acupuncturist, public insurers should be absolutely *thrilled* to get these services provided more cheaply than by an RN.

    You say you don’t recommend, merely observe, that CAM practitioners (as far as I know, the only CAM practice you accept as clearly evidence-based is acupuncture, so I take it that you mean acupuncturists) can provide as good or better care than doctors do in some circumstances. Still not recommending anything, you warn us to keep this fact in mind nevertheless. You also compare the capacities of CAM practitioners (acupuncturists?) to those of practice nurses when properly supervised by an MD.

    1) If an acupuncturist can fill a physician extender role the same way a practice nurse can, why would public insurers be reluctant to pay them? Why would physician-extending be money-saving when done by a nurse but an add-on when performed by an acupuncturist?

    2) I looked up practice nurses. Let’s say I accept that acupuncture is evidence-based (compared to no care) for some types of pain in some conditions. How does training in acupuncture prepare a person to fill the role of a practice nurse as described below?* Even when working out of a medical clinic?

    3) Perhaps you are thinking of NDs, not acupuncturists, when you describe CAM practitioners filling a physician extender role? (My understanding is that in US states where NDs are licensed they are reimbursed by public insurers.) This doesn’t address the appropriateness of acupuncture being taught in medical school and performed or prescribed by MDs. These are two different scenarios. Naturopathy is a parallel practice taught on the basis of a parallel reality in parallel schools and recognized by some politicians and members of the general public; vs the introduction of a baseless, non-medical procedure into the practice of medicine. When I insist that as a member of the general public I strongly oppose the latter, you appear to ask me to keep the former in mind.

    I am still confused.

    *
    http://ww2.prospects.ac.uk/p/types_of_job/practice_nurse_job_description.jsp
    Practice nurse:
    Job description and activities
    Practice nurses work in general practitioner (GP) practices providing assessment, screening, treatment, care and education to patients from all sections of the community, from infants through to the elderly.

    Typical work activities include:

    providing advice, consultation and information about a range of health conditions and minor ailments, referring to other members of the practice team as necessary;
    performing investigatory procedures;
    performing minor operations;
    conducting first-registration checks;
    setting up and running clinics for conditions such as asthma, diabetes and skin disorders as well as well-woman/man clinics;
    giving contraceptive advice and fitting contraceptive devices;
    offering cervical smear and pregnancy tests;
    taking blood and urine samples, other specimens and swabs;
    performing routine procedures, such as ear syringing, eye washing, applying and removing dressings, and treating wounds, etc.;
    offering specialist information and advice in areas such as blood pressure, weight control, giving up smoking, heart conditions, etc.;
    administering infant injections and vaccinations;
    administering travel immunisations and offering travel health care advice;
    offering first aid and emergency treatment, as required;
    advising patients in respect of their continuing medical and nursing needs;
    re-stocking and maintaining clinical areas and consulting rooms;
    taking accurate and legible notes of all consultations and treatments and recording these in patients’ notes;
    updating/amending the clinical computer system with details of patient and treatments;
    liaising with other practice nurses, GPs, reception and office staff.

    To become a practice nurse generally requires two years’ professional experience post training.

  53. pmoran says:

    Allison, doctors don’t sit in their offices saving lives all day. The majority of daily medicine practice is routine stuff that requires no depth of medical knowledge or skill. By taking over some of that role nurses can preserve expensive medical skills for where they are best exercised and contribute to a cost-efficient health care system.

    That does not apply to CAM practitioners. The better trained ones may be able to do a lot of the same but they cannot be cost-effectively and safely integrated into the medical system as independent primary care providers for the reasons I mentioned.

    We can however pick and choose from CAM it if we wish, and this is what a lot of doctors want to do.

    You want to talk about acupuncture specifically. As I have often said, acupuncture is mainly a placebo, but a very good one. It may also have some physiological effects through release of endorphins, distractant and counter-irritant effects and through the enforced relaxation of acupuncture sessions. It works better than doing nothing and can probably add something to “usual medical care” in most medical contexts.

    This is why the Mayo clinic and other integrative centres are prepared to prize patient interests over selected scientific niceties and explore whether acupuncture can help poor blighters with cancer pain.

    Now it may turn out that acupuncture is not a cost-effective solution and it is more likely to end up that way if skeptics’ attempts to completely discredit acupuncture turn out to be as successful as they hope. But it is not the horrific betrayal of the objectives of medicine that it is often portrayed to be here.

  54. JMB says:

    @pmoran

    Maybe the research has been done and I am unaware of it, but I would suspect physiologic effects could be observed in patients who respond to sugar pills or saline injections. If those trials have not been done, it was because they weren’t deemed worth the research money. Just because CAM therapies tout physiologic response does not mean they are any better than traditional placebos. There are plenty of physiologic responses that can be manipulated by manipulating emotions, regardless of the composition of the pill. An intervention that is totally novel to the patient, and has had testimonies for effectiveness by friends (or celebrities), will elicit a more powerful placebo effect, at least on initial use. There may be some CAM therapies that consistently perform better than placebo, but then those therapies are considered science based. However, the scientists must be careful to choose an appropriate placebo to achieve a double blind effect, which can be difficult. Integrative medicine seems to abandon the concept of placebo just because it is difficult to design a placebo for a double blind trial of effectiveness. That is a cop out because of the difficulty of experimental design.

    I wouldn’t leave people with the impression that there is any proof that CAM is any more than placebo effect.

  55. pmoran says:

    Hi, JMB. I understand what you say. . I am sensitive to sending the wrong message to the public, but I think the risks of that are overstated. The public already displays considerable discrimination in how they use CAM.

    The thing that some skeptics can overlook is that with CAM and integrative medicine we are nearly always talking about medical needs that the “working better than placebo” model of medical interactions has already failed to satisfy. Does that not change anything, — not at all?

    We both seem to accept that CAM can provide a structure upon which beneficial psychosociomedical interactions can occur. The”treatment” is in part a symbol of an ongoing desire to help. Part of its worth lies in the nocebo effects of the patient having to endure not fully relieved symptoms on their own, when the mainstream has run out of options.

    Nybgrus and others suggest that the mainstream should be able to do all that too, without resorting to placebo or CAM.

    I think that is easier said than done, for a number of reasons including the fact that evolution has provided us with a clientele that thrives best symptomatically when “something” is being done, as is shown by every one of hundreds of thousands of intervention studies. That “something” may be shown not to work better than placebo in other comparisons, but we don’t have any firm handle on what that means. Clinical studies are rarely ever designed to test that. There is some indication that placebo influences can be powerful under the right conditions.

    There is also some preciousness in the insistence that the “working better than placebo” model be strictly adhered to in all contexts. Often that can mean using a drug that works only marginally better than placebo (and may yet be proved not to even do that in further studies), but which also has the potential to produce about the same number of side effects.

    That, or nothing. Are those ethical constraints upon the knowing use of placebo as unbreakable as some hold? I don’t know, but I have to ask..

    I am not so much wanting to push CAM as to soften hardline attitudes that may be denying some patients useful benefits, in the same way that an extraordinary variety of other medical rituals have, throughout hundreds of thousands of years of evolution, until a mere century or so ago.

  56. JMB says:

    @pmoran

    I guess I’m a leftover 70′s hippie. The idea of freedom from the 70′s requires that our societal institutions should stop trying to deceive us. I think incorporation of CAM into integrative medicine is a deception. While deception may increase the placebo effect, it can also lead to disillusionment. Certainly the greater use of CAM encouraged by integrative medicine will result in a larger number of patients who feel deceived by their mainstream healthcare providers.

    I also think there has been a history of development of ethical answers to the use of placebo in SBM, in which input has been received from many different sources, more than just physicians. Integrative medicine seems to have arrived at different answers to the ethical questions without adequate participation by nonphysicians. Just because it is ancient doesn’t make it ethical.

  57. GLaDOS says:

    As a general rule of thumb, you shouldn’t lie to people. Yet humans fudge the truth daily and we’re ok with that. Still the general rule constrains the extent of the fudging.

    As a general rule, doctors should not lie to patients. That’s not a black-and-white statement with no room for Benadryl 25 mg prn anxiety.

    From what I have observed, once doctors institutionalize the bullshit even just a little bit, they suffer brain damage. They begin prescribing daily hydrocortisone to eight year olds for adrenal fatigue.

    The rule against lying is there to prevent early onset dementia in the doctors.

  58. GLaDOS says:

    My prior comment is in moderation due to bullsh_t. Dammit I need that word so bad.

    Nick change due to boredom.

  59. pmoran says:

    Glados: From what I have observed, once doctors institutionalize the bullshit even just a little bit, they suffer brain damage. They begin prescribing daily hydrocortisone to eight year olds for adrenal fatigue.

    In which mainstream institution have you observed that, or anything comparable?

  60. GLaDOS says:

    Mine, which I’m not going to name. I share a patient with an MD who has trained as a naturopath and who is prescribing hydrocortisone for adrenal fatigue, which he feels has some relation the the child’s ADHD and mood symptoms.

    I will scout the web for examples of MDs not connected to me doing stuff like this, brb.

  61. pmoran: “I am not so much wanting to push CAM as to soften hardline attitudes that may be denying some patients useful benefits.”

    Please provide evidence that anyone is being denied useful benefits.

    If I am open to believing in acupuncture and my neighbour has gotten great results for her ___, then I am an excellent candidate for any enhanced placebo effect of acupuncture. I also have a referral: I can see my neighbour’s acupuncturist. This process, that happens every day, does not require the facilitation of an MD.

    Please explain the value-add of involving an MD in this scenario.

    If I look to my doctor for science-based support and she suggests I get an acupuncturist for my mother’s ICU delerium because I’m really unhappy and the ICU docs can’t seem to fix it, I am going to be even unhappier because now I have to fire the doctor I depend on.

    Please explain the value-add of an MD suggesting acupuncture in this scenario.

  62. Delirium.

    [This is the current issue I am struggling with, by the way. The smartest person I know has been hospitalized since March 5 weeks ago with pneumonia and subsequently diagnosed with multiple myeloma. She’s 66. The smartest person I know is under mechanical ventilation and trying frantically and single-mindedly to pull out her tubes and escape from the hospital. She mostly recognizes us. The smartest person I know was in a restraint chair last night getting haldol as I walked in so that she wouldn’t throw herself out of bed. Music has been suggested. She has been moved to a sunny room with huge windows to reset her circadian clock. She’s on dialysis and getting aggressive treatment with Velcade in an attempt to preseve her kidneys. Nurses encourage us to spend time with her to help her settle. If there were a qi-manager on staff, or if her nurses were licensed to wave their hands over her to redirect her energies, I would lose faith in the hospital. Fortunately I’m in Canada. Hospitals evaluate ROI as a health return on investment, not a money return on investment, and acupuncture and reiki are low ROI with this calculus. We aren’t being subjected to any of this.]

  63. GLaDOS says:

    OK here’s a board certified MD in Boston using hydrocortisone for ADHD:

    http://francisholisticmedicalcenter.com/images/Childhood_Behavior.pdf

  64. pmoran says:

    pmoran: “I am not so much wanting to push CAM as to soften hardline attitudes that may be denying some patients useful benefits.”

    Please provide evidence that anyone is being denied useful benefits.

    If you believe that some of the reported patient benefits from placebo are real, yet you want to deny doctors the option of using any kind of “not better than placebo” medicine, how can you not be denying some patients benefit?

    Or is your position that the mainstream has entirely adequate answers?

  65. GLaDOS says:

    pmoran: “If you believe that some of the reported patient benefits from placebo are real…”

    Then the onus is on you, the believer, to *prove* that those benefits exist to the rest of us, lest we think you a loonie.

    Or is your position that the mainstream has entirely adequate answers?

    How do I know when I’ve found an “adequate answer?” When my pain is gone? When I no longer fear dying? When I finally lose those 20 lbs? Wat?

  66. nybgrus says:

    If you believe that some of the reported patient benefits from placebo are real, yet you want to deny doctors the option of using any kind of “not better than placebo” medicine, how can you not be denying some patients benefit?

    Once again, you shirk and dodge. First, a claim that acupuncture has something more than placebo, but no answer as to what that is or the biological plausibility of it. Nevermind the fact that even if it does has something more than placebo all the data we have so far shows us that is a very small effect.

    Now a claim that doctors should have the option of using placebo treatments (unless you want to Bill Clinton me on “not better than placebo” being different and better than “placebo”) – something that is simply unethical by the very doctrines of our profession.

    And as Allison said – where is your evidence that anyone is being denied this option should they really want it? Besides the fact that you don’t see a group of us “hard liners” blocking the entrances to acupuncture clinics, it is even being practiced in academic hospitals! Of course, the problem is that you think that practice is just fine and we here think that it indeed should be denied use in an actual hospital practicing actual medicine because it is a “treatment no better than placebo” and because medical ethics dictates that we, regardless of observed benefits, cannot administer placebo treatments to patients. The one “out” I can think of to that is to outright tell the patient that it is a complete placebo with no illusion that it has some other biologically active mechanism (which, as you should know, is called “informed consent”). The problem with that is it is a waste of physician time and hospital resources that are, quite simply, better spent elsewhere. That it it wouldn’t exactly work on a comatose or delirious patient.

    My heart goes out to you Allison. I am sorry for your mother’s condition and the situation you are in. My sincerest hopes that she can get better with treatment.

  67. GLaDOS says:

    …and because medical ethics dictates that we, regardless of observed benefits, cannot administer placebo treatments to patients.

    The word “placebo” like the word “love” or “faith” takes its meaning from context. It’s just an awful word. So you have to bend over backwards to be exact about what you mean by “placebo,” else you will get in trouble.

    Instead of your phrase above I would say, “We can’t tell patients that an intervention has a specific effect apart from all the non-specific effects of the treatment setting unless that’s really true.”

  68. nybgrus says:

    @glados: You are correct. That is a much better (though I think not perfect) way of saying it. When I refer to administering placebo treatments to patients I mean intentionally and knowingly administering a treatment which is known by the person administering it to lack the specific effect it is purported to have.

  69. GLaDOS says:

    Pills are boring placebos. What we need are things that froth a bit and change color –but slowly over say 5-10 minutes, forcing the patient to sit still and watch the process.

    Some people are concrete thinkers who really do need a tangible signifier of “medicine,” else they can’t quiet their own anxiety. I don’t feel any moral problem about providing a placebo to such patients. I think of it as part of the “treatment setting.”

    That said, I still avoid placebos in residential programs because there are too many people involved. Reality is the only way to keep everyone on A shift, B shift, and C shift largely on the same page.

    An aside about concrete thinkers: Head injury can mess up mental representation. So a guy who used to be able to hook up with Rosy Palm in the shower before his car accident now finds he can’t get off. He’s got to *see* some naughty bits to come. So you must prescribe porn else there will be groping.

  70. GLaDOS,

    Porn only needs to be prescribed in an institutional setting, right? Non-institutionalized folks can get their own and not have it taken away from them… Right?

    Even in an institutional setting, do you really need to prescribe it, or simply communicate that the individual is allowed to make use of it? Is this communication standard with all residents over fourteen, or restricted to a special deserving subset (or special groping subset)?

    My sister prescribes alcohol to hospitalized alcoholics to prevent seizures, and gives permission for families to use TCM on patients who are dying anyway. But she doesn’t prescribe cupping or coining.

  71. daedalus2u says:

    Alison, one of the things that causes delirium is insufficient functional connectivity. Often that is due to neuroinflammation and a reduction in the basal NO level in the brain.

    http://daedalus2u.blogspot.com/2008/01/resolution-of-asd-symptoms-with-fever.html

    That should show up as white matter hyperintensities on MRI.

    I think that neuroinflammation often accompanies severe infections because the mitochondria in neurons have to be protected from the very high NO levels of sepsis (due to NO from iNOS to prevent biofilm in the vasculature) by neuroinflammation. I think that is where the choreas of strep come from.

  72. GLaDOS says:

    LOL Alison I don’t write “porn prn” in the chart. But if someone is way to horny I ask if porn might help. Sometimes it’s worth a try. Sometimes it makes things worse.

  73. daedalus2u says:

    There was an article, I think in the NYT about people with Alzheimer’s who were given chocolate as medicine and it was put on their chart.

    The regulation-nazis didn’t like it and made a stink, but the medical staff pushed back and it was declared to be ok.

  74. GLaDOS,

    Ah, I see. The lack of porn produced by doctors, or distributed through medical clinics under the supervision of doctors, or available contingent on prescription by doctors, is not resulting in anyone being denied the benefits of porn.

    Funny how something can be both potentially beneficial and non-medical.

  75. daedalus2u,

    My sister allows as how her prescription of two oz whiskey per night (as opposed to lorazepam or horrible hospital sherry) is partly to shock the nurses.

  76. On the theme of the salutary effects of porn, chocolate and shots of whiskey.

    One of Annie Sprinkle’s lovers Willem claims she saved his life by giving him a blow job when he was suffocating from an asthma attack and refused to see a doctor:

    http://anniesprinkle.org/writings/101_uses.html

    Should asthma clinics include sex workers so that patients aren’t denied the benefits of orgasms?

  77. daedalus2u says:

    Alison, that is probably due to the nitric oxide that activity produces.

  78. GLaDOS says:

    I like the idea of chocolate in the nursing home. But it would never work in a residential school.

    Kids living in institutions are prone to having somatic complaints as a means of accessing adult attention. Add chocolate prn as an option, and the nurses would quit en masse.

  79. gerastuff says:

    Also a point that I’ve not seen anyone make is their inner contradiction:

    “Empirical evidence, when it exists, is viewed as the “best” evidence on which to make a clinical decision, superseding clinical experience and physiologic rationale. But these latter forms of medical knowledge differ in kind, not degree, from empirical evidence and do not belong on a graded hierarchy.”

    Note the part “PHYSIOLOGIC RATIONALE”. They might have a point about clinical evidence (just for the sake of the argument since I don’t think they have any base on that either); but what about physiologic rationale?

    Mmm… let me se… why would they forget patophysiologic rationale,
    can it be because most (if not all) of CAM proposed treatments have NO demonstrable physiologic base whatsoever?

    If they are bringing this very points now as criticism against EBM seems only fair that their suggestion incorporate this same analysis.

    But for instance, homeopaths have struggled without success to provide any physiological explanation for the effect of NO active ingredient in the body (apart from placebo effect obviously); or what about acupunture, where even considering the weak evidence they try to propose, trial after trial shows no consisten “meridian” or “qi” system that supposedly is the “physiological rationale”.

    It seems to me extremely misleading and unfair, to demand that EBM be more physiologically based (which I agree must be done and is being done) backed up with basic science; and then forget entirely this criticism when referring to CAM and bending over to “clinical evidence” and “patient goals and vaues” which coincidentally is the only ground where they can ever offer some appearance of “evidence”.

    Furthermore, where they to evaluate CAM as they demand be done for EBM, the meager “evidence” they offer for their claims would be inherently undermined by the absolute lack of “physiologic rationale” to support those therapies.

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