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The College of Physicians and Surgeons of Ontario’s muddled draft policy on “non-allopathic” medicine

Detroit is my hometown, and three and a half years ago, after nearly twenty years away wandering between residency, graduate school, fellowship, and my first academic job, I found myself back in Detroit minted as surgical faculty at Wayne State University and practicing and doing research at the Barbara Ann Karmanos Cancer Institute. One thing that I had forgotten about while I was away for so many years is just how intimately southeast Michigan interacts with Canada. This closeness is not surprising, given that Detroit and Windsor are separated by only about a half mile of Detroit River. Indeed, a there are a lot of Canadians who cross the border on a daily basis to work in the Detroit area, many of them in the medical center within which my cancer center is located. The reason I point this out is not to wax nostalgic for trips to Windsor or for the occasional trip to Stratford to see plays but to point out that Ontario is right next to us. What happens there is of concern to me because I know quite a few people who live there and because it can on occasion influence what goes on over here on the U.S. side of the border.

I recently learned that the College of Physicians and Surgeons of Ontario (CPSO) has been working on updating its policy on the use of nonconventional medical therapies. The wag in me can’t help but wonder why such a policy would need to say anything other than that, if it isn’t science- and evidence-based, the CPSO doesn’t support using it, but in a less sarcastic moment I realized that such a policy is probably not that bad an idea, as long as it doesn’t legitimize pseudoscience, which is, of course, the biggest pitfall to be avoided when writing such a policy. Not too long ago, the CPSO released its draft policy and has asked for public comments, with the deadline being September 1. I was happy to learn that I had not missed the deadline, because there is much to comment about regarding this policy, but it’s definitely true that time’s short. Unfortunately, I wasn’t so happy when I read the title of the draft policy, namely Non-Allopathic (Non-Conventional) Therapies in Medical Practice, with a subtitle of “Formerly named Complementary Medicine.” The full policy in PDF form can be found at this link.

“Allopathy” versus everything else?

Regular readers of SBM will probably notice one thing right away, even before clicking on either of the links and reading the draft policy. The problem is right there in the title and, in fact, I was floored when I first read the title. My jaw dropped, and dropped hard. Basically, I couldn’t believe that the CPSO had decided to use the term “allopathic” to describe science- and evidence-based medicine. True, that wasn’t the only problem, but it gave me a sinking feeling to see such a term right there in the title. So what’s the problem?

“Allopathic medicine” was a derogatory term originally coined by Samuel Hahnemann, the inventor of homeopathy to contrast homeopathy with the medicine of the time, namely that of 200 years ago. Hahnemann, as you may recall, believed in what he called the Law of Similars, which states that “like cures like,” or, to be more clear, that medicines that cause the same symptoms as a disease should be used to treat the disease. Doing this would stimulate the “vital force” and lead to resolution of the symptoms. Of course, this is nothing more than the principles of sympathetic magic transmuted (if you’ll excuse the term) into a different element, namely that of medicine; there has never been any convincing evidence—or even much in the way of evidence at all—that “like cures like” (or, using the Latin that Hahnemann favored, similia similibus curentur) is a general principle in biology or medicine. According to Hahnemann, “allopathy,” as opposed to homeopathy, is medicine that violated the law of similia similibus curentur and treats disease using remedies whose effects differ from those produced by that disease, the term meaning “other than the disease.” From its very origin, in fact, “allopathy” has been a derogatory term for medicine that is not homeopathy. Indeed, you can even find quotes to that effect documented in—of all places—the Wikipedia entry on allopathy. For instance, James Whorton points out in his book Nature Cures: The History of Alternative Medicine in America:

One form of verbal warfare used in retaliation by irregulars was the word “allopathy.” Coined two hundred years ago by Samuel Hahnemann, founder of homeopathy, it was taken from Greek roots meaning “other than the disease” and was intended, among other things, to indicate that regular doctors used methods that were unrelated to the disharmony produced by disease and thus were harmful to their patients. “Allopathy” and “allopathic” were liberally employed as pejoratives by all irregular physicians of the nineteenth century, and the terms were considered highly offensive by those at whom they were directed. The generally uncomplaining acceptance of [the term] “allopathic medicine” by today’s physicians is an indication of both a lack of awareness of the term’s historical use and the recent thawing of relations between irregulars and allopaths.

The other aspect of the term “allopathy” is that it was consciously used by practitioners of “unconventional” medicine to relegate “conventional” medicine to nothing more than another “competing” school of medicine. The term thus serves the simultaneous purpose of bringing “allopathic medicine” down to homeopathy’s level and elevating homeopathy to the level of conventional medicine. Far better, albeit still imperfect, characterizations could be:

  • Science-based medicine versus nonscientific medicine
  • Conventional medicine versus unconventional medicine
  • Medicine versus unproven medicine

Other possibilities come to mind. Of course, my preferred one (reality-based medicine versus magic) is probably a bit too stark. Be that as it may, I would contend that accepting the language of practitioners of unscientific medicine and using it in an official policy statement is not a good idea. Language has power and meaning. No one knows that better than promoters of “complementary and alternative medicine” (CAM) or “integrative medicine” (IM) or whatever it is that quacks decide to call it next. While the use of language in the CPSO draft is disturbing enough in and of itself, there are more substantive problems with the draft that need to be discussed.

Beyond “allopathic medicine”

The opening of the CPSO statement does not begin any more auspiciously than the title, after which the statement quickly devolves into meaningless platitudes that accept many of the false equivalencies promoted by CAM practitioners when arguing for pseudoscience. For example, check out how the draft opens:

In increasing numbers, patients are looking beyond allopathic medicine to nonallopathic therapies for answers to complex medical problems, strategies for improved wellness, or relief from acute medical symptoms. Patients may seek advice or treatment from a range of health care providers, including Ontario physicians.

The College supports patient choice in setting treatment goals and in making health care decisions, and has no intention or interest in depriving patients of non-allopathic therapies that are safe and effective. As a medical regulator, the College does, however, have a duty to protect the public from harm. Thus, the object of this policy is to prevent unsafe or ineffective non-allopathic therapies from being provided by physicians, and to prohibit unprofessional or unethical physician conduct in relation to these therapies.

Right from the beginning, all the buzzwords and false equivalencies are right there. There’s the appeal to popularity in the form of the unreferenced, unsupported statement that more patients are embracing non-science-based medicine. That’s rapidly followed by the platitude assuring us that the CPSO supports patient “choice,” which implies by contrast that those who might not be as open to “non-allopathic” medicine are somehow against “patient choice.” particularly given the line of how the CPSO has “no intention or interest” in “depriving” (note the word choice) of their woo. Of course, one wonders what these “non-allopathic” treatments are that are both safe and effective might be. After all, if they were both safe and effective they wouldn’t be “alternative.” I’m tempted to repeat that old trope that alternative medicine that is proven to be safe and effective ceases to be “alternative” and becomes simply “medicine.” Never mind. I just did. So did the CPSO:

The categorization of specific therapies as non-allopathic is fluid: as clinical evidence regarding efficacy is accumulated, certain non-allopathic therapies may gain broad acceptance and thus be accepted in allopathic medicine.

I’ve tried to think of an example of any such therapies that have made the leap from “non-allopathic” to “allopathic” medicine and am hard-pressed to do so. Be that as it may, just because this is an old trope doesn’t mean it isn’t true. Substituting the term “non-allopathic” medicine for term “alternative” medicine or CAM in this draft statement not-so-subtly equates what was once called CAM or “alternative medicine” with “allopathic medicine.” Again, language matters, and the CPSO knows it. Its choice of the the term “non-allopathic” was deliberate:

Different operative terms have been adopted that were deemed to be value-neutral: ‘Allopathic medicine’ refers to traditional or conventional medicine (as taught in medical schools) and ‘non-allopathic therapies’ refer to complementary or alternative medicine.

Notice also how the CPSO chooses to characterize patients looking for CAM as “looking beyond” allopathic medicine, which implies that CAM modalities are somehow ahead of or superior to “allopathy.” A more appropriate way to phrase this concept would be to say that patients are looking “outside of” science-based medicine or “elsewhere than” science-based medicine. But, no. Patients are “looking beyond” that tired, old, hidebound scientific medicine.

Imagine my relief that the College is committed to preventing unsafe or ineffective “non-allopathic” therapies from being provided by physicians. You know, ineffective like homeopathy.

Platitudes mixed with disturbing statements

If there’s one thing about this draft that impresses me about the CPSO draft policy is the sheer number of meaningless platitudes the CPSO packed into it. Mixed in with these platitudes are statements that range from disturbing to just plain puzzling. For instance, one puzzling aspect of the draft occurs where the CPSO points out that physicians should “refrain from exploitation” and abusing his power over patients and avoid conflicts of interest. No one, least of all I, would argue that physicians should exploit their patients or engage in activities that represent a blatant conflict of interest, but nowhere in the draft is this principle related to the use of “non-allopathic” medicine by patients or physicians. At least for the other principles the draft at least takes a stab at trying to relate them to patient autonomy, which, of course, the CPSO supports. The CPSO also expects physicians to:

  1. Act in patients’ best interests, in accordance with fiduciary duties;
  2. Respect patient autonomy with respect to health care goals, and treatment decisions;
  3. Communicate effectively and openly with patients and others involved in the provision of health care;
  4. Maintain patient trust through a commitment to altruism, compassion and service.

As opposed to, I suppose, advocating not acting in patients’ best interests, not respecting patient autonomy, not communicating effectively and openly, and not being committed to altruism, compassion, and service. I know, I know, I’m being a bit curmudgeonly, and I realize that these sorts of principles have to be repeated and emphasized, but it’s about the specifics of how physicians will adhere to such principles “where the rubber hits the road,” so to speak that such a policy should provide guidance. I would argue that it is a physician’s responsibility always to be honest with his patients and to pull no punches when it comes to giving his professional opinion. That is the very essence of acting in the patient’s best interest and communicating effectively and openly. What, then, am I to make of some of the statements in this draft that sound suspiciously like advocating pulling punches? For instance:

The College expects physicians to respect patients’ treatment goals and decisions, even those which physicians deem to be unfounded or unwise. In doing so, physicians should state their best professional opinion about the goal or decision, but must refrain from expressing non-clinical judgements.

I can’t help but wonder whether calling, for example, homeopathy “quackery” would be viewed as a “non-clinical” judgment by the CPSO. The language used smacks of the CAM-enabling sort of language that demands that we physicians above all remain “nonjudgmental.” Personally, I would counter that it is our professional responsibility to be judgmental when it comes to evaluating the evidence for a treatment. It is our duty to judge what treatments are safe and effective and which are not; that’s what our patients come to us for.

Here’s another problematic passage:

When providing non-allopathic therapies, physicians are expected to demonstrate the same commitment to clinical excellence and ethical practice, as they would when providing allopathic care.

The problem here is that providing “non-allopathic” care that is not evidence- and science-based (in other words, virtually all of it) is inherently unethical and represents anything but “clinical excellence.” This is a rather amusing conundrum to me. Consider this example. If a physician (and, make no mistake, there are a fair number of physicians who do this) offers homeopathy, which is nothing more than magical water supposedly imbued with mystical healing caused by the “memory of water” remembering whatever remedy that was in it before and forgetting, as Tim Minchin puts it, all the poo that’s been in it. How can any physician ethically offer homeopathy, for example, to a patient? Similar arguments construct themselves for other “non-allopathic” therapies, such as reiki (which is faith healing that substitutes Eastern mysticism for Christianity as its basis) or acupuncture, which postulates that sticking needles into “meridians” that have no detectable anatomic counterpart somehow “unblocks” the flow of vitalistic mystical life energy to healing effect. Yet, the CPSO goes on to state:

Physicians must always act within the limits of their knowledge, skill and judgement9 and never provide care that is beyond the scope of their clinical competence.

This expectation applies equally to treatments or therapies that the physician proposes and those that may be requested directly by patients. Where patients seek care that is beyond the physician’s clinical competence, physicians must clearly indicate that they are unable to provide the care. Physicians should consider whether a referral can be made to another physician or health care provider for care the physician is unable to provide directly.

While this is simply a restating of basic physician ethics when it comes to science-based medicine, I can’t help but wonder: Does this policy in the context of emphasizing patient autonomy and choice somehow obligate or imply an obligation for an Ontario physician to refer to a “non-allopathic” practitioner if that is what the patient wants? Shouldn’t there be a clear statement that a physician is not obligated to support the use of “non-allopathic” medicine if he believes it—and correctly so—to be quackery? The whole thing is a muddle, particularly given the statements elsewhere in the policy about how diagnosis and treatment should be based on the principles of “allopathic” medicine?

A brief policy statement

It’s obvious from the wishy-washy approach to the scientific basis of medicine, the waffle words when it comes to whether an “allopathic” physician should support “non-allopathic” therapies, and the apparently inadvertent use of language favored by quacks that there were far too many “alternative” practitioners involved in drafting this policy. Similarly, the comments are dominated by believers, although I must admit that one of them does point out the conflict inherent in this policy, as the CPSO tries to have it both ways:

“To act in accordance with the standards of allopathic medicine, physicians providing non-allopathic care must reach an allopathic diagnosis”

This doesn’t make sense! If I want non-allopathic care, then that includes a non-allopathic diagnosis. Allopathic labelling is only useful for determining which prescription to write and has no business in non-allopathic medicine!

This would be a bit of a problem in traditional Chinese medicine, where the diagnoses are based on “imbalances” in heat, moisture, etc., and some diagnoses come about by mapping organs to locations on the tongue. Similarly, in homeopathy, diagnoses are not necessarily based on physiology and treatments are based on homeopathic “provings.” Yes, this believer nailed the conundrum that the CPSO is trying to dance around.

To that end, let me propose a much briefer policy statement for the CPSO to consider in a few bullet points:

  • Medicine should be science- and evidence-based. “Alternative” and “evidence-based,” “allopathic” and “non-allopathic,” “conventional” and “unconventional” are all false dichotomies. If a treatment is not evidence- and science-based, it is not medicine. Such a treatment becomes “medicine” only when it is demonstrated to work by science.
  • Competent adults have every right to seek out non-science-based medicine if that is what they desire. However, informed consent mandates that physicians who encounter such patients provide an honest professional assessment of such treatments based on science.
  • Physicians should always inquire about the use of non-science-based medicine when evaluating their patients, so that they can take into account possible interactions with medical treatments.
  • Physicians are in no way obligated to refer patients to “alternative medical” practitioners. For many forms of “alternative medicine” doing so is unethical because such modalities are not science- or evidence-based.

I’m sure readers can come up with their own versions or suggest modifications and/or additions to the bullet points above.

In the meantime, there is still more than a week left before the September 1 deadline for supporters of science-based medicine to let the CPSO know the problems in its draft policy by e-mailing ComplementaryMedicine@cpso.on.ca or filling out CPSO’s online survey. It’s clear from the comments that are there now that more input from supporters of science-based medicine is needed.

Michael Kruse at Skeptic North has more.

Posted in: Homeopathy, Politics and Regulation, Public Health

Leave a Comment (33) ↓

33 thoughts on “The College of Physicians and Surgeons of Ontario’s muddled draft policy on “non-allopathic” medicine

  1. skepkids says:

    As an Ontario physician, I received an invitation to review this policy a few months ago. Admittedly I read through it quickly however I actually thought it was pretty good at first (other than the sickening use of “allopathy” in the title).

    I thought the whole bit about requiring an “allopathic diagnosis” was a clever way to make it impossible to practice certain forms of quackery (such as reiki where the diagnosis would be something like ‘an imbalance in energy’).

    Further, the policy requires physicians to give evidence-based advice to their patients when it comes to CAM – something which removes the double standard where CAM doesn’t need to be evaluated by the scientific method. Physicians who follow this policy honestly won’t be able to use, for example, acupuncture because it requires a “non-allopathic diagnosis” and it can’t be recommended to patients based on the current evidence.

    I agree with Dr Gorski that the language (especially the use of the word “allopathy”) is troublesome but I had no major problems with the meat of this policy on the first read. Perhaps it deserves a review.

  2. Shelley says:

    Thanks very much for this info. I’ve completed the survey and left extensive comments for the college. I hope others from Ontario will also do so.

    P.S. As a former Windsor resident, I know Detroit well and return to the area often. There are many people who go back and forth across the border, including patients going both ways: Canadians looking for care not easily or quickly available, and Americans, who frequently borrowed health care cards from Canadian friends and family in order to obtain “free” health care.

  3. humesghost says:

    Skepkids: On a quick read, the “meat” of CPSO policy can seem quite reasonable – there are lots of promising noises about the need for evidence, etc. But if you read more closely, lots of the evidence talk is seriously weakened by weasel words and caveats. For a detailed analysis of this, read the response from the Committee for the Advancement of Scientific Skepticism (CASS) at http://www.cficanada.ca/blogs/entry/media_advisory_ontario_doctors_given_the_green_light_to_promote_quackery/. (This is also linked from Michael Kruse’s Skeptic North post, linked above.)

  4. If Samuel Hahnemann can invent the term allopathy to describe non homeopathic medicine, then I can invent the term quackopathy for all non-science based medicine. Quackopathy would be reserved for modalities that have specifically failed to be scientifically validated (nearly all sCAM)rather than those yet to be validated except that the clincal practice of said yet to be validated modalities outside of research trials would still be quackopathy.

    I am ashamed that when I was still fairly new to this topic, I ignorantly used the term allopathy to refer to sceince-based/ non sCAM medicine/ non quackopathy, not understanding the origin of the term.

  5. windriven says:

    At around line 100 the Policy states: “[P]hysicians should state their best professional opinion about the goal or position, but must refrain from expressing non-clinical judgments.”

    Would it offend the letter or spirit of this policy statement if a physician stated to his or her patient that quackery is quackery, unsupported by the merest shred of scientific plausibility much less scientific evidence, and that anyone who would resort to such treatment is a rube? Is rubery a clinically recognized diagnosis in the DSM?

    If it isn’t it should be.

  6. ConspicuousCarl says:

    Everyone should look at (and complete, if you can stand it) the CPSOs feedback survey for the policy:

    http://www.surveymonkey.com/s/56B9RB8

    The questions asked there are even more absurd than the policy itself…

    (in a select-all-that-apply question)

    Do you believe that physicians must only propose non-allopathic therapies that:

    > Have a reasonable chance of improving patient health, or remedying symptoms

    > Offer more benefits than risks

    > Take into account patients’ financial status when patients are paying for treatment directly

    Given that the first two are probably supposed to be obvious “yes’s”, it is disturbing that they appear to be offering a third implied positive which suggests that a patient might receive shoddy medicine because they can’t afford something better.

    Each question has a “details” box for text. I said that a person’s financial status should not affect the medical advice they receive, and if a person can’t afford the medicine then they need financial assistance, not altered medical advice.

    If physicians recommend non-allopathic therapies, do you think their recommendation should be supported by scientific evidence?

    I nearly went made responding to several questions in this same theme of asking if good science or ethics ought to be followed when offering fraudulent therapies. The entire survey is plagued by a clear indication that the CPSO thinks there is a valid category which might be called “alternative” or “non-allopathic” and contains scientifically-proven medicine.

    For all of these, I repeated some form of the observation that the question makes no sense and that anything with real evidence to support it is not alternative.

    Should physicians have a higher quality of evidence (more scientific evidence, as opposed to anecdotal evidence) to support treatment options that might have a significant impact on the patient: either very risky or very expensive and not covered by OHIP?

    A creepy implication that insurance coverage means it is OK to sell bullshit because hey, we are screwing everyone instead of only the patient.

    I said no, because all practices require the same standard, and insurance coverage does not justify bad science.

    In the final comment box, I told them the entire policy on alternative medicine was an unnecessary duplication of science and ethics policies, tainted by an incoherent suggestion that fake medicine be administered ethically. I suggested that the entire document be replaced by the following statement:

    “Words like ‘non-allopathic’, ‘alternative’, and ‘complementary’ have no scientific meaning. The CPSO has established ethical and scientific standards which apply to all practices, and no medical practice, existing or proposed, is exempt from these standards.”

  7. aeauooo says:

    Maintain patient trust through a commitment to altruism, compassion and service.

    Perhaps the CPSO has a different understanding of the meaning of altruism than the one with which I am familiar.

    I suspect that health care professionals who practice self-renunciation in the work place do not survive very long. I suspect that most health care professionals are to some extent, self-sacrificing, but we are compensated for our work.

    I like to think that providing the same quality of care in my volunteer work as I do when I am paid is altruistic. In The Perennial Philosophy, Aldous Huxley wrote that true altruism is rare; that is, we are rarely, if ever, completely disinterested.

    Feeling good about myself is a reward for volunteer work, therefore, my volunteer work is not altruistic. Receiving a paycheck nullifies the altruism of any act performed in the workplace.

  8. pmoran says:

    I agree strongly about this misuse of the term “allopathic”. The mainstream has proved itself to be quite eclectic in its choice of remedies, in accord with its less doctrine-bound approach to medicine. Alternative modalities including some versions of homeopathy are as “allopathic”.

    I find policy decisions less clear. They pose a different class of questions.

    Remember that the very need for a “CAM policy” has arisen despite?/ because of? mainstream withdrawal into increasingly EBM-dominated medicine.

    The science of medical interactions is also still unclear in some respects.

  9. CC says:

    At around line 100 the Policy states: “[P]hysicians should state their best professional opinion about the goal or position, but must refrain from expressing non-clinical judgments.”

    Would it offend the letter or spirit of this policy statement if a physician stated to his or her patient that quackery is quackery, unsupported by the merest shred of scientific plausibility much less scientific evidence, and that anyone who would resort to such treatment is a rube? Is rubery a clinically recognized diagnosis in the DSM?

    Isn’t “that treatment has been shown to not work” or “has not been shown to work” a clinical judgement? You don’t have to call the patient a rube. (Even if they are.) At least they’re in a doctor’s office asking about it instead of in a quack’s office buying it.

  10. Harriet Hall says:

    @pmoran,

    “mainstream withdrawal into increasingly EBM-dominated medicine.”

    That’s a very biased description of medicine’s increasing emphasis on trying to find out what really works. Withdrawal from what? From belief-based treatments and quackery.

  11. pmoran says:

    @pmoran,

    “mainstream withdrawal into increasingly EBM-dominated medicine.”

    That’s a very biased description of medicine’s increasing emphasis on trying to find out what really works. Withdrawal from what? From belief-based treatments and quackery.

    Biased, or historically accurate?

    Harriet, I was thinking mainly of “trying anything that might help”, even if only on anecdotal or weak evidence.

    That is how medicine always was. Despite many massive medical triumphs, we have ended up removing far more treatments from consideration than we have provided safe cost-effective options for many very common complaints.

    The mind-set of EBM and medical skepticism is that it is utterly wrong to use treatments that are not proven, even if never adequately tested, and that is a key difference from CAM (aside from, usually, an unbridgeable gulf in medical knowledge.)

    Now I understand why that should be so. I thoroughly agree that the mainstream should be dominated by EBM/SBM. But the very phenomenon of CAM shows that the public (our employer, the true “owner” of medicine) is not so sure.

    So our policies in relation to CAM have deep political implications.

    It is not enough to say “this is how things should be” if that merely drives more of CAM underground.

    We need to ask what we most want to achieve and I wonder whether in this specific context we should have policies that emphasise patient safety rather than scientific correctness. The public will find it easier to understand those concerns, so long as they are not exaggerated.

  12. David Gorski says:

    Remember that the very need for a “CAM policy” has arisen despite?/ because of? mainstream withdrawal into increasingly EBM-dominated medicine.

    You say that as though it were a bad thing.

    Hint: EBM-dominated medicine is not a bad thing. Of course, SBM-dominated medicine would be better, and both are better than the alternative, namely belief-based or anecdote-based treatments.

  13. Harriet Hall says:

    @pmoran,

    “The mind-set of EBM and medical skepticism is that it is utterly wrong to use treatments that are not proven, even if never adequately tested,”

    Arrgh! This is a straw man argument, Peter. I have repeatedly said that I have no objection to patients using any treatment they want to use, whether tested or not, even if there is potential harm – as long as they get accurate information so they can give informed consent. The problem is when MDs prescribe untested treatments in a way that misleads patients.

  14. I think I can see where pmoran is coming from.

    Here’s my anecdote, most of our doctors or other health care provider do not identify themselves as Evidence Based Medical people. The one provider that we have worked with (not in our regular network) who did claim to make recommendations that were EBM I was quite unhappy with. She seemed to drag her feet on a safe device that we were interested in for our child because it had not yet been recommended by an east coast children ‘s hospital as an “Evidenced Based” support for his condition. She neglected to recommend a relevant school program for our child because she felt there was no evidence that it would be helpful. When I looked online for studies on children with my son’s condition, I found very little research had been done. There was actually very little evidence of anything that would be helpful.

    Luckily we found the school program through other channels and it was very helpful. Looking at the program it was pretty clearly plausible that it would be helpful, but our EBM provider didn’t seem to consider that.

    So my one impression of EBM (which could have been a poor representative of the movement) is that it pretty clearly screws people with under-researched, rare or multiple conditions.

    Of course, this is just from an average laymen’s perspective.

  15. pmoran says:

    I see no need to resile from what I have said above.

    David, I agree with you! I stated: “I thoroughly agree that the mainstream should be dominated by EBM/SBM.

    Harriet, again you accuse me of a straw man while responding to one of your own. We were talking about “what doctors should do” as a general ethical policy and you respond with how you react to what patients might want to do, which I have never, ever objected to.

    You both are brilliant at what you do well, David at dissecting out complicated areas of medical knowledge, and you, Harriet, at presenting very readable, easily understood, and relatively unbiased appraisals of specific CAM claims. I am adept at neither.

    It is still possible that you both may have something yet to learn about CAM culture and the aspects of mainstream medicine that have led to its recent expansion –matters relevant to how we present ourselves to the public.

    Remember that despite all the often well-deserved back-slapping you receive here, and the easily refuted attempts at scientific argument from medical ingenues, there may still matters yet to be understood about medicine in general and CAM in particular.

    1. Harriet Hall says:

      @pmoran,
      Don’t accuse me of straw man: I was responding to exactly what you said:
      “The mind-set of EBM and medical skepticism is that it is utterly wrong to use treatments that are not proven, even if never adequately tested,”

      That is a straw man any way you look at it. I don’t think anyone believes it is “utterly wrong” to use treatments that are not proven. Doctors use unproven treatments all the time, both in research settings and in common practice when no proven treatment is available. It is not “utterly wrong.” But it is utterly wrong to substitute an unproven treatment for a proven one or to mislead patients by giving them the impression that a treatment has been proven when it hasn’t.

  16. rogerman says:

    On a related note, readers might be interested to know that the Province of Ontario has recently passed legislation laying the groundwork for creating a “College of Naturopathy” and a “College of Homeopathy” (http://www.health.gov.on.ca/en/news/bulletin/2009/regulatory_councils_homeopaths.aspx). Legitimizing quackery as a “regulated health profession”, a shrewd bureaucratic maneuver to corral and tax the genies, or simple, mindless vote pandering? Whatever the rationale, Ontario physicians need a cogent policy guiding patient counsel where these “health professions” are concerned yesterday.

  17. rork says:

    I’m disappointed with the language, but maybe saying it plainly was thought to resemble shrieking. I find (perhaps like michele) that some “real” doctors are not-so-good at executing SBM, just cause they aren’t smart or educated enough, or their logical and analytic abilities are weak, or they are self interested. Some possible examples of self interest I have lived with:
    Internal radiation for breast cancer: Some centers do it this way cause, well, cause that’s the way they do it, and perhaps cause some patients like it for convenience (done in about 1 week). I think there is an element of “sounds cool to the patient” though. Evidence that it beats top-line external radiation was crappy when I reviewed the subject about 2 years ago. If they did decent trials I think it likely to be proven inferior. The doctors administering these treatments may suspect that (but some don’t really keep up, or can’t adequately follow the literature, or don’t want to), but don’t really talk about their misgivings.
    Radioimmunotherapy with Bexxar (or Zevalin) is a local poster-child here in Ann Arbor cause of development by a local hero, Mark Kaminski. The concern is that docs don’t use these methods, cause they’d have to send the patient to a specialist rather than getting to infuse alternative chemo drugs themselves, which is their bread and butter.

  18. ConspicuousCarl says:

    rogerman on 23 Aug 2011 at 9:55 am

    On a related note, readers might be interested to know that the Province of Ontario has recently passed legislation laying the groundwork for creating a “College of Naturopathy” and a “College of Homeopathy” (http://www.health.gov.on.ca/en/news/bulletin/2009/regulatory_councils_homeopaths.aspx).

    And in 2012, the Prisons Bureau will add “shiv making” to its inmate education curriculum (policy formation survey, Q. 42: “Should inmates follow fair racial equality practices when stabbing each other? Yes / No / Unsure”).

    Kill me now.

  19. S.C. former shruggie says:

    Being an Ontario resident I filled out the questionnaire yesterday. The questions are as alarming as Carl suggests. I hope my comments on every question make some difference. I doubt it though, even with the Soylent Green references. This province appears increasingly mired in woo.

    I find it especially insulting the way the directed questions for public input play up the health freedom trope of lowering the bar for evidence in the name of giving consumers what they want. Hello, College of Physicians and Surgeons of Ontario. You’re talking about regulations. They’re not supposed to give people whatever they want, even if unsafe and ineffective! They’re regulations!

  20. pmoran says:

    Harriet: “Don’t accuse me of straw man: I was responding to exactly what you said:
    “The mind-set of EBM and medical skepticism is that it is utterly wrong to use treatments that are not proven, even if never adequately tested, — ”

    No, you took this as a personal attack even though I went on say “I understand why that should be so. I thoroughly agree that the mainstream should be dominated by EBM/SBM.”

    At the time I was contrasting certain patient expectations of doctors that I believe contribute to CAM use and the attitudes that direct the prescribing and treatment suggestions of most mainstream doctors.

    My point was never that it is wholly wrong for the mainstream to confine itself to proven methods (especially if the public purse or insurers are footing the bill), but that to the extent that we do so we will have to contend with more dissatisfied clientele and more use CAM.

    There is a conflict of legitimate perspectives that ethical guidelines have to teeter between.

  21. Harriet Hall says:

    @pmoran,
    “No, you took this as a personal attack”

    I didn’t think I took it as a personal attack, but perhaps you know more about my thinking than I do. I took it as an inaccurate characterization of EBM and medical skepticism.

    “There is a conflict of legitimate perspectives that ethical guidelines have to teeter between.”

    This sounds suspiciously like a disparagement of the science-based medicine perspective. It sounds like you are advocating some kind of ill-thought-out practical expediency that disregards scientific truth. I hope my perception is wrong. Your comments are confusing to me. Can you help us to understand in detail, and with examples, exactly what your different “legitimate perspective” involves?

    “My point was never that it is wholly wrong for the mainstream to confine itself to proven methods”

    Good grief! I never thought that was your point. I can’t even imagine how anyone could think SBM was “wholly wrong.”

    ” to the extent that we [stick to SBM] we will have to contend with more dissatisfied clientele and more use CAM.”

    I don’t think that’s necessarily true; I think we can find ways to satisfy patients within the conventional medical system. But even if it were true in the short term, I could live with that. The goal of SBM is not to give the clientele what they want or to stop them from using CAM. It is to offer them proven treatments and to give them accurate information about unproven treatments so they can make informed decisions.

  22. David Gorski says:

    This sounds suspiciously like a disparagement of the science-based medicine perspective.

    Methinks there’s no “sounds suspiciously like” to it to me. Peter’s been disparaging the SBM perspective, either subtly or not-so-subtly, for quite a while now.

    It sounds like you are advocating some kind of ill-thought-out practical expediency that disregards scientific truth.

    Isn’t this what Peter’s been doing for at least the last year with his frequent tongue lashings of us “dogmatic” advocates for SBM and his frequent statements implying that we care more about SBM “purity” than patients?

  23. pmoran says:

    David, I have never ever challenged the principles of EBM or SBM except when it is assumed that ALL of medicine fits into the model of medicine it gives primacy to, as exemplified by the placebo-controlled trial.

    That model explicitly and deliberately excludes all other influences on patient well-being. Totally.

    To point that out, and that not all of the science supports that model for all questions is not in the least “disregarding scientific truth”.

    What we seem to be seeing here is a “scientific orthodoxy” that science itself would normally reject as being too presumptious.

    Instead of seriously considering mildly dissenting opinion, the method seems to be to rummage around until something is found said that can be interpreted as objectionable. Potentially valid points elsewhere can then be ignored as arising from an untrustworthy source.

  24. weing says:

    “That model explicitly and deliberately excludes all other influences on patient well-being.”
    I think you have to define your terms. Is “well-being” a subjective well-being or an objective measurement. If a patient feels better on a placebo albuterol for asthma, will you forego treatment with steroids to decrease the ongoing inflammation in the airways? When the patient’s lung disease progresses to the extent that subjective illness and objective illness converge, it may be too late to reverse the damage and the patient ends up living and objectively shorter life, have you really done your best for the patient?

  25. Harriet Hall says:

    @pmoran,

    “I have never ever challenged the principles of EBM or SBM except when it is assumed that ALL of medicine fits into the model of medicine it gives primacy to, as exemplified by the placebo-controlled trial.
    That model explicitly and deliberately excludes all other influences on patient well-being. Totally.”

    Wrong, wrong, wrong! SBM doesn’t have a “model” – it only assumes that everything in medicine can be studied systematically using scientific methods and reason. Over-reliance on the placebo-controlled trial is a failing of EBM that we have repeatedly criticized. Many other kinds of evidence (epidemiology, case studies, etc.) are useful, and prior plausibility should be part of the equation. In no way does SBM exclude any kind of influences on patient well-being: it aspires to study all influences on patient well-being in order to understand the truth and offer our patients the best possible care. Patient well-being, both subjective and objective, can and should be studied with science.

    It sounds like you are advocating “other ways of knowing,” but science is the only reliable way of knowing. Your reasoning is flawed: you are setting up straw men to knock down, setting up a false dichotomy, and resorting to special pleading.

    I am wondering if you have had some personal experience that has biased your opinions.

  26. ConspicuousCarl says:

    pmoran on 23 Aug 2011 at 11:01 pm

    David, I have never ever challenged the principles of EBM or SBM except when it is assumed that ALL of medicine fits into the model of medicine it gives primacy to, as exemplified by the placebo-controlled trial.

    That model explicitly and deliberately excludes all other influences on patient well-being. Totally.

    Yuck.

    The funny thing is that when I read this, I thought “we could have saved a lot of time if he had started with this statement”. And yet, my next thought was one I often have when encountering that kind of disconnected-from-reality statement: I don’t even know where to begin.

  27. pmoran says:

    And now the sneering from ConspicuousCarl.

    As I have allowed, the pathophysiological model of medicine is the correct focus for the majority of mainstream medicine.

    The paradigmatic example of it being applied “to the exclusion of everything else” is when sham acupuncture produces an effect size of 0.6 (medium to strong) with some conditions in some populations and the only message derived from that is that the supposedly “real” acupuncture performed little better. That is just one of dozens of examples I could provide.

    We need to know for sure what is happening with these people, not only so as to have the fullest understanding of our craft, but also so as to know how to talk about CAM wherever there is a possibility of a acceptable cost/risk/effectiveness profile from CAM use (presumably by by those unaffected by ethical concerns).

    We owe that to the public.

    Others are considering the implications of modern research into the placebo and other “incidental” effects of medical interactions. Benedetti and Kaptchuk have gotten together with this —

    http://www.sciencedirect.com/science/article/pii/S0140673609617062

  28. ConspicuousCarl says:

    pmoran:

    I won’t pretend that sneering is not often part of my routine, but it is usually not supposed to be the only content.

    Until you made the statement I quoted, I really was reading this stuff wondering if maybe there was some misunderstanding, and eventually you might explain to Hall and Gorski what you meant.

    It may only have been my personal moment of clarity when you said that, and suddenly it seemed obvious to me that you were stuck on one of those caricature ideas of “mainstream medicine” somehow ignoring part of reality. The “yuck” is because the first thing you said which I thought I really could nail down a single meaning for sounds like nonsense. Sorry, but that really is what it sounds like. Your offer of acupuncture is not helping, as you gave a rather blunt summary of the analyses which have been offered here.

    Counseling, appendectomies, and statins are parts of mainstream patient care, and they are hardly some kind of singular exclusive rut.

  29. GLaDOS says:

    Well this new policy statement might get Narconon Canada out of hot water for prescribing “non-allopathic” remedies for substance abuse.

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