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Reporting back on my Grand Rounds experience at FSU

Last Thursday, I had the distinct privilege and honor to be invited to speak at Grand Rounds at the Florida State University College of Medicine in Tallahassee. Ray Bellamy, who is on the faculty there and is also the husband of our very own Jann Bellamy (who is herself is the founder of the Campaign for Science-based Health Care), invited me down to give a talk on “complementary and alternative medicine” (CAM) and “integrative medicine” (IM). Although I’ve spoken to skeptics’ groups, such as local groups or even to workshops at The Amazing Meeting, and to medical students’ groups, this represented the first time I had been invited to speak in front of a large group of medical professionals, not all of whom necessarily agreed with our viewpoint here at SBM. So it was with some trepidation that last Wednesday I braved the trip to Tallahassee, with the unfortunately requisite connection in Atlanta that necessitated my practically running from one end of that massive airport to the other in order to make my connection to the little puddle jumper of a jet that took me to Tallahassee. Whether or not my talk was a success or not, readers can judge for themselves, as it’s been posted online on the FSU Grand Rounds page. (Just scroll down to November 10 and then hit the link. Unfortunately, it appears that you’ll need Microsoft Silverlight to get the video to work.) I haven’t watched the whole thing yet, but I encourage you to do so and tell me how good (or bad) I was and why. I want to get better, and I won’t rest until I’m as good at communicating medicine as Neil deGrasse Tyson or Richard Wiseman, for instance, is at communicating science.
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Dummy Medicine, Dummy Doctors, and a Dummy Degree, Part 2.3: Harvard Medical School and the Curious Case of Ted Kaptchuk, OMD (concluded)

Dummy Medicine, Dummy Doctors, and a Dummy Degree, Part 2.3: Harvard Medical School and the Curious Case of Ted Kaptchuk, OMD (concluded)

A Loose End

In the last post I wondered if Ted Kaptchuk, when he wrote the article titled “Effect of interpretive bias on clinical research,” had understood this implication of Bayes’s Theorem: that interpretations of most scientific investigations are exercises in inverse probability, and thus cannot logically be done without consideration of knowledge external to the investigation in question. I argued that if Kaptchuk had

…understood the point when he wrote his treatise, he was dishonest in not explaining it and in not citing at least one pertinent article, such as Steven Goodman’s (which I’m willing to bet he had read). If he didn’t understand the point he should have withheld his paper.

In researching more of Kaptchuk’s opinions I’ve discovered that he had certainly read Goodman’s article, but that he either didn’t understand it or preferred to obscure its implications in deference to his ongoing project in belittling scientific knowledge. In a letter to the editor of the Annals of Internal Medicine in 2001, Kaptchuk opined that even if “more trials of distant healing with increased methodologic rigor” were positive, it still would not “be persuasive for the medical community”:

The situation resembles the predicament with homeopathy trials, another seemingly implausible intervention, where the evidence of multiple positive randomized, controlled trials will not convince the medical community of its validity. Additional positive trials of distant healing are only likely to further expose the fact that the underpinning of modern medicine is an unstable balance between British empiricism (in the tradition of Hume) and continental rationalism (in the tradition of Kant).

…It seems that the decision concerning acceptance of evidence (either in medicine or religion) ultimately reflects the beliefs of the person that exist before all arguments and observation. [Kaptchuk cites the second of the two Goodman articles that I referred to above, discussed here]

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Posted in: Acupuncture, Book & movie reviews, Health Fraud, Legal, Medical Academia, Medical Ethics, Politics and Regulation, Science and Medicine, Science and the Media

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Please Don’t Define “Complementary and Alternative Health Practices”!

Since I have a master’s and doctoral degree in health education and since I’m a professor in a department of public health with an undergraduate curriculum that includes substantial attention to health education, I participate in the email discussion group of HEDIR, the Health Education Directory. On August 16th, I received a message to the discussion group from the American Association for Health Education inviting participants to complete an online survey from the Joint Committee on Health Education and Promotion Terminology with results to be analyzed at the Committee’s meeting in September 2011.

The survey items include various terms used by health educators, the currently approved terminology, and three choices followed by a type-in box:

  • This term should remain as defined
  • This term should remain in the report but modified in definition
  • This term is no longer commonly used in health education/health promotion literature

If modify, please provide the suggested wording and reference for that definition if you are citing it from a specific source.

For one of the terms, my preferred response would have be have been a fourth choice that was not offered: The term is commonly used in health education/health promotion and elsewhere, but it should not be used because its use only serves to distort our thought processes and promote quackery.

Here is the term along with the definition presented in the survey:

Complementary and Alternative Health Practices: These practices generally include natural substances, physical manipulations, and self-care modalities. These approaches often incorporate aspects of interventions derived from traditional practices. The approach in Western societies has been to select specific approaches from these systems and apply them to health maintenance, health enhancement, or disease management. Such approaches can be used to compliment[sic] conventional allopathic care (complementary therapy), or as an alternative to conventional approaches (alternative therapy). Many of these complementary and alternative approaches have not been validated through experiential research, but those that have, such as acupuncture for pain, are being integrated into conventional health practices (integrative medicine).

And here are my objections to the term and to the definition given:

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Dummy Medicine, Dummy Doctors, and a Dummy Degree, Part 2.2: Harvard Medical School and the Curious Case of Ted Kaptchuk, OMD (cont. again)

“Strong Medicine”: Ted Kaptchuk and the Powerful Placebo

At the beginning of the first edition of The Web that has no Weaver, published in 1983, author Ted Kaptchuk portended his eventual academic interest in the placebo:

A story is told in China about a peasant who had worked as a maintenance man in a newly established Western missionary hospital. When he retired to his remote home village, he took with him some hypodermic needles and lots of antibiotics. He put up a shingle, and whenever someone came to him with a fever, he injected the patient with the wonder drugs. A remarkable percentage of these people got well, despite the fact that this practitioner of Western medicine knew next to nothing about what he was doing. In the West today, much of what passes for Chinese medicine is not very different from the so-called Western medicine practiced by this Chinese peasant. Out of a complex medical system, only the bare essentials of acupuncture technique have reached the West. Patients often get well from such treatment because acupuncture, like Western antibiotics, is strong medicine.

Other than to wonder if Kaptchuk had watched too many cowboy ‘n’ Native American movies as a kid, when I first read that passage I barely blinked. Although the Chinese peasant may have occasionally treated someone infected with a bacterium susceptible to his antibiotic, most people will get well no matter what you do, because most illnesses are self-limited. Most people feel better even sooner if they think that someone with special expertise is taking care of them. If you want to call those phenomena the “placebo effect,” in the colloquial sense of the term, fine. That, I supposed, was what Kaptchuk meant by “strong medicine.”

Turns out I was mistaken. Let’s briefly follow Kaptchuk’s career path after 1983. In the 2000 edition of The Web, he wrote:

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Posted in: Acupuncture, Basic Science, Book & movie reviews, Chiropractic, Clinical Trials, Homeopathy, Medical Academia, Science and Medicine

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Andrew Weil and “integrative medicine”: The ultimate triumph of quackery?

A board certification in woo?

I’ve been harshly critical of the entire concept of “integrative medicine” (IM), which has over the last few years nearly supplanted the former term used for non-science-based medicine or medicine based on prescientific ideas represented as though it were scientific medicine, “complementary and alternative medicine” (CAM). Indeed, just last week I pointed out how IM is far more about marketing than it is about science or medicine, and over the last three years I’ve been particularly harsh on the concept of “integrative oncology,” which is actually being represented as a “subspecialty” of IM. Despite the utter lack of a rationale based on science or the scientific basis of medicine, IM has still been making inroads into academic medical centers, where I tend to refer to it with the unapologetically disparaging term “quackademic medicine.” Even worse, now, increasingly, such woo has been insinuating its way into community medical centers as well.

Arguably, the man who has done more than any individual to promote the quackification of science-based medicine is Dr. Andrew Weil. (At least, I can’t think of any single person who’s done more during his lifetime to promote the infiltration of quackery into medicine. Readers are free to chime in if they know of someone who could challenge Weil for the title of King of Quackademic Medicine.) As I pointed out the last time I discussed him, Dr. Weil doesn’t really like science-based medicine. Oh, no, he doesn’t like it at all. Unfortunately, he’s been very successful in promoting quackademic medicine. He’s also arguably been the single most successful person at legitimizing what used to be viewed as quackery. Master of the domain of “integrative medicine,” having formed a model of an “integrative medicine in residency” that’s spread like kudzu through quackademia, all from his redoubt at the University of Arizona, Dr. Weil has now announced his intention for the next phase of his “integrating” pseudoscience with SBM. I learn this from The Integrator Blog, which has as a recent headline from last week Special Report: “Strategic Change in Direction” as Weil’s Arizona Center Commits to Creation of American Board of Integrative Medicine:

In a major strategic shift, the University of Arizona Center for Integrative Medicine (ACIM) has announced that it will lead the creation of a formal specialty for medical doctors in integrative medicine. ACIM, founded by Andrew Weil, MD and directed by Victoria Maizes, MD, is in dialogue with the American Board of Physician Specialties toward establishing an American Board of Integrative Medicine. They are collaborating with leaders of the American Board of Integrative and Holistic Medicine (ABIHM). Here is the ACIM announcement, a statement from two ABIHM leaders, a brief interview with Maizes and the list of 18 founding Board members. Is this the right strategic choice? What impact will this have on integrative medicine and the broader integrative healthcare movement?

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Posted in: Medical Academia, Politics and Regulation

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Survey says, “Hop on the bandwagon of ‘integrative medicine’!”

A Brief Clinical Vignette

In researching this post, I found an article published nearly two years ago in The Hospitalist entitled Growth Spurt: Complementary and alternative medicine use doubles, which began with this anecdote:

Despite intravenous medication, a young boy in status epilepticus had the pediatric ICU team at the University of Wisconsin School of Medicine and Public Health in Madison stumped. The team called for a consult with the Integrative Medicine Program, which works with licensed acupuncturists and has been affiliated with the department of family medicine since 2001. Acupuncture’s efficacy in this setting has not been validated, but it has been shown to ease chemotherapy-induced nausea and vomiting, as well as radiation-induced xerostomia.

Following several treatments by a licensed acupuncturist and continued conventional care, the boy’s seizures subsided and he was transitioned to the medical floor. Did the acupuncture contribute to bringing the seizures under control? “I can’t say that it was the acupuncture — it was probably a function of all the therapies working together,” says David P. Rakel, MD, assistant professor and director of UW’s Integrative Medicine Program.

The UW case illustrates both current trends and the constant conundrum that surrounds hospital-based complementary medicine: Complementary and alternative medicine’s use is increasing in some U.S. hospitals, yet the existing research evidence for the efficacy of its multiple modalities is decidedly mixed.

My jaw dropped in horror when I read this story. Acupuncture for status epilepticus? There’s no evidence that it works and no scientific plausibility suggesting that it might work. And what does the questionable research suggesting that acupuncture might ease chemotherapy-induced nausea and vomiting or radiation-induced xerostomia (which, if you look more closely at the studies, it almost certainly does not, but that’s a post for another time) have to do with this case, anyway? Nothing. Worse, Dr. Rakel fell for the classic post hoc ergo propter hoc fallacy; i.e., despite his disclaimer, he appears to be implying that, because the child recovered, acupuncture must have contributed to his recovery. He also repeats the classic fallacy that I’ve written about time and time again in the context of cancer therapy, namely that if a patient is using quackery as well as science-based medicine, then either it was the quackery that cured him or the quackery somehow made the conventional medical care work better.

I expect better from an academic medical center like the University of Wisconsin. Unfortunately, increasingly I’m not getting it. Quackademic medicine is infiltrating such medical centers like kudzu.
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Dummy Medicine, Dummy Doctors, and a Dummy Degree, Part 2.1: Harvard Medical School and the Curious Case of Ted Kaptchuk, OMD (cont.)

Rave Reviews

In 1983, Ted Kaptchuk, the senior author of the recent “albuterol vs. placebo” article, and soon to become the long-time Second-in-Command of the Harvard Medical School “CAM” program, published The Web that Has No Weaver:

The book received rave reviews:

A major advance toward the synthesis of Western and Eastern theory. It will stimulate all practitioners to expand their understanding of the causes and treatment of disease.

–Paul Epstein, MD, Harvard Medical School

A lucid and penetrating exposition of the theory and practice of Chinese medicine. While the book’s rich detail makes it of great use to practicing healers, it is in its entirety very simply written, enjoyable reading for the layman…it brings a demystifying balance…Instructive, profound, and important!

Professor Martin Schwartz, University of California, Berkeley

…demystifies Oriental medicine in a remarkably rational analysis…

—Science Digest, Nov. 1982

…an encyclopedia of how to tell from the Eastern perspective ‘what is wrong.’

Larry Dossey

Dr. Kaptchuk has become a lyricist for the art of healing…

—Houston Chronicle

Although the book is explicitly detailed, it is readable and does not require previous knowledge of Chinese thought…

—Library Journal

The 2nd edition was published in 2000, to more acclaim:

…opens the great door of understanding to the profoundness of Chinese medicine.

—People’s Daily, Beijing, China

…weaves a picture…that is eminently understandable from a Westerner’s point of view…adds a valuable analysis of the current scientific understanding of how the therapies work and their effectiveness.

Brian Berman

Ted Kaptchuk’s book was inspirational in the development of my acupuncture practice and gave me a deep understanding of traditional Chinese medicine…

Dr. George T. Lewith

…a gift for all who share an interest in deep understanding of healing. This new edition is essential reading…

Michael Lerner, President, Commonweal

Even Edzard Ernst, still in his foggy period, called the 2nd edition “a brilliant synthesis of traditional and scientific knowledge…compulsory reading…”

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Dummy Medicine, Dummy Doctors, and a Dummy Degree, Part 2.0: Harvard Medical School and the Curious Case of Ted Kaptchuk, OMD

Review

The recent albuterol vs. placebo trial reported in the New England Journal of Medicine (NEJM) found that experimental subjects with asthma experienced substantial, measured improvements in lung function after inhaling albuterol, but not after inhaling placebo, undergoing sham acupuncture, or “no treatment.” It also found that the same subjects reported having felt substantially improved after either albuterol or each of the two sham treatments, but not after “no treatment.” Anthropologist Daniel Moerman, in an accompanying editorial, wrote, “the authors conclude that the patient reports were ‘unreliable,’ since they reported improvement when there was none”—precisely as any rational clinician or biomedical scientist would have concluded.

In Part 1 of this blog we saw that Moerman took issue with that conclusion. He argued, with just a bit of hedging, that the subjects’ perceptions of improvement were more important than objective measures of their lung function. I wondered how the NEJM editors had chosen someone whose bibliography predicted such an anti-medical opinion. I doubted that Editor-in-Chief Jeffrey Drazen, an expert in the pathophysiology of asthma, had ever heard of Moerman. I suggested, in a way that probably appeared facetious, that Ted Kaptchuk, the senior author of the asthma report, might have recommended him. (more…)

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Dummy Medicines, Dummy Doctors, and a Dummy Degree, Part 1: a Curious Editorial Choice for the New England Journal of Medicine

Background

This post concerns the recent article in the New England Journal of Medicine (NEJM) titled “Active Albuterol or Placebo, Sham Acupuncture, or No Intervention in Asthma.” It was ably reviewed by Dr. Gorski on Monday, so I will merely summarize its findings: of the three interventions used—inhaled albuterol (a bronchodilator), a placebo inhaler designed to mimic albuterol, or ‘sham acupuncture’—only albuterol resulted in a clinically important improvement of bronchial airflow; for that outcome the two sham treatments were equivalent to “no intervention.” For all three interventions, however, self-reported improvements were substantial and were much greater than self-reported improvements after “no intervention.” In other words, dummy treatments made the subjects (report that they) feel better, whereas real medicine not only made them feel better but actually made them better.

Before proceeding, let me offer a couple of caveats. First, the word ”doctors” in the flippant title of this post refers mainly to two individuals: Daniel Moerman, PhD, the anthropologist who wrote the accompanying editorial, and Ted Kaptchuk, the Senior Author of the trial report. It does not refer to any of the other authors of the report. Second, I have no quarrel with the trial itself, which was quite good, or with the NEJM having published it, or even with most of the language in the article, save for the “spin” that Dr. Gorski has already discussed.

My quarrels are the same as those expressed by Drs. Gorski and Novella, and by all of us on the Placebo Panel at TAM. This post and the next will develop some of those points by considering the roles and opinions of Moerman and Kaptchuk, respectively.

A True Story

Late one night during the 1960s a friend and I, already in a cannabis-induced fog, wandered into a house that had been rented by one of his friends. There were about 8-10 ‘freaks’ there (the term was laudatory at the time); I didn’t know any of them. The air was thick with smoke of at least two varieties. After an uncertain interval I became aware of a guy who was having trouble breathing. He was sitting bolt upright in a chair, his hands on his knees, his mouth open, making wheezing sounds. He took short noisy breaths in, followed by what seemed to be very long breaths out, as though he was breathing through a straw. You could hear the wheezing in both directions. Others had also noticed that he was in distress; they tried to be helpful (“hey, man, ya want some water or somethin’?”), but he just shook his head. He couldn’t talk. My friend, who had asthma himself, announced that this guy was having an asthma attack and asked if he or anyone else had any asthma medicine. No one did.

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SOS DD

What does it take to become a doctor?  Endurance and perseverance help. It is a long haul from college to practice.  But the skill that is most beneficial is the ability to consume prodigious amounts of information, remember it, and recall it as needed.  Although I often relied on ‘B’ to get me through some of the exams.

Thinking, specifically critical thinking, is not high on the list of abilities that are needed to become or be a doctor. Day to day, doctors need to think clinically, not critically.  Clinical thinking consists of synthesizing the history, the physical and the diagnostic studies and deciding upon a diagnosis and a treatment plan.  It is not as simple as you might think.  When medical students start their clinical rotations and you read their notes, you realize they have what amounts to an advanced degree at Google U.  They know a huge amount of information, but have no idea how the information interrelates and how to  apply the that information to a specific clinical scenario.  With time and experience, and it takes at least a decade, students become clinicians and master how think clinically, but rarely the need to think critically.

The volume of data combined with time constraints ensures that we need to rely on the medical hierarchy to help manage the information overload required to apply science and evidence based therapy.  There is just to much data for one tiny brain to consume. Other doctors rely on me for the diagnosis and treatment of odd infections.  In turn, I  rely on the published knowledge and experience of my colleagues who have devoted a career to one aspect of infectious diseases.  There is little time for most doctors to read all the medical literature carefully, and usually little need.  We have people and institutions  we use as surrogates.

Not only is critical thinking usually not required to be a good physician, but medical practice can conspire to give physicians a false sense of their own abilities.  Really.  Some doctors have an inflated sense of self worth.  Who would have thought it?  Spend time with some doctors and listen to them pontificate on politics or economics with the same (false) assurance that have in their true field of expertise, and you will run screaming from the room. (more…)

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