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Defending CAM with Bad Logic and Bad Data

At SBM our mission is to promote the highest standards of science in medicine, and to explore exactly what that means, both in the specific and the general. We do spend a lot of space criticizing so-called CAM (complementary and alternative medicine) because it represents a semi-organized attempt to reduce or even eliminate the science-based standard of care, and to sow confusion rather than clarity as to how science works and what the findings of medical science are.

CAM proponents tend to use the same bad arguments over and over again. They have no choice (other than deciding not to be CAM proponents) – if a treatment were backed by solid logic and evidence it would not be CAM, it would just be medicine.  As SBM’s fourth year comes to a close I thought I would round up the most common bad arguments that CAM proponents put forward to defend their position. Like creationists, pointing out the errors in their facts and logic will not stop them from continuing to use these arguments. But this lack of imagination on their part makes it somewhat easy to counter their arguments, since the same ones will come up again and again.

The argument from antiquity

Our SBM colleagues in Australia have been critical of the incorporation of unscientific methods into academia. In defense of this practice:

Professor Iain Graham from Southern Cross University’s School of Health yesterday defended his university, saying the use of alternative therapies, such as homeopathy, can be traced as far back as ancient Greece.

This is a common claim – that some CAM modalities have been around for centuries, or even thousands of years, and so they must work. I am not sure if professor Graham intended to state that homeopathy can be traced back to ancient Greece, perhaps he just meant that some CAM therapies can, and chose homeopathy as a bad example. For the record, homeopathy was invented by Samuel Hahnemann about 200 years ago.

But I wonder what CAM modalities he had in mind. Chiropractic? About 100 years. Therapeutic touch? A few decades. Acupuncture is a complex question, but what passes for acupuncture today is less than 100 years old. Perhaps he was thinking about blood letting or trepanation.

It is true, however, that some basic concepts, like the notion of a life energy, can trace it roots to ancient Greece, and other ancient cultures. However, such notions are pre-scientific nonsense. Scientists abandoned the notion of life energy over a century ago because there was no evidence that such a force exists (and there still isn’t) and after figuring out all the basic processes of life there was essentially nothing left for the alleged life force to do.

For some reason, however, professor Graham believes that antiquity in science is a virtue – the “argument from antiquity” logical fallacy. The unstated assumption is that if an idea has survived for hundreds or thousands of years it must be legitimate. This is demonstrably false. Galenic medicine (blood letting, purging, etc. based on the notion of the four humours) survived for thousands of years, and yet it was based on complete and utter primitive nonsense. In fact its tendrils still exist – there is still blood letting, cupping (which is just another form of blood letting), and similar practices going on in the world. It was replaced in the West because of the advent of science in medicine – a trend that Graham and other CAM proponents apparently want to reverse.

The argument from popularity

Graham also states in the same article:

“Eighty per cent of Australians seek alternative therapies,” Prof Graham said.

“Obviously orthodox medicine is not working for everyone,” he said.

The argument from popularity is almost ubiquitous in CAM apologetics. We are constantly being told that CAM is popular and that its popularity is growing. This argument is used to justify incorporation of CAM into academia, spending research funds on CAM, and licensing CAM practitioners.

As with the argument from antiquity, the facts are often fudged. For example, I highly doubt that the 80% figure quoted for Australia is correct. Most such figures are highly inflated by including all sorts of practices in the CAM category, like exercise, eating organic food, and sometimes prayer is included. US surveys show the percentage of CAM use is around 1/3, but this is mostly things like massage and chiropractic manipulations. Homeopathy is around 3-4%, and acupuncture 6-7%. In fact, only manipulation and massage were in the double digits.

This is all marketing deception – create a false category (CAM), pad it out with commonly used methods, and then claim that the extreme fringes are therefore getting more popular. I don’t know how Graham got to 80% (I doubt such methods are that much more popular in Australia) but it is close to one survey from 2007 that found that 69% of Australians used one of the 17 most popular forms of CAM in the last year. However, they included in their list: martial arts, yoga, massage, meditation, and taking multivitamins. I am not sure what taking multivitamins says about the popularity of homeopathy, but apparently professor Graham thinks that is significant.

In any case – I will grant that CAM as a marketing concept has been somewhat successful, and even that it has gained popularity recently (although not as much as advocates would have you think). That is entirely irrelevant, however, to the question of whether or not any particular CAM modality is science-based and appropriate for a university curriculum.

Universities are supposed to be thought-leaders, to have intellectual standards that rise above the mere notion of popularity. They are supposed to uphold academic standards of scholarship, and in scientific disciplines high standards in science. The medical profession should be science-based and have high professional standards – not cater to the latest fad. It is therefore very odd and disturbing to defend a university policy or professional conduct based upon popularity. Should we allow surveys of public opinion to determine whether or not we teach creationism or astrology in our universities?

False choice

The second part of Graham’s quote was:

“Obviously orthodox medicine is not working for everyone,” he said.

This is a common assumption, even among CAM critics. If people are choosing to use CAM then they must be dissatisfied with mainstream medicine.  This is a way of providing a false choice – if there are deficiencies in science-based medicine, then CAM is an appropriate “alternative.” Again – this is a similar strategy to the creationists, whose main style of argument is to attempt to poke holes in evolutionary theory, then propose creationism as the only alternative, without ever providing actual evidence for creation.  CAM proponents therefore spend a lot of time criticizing mainstream medicine, and then present CAM as the only alternative.

The claim that people are using CAM because they are not satisfied with science-based medicine, however, is not based upon any evidence. In fact, what evidence we have strongly suggests this is wrong. Surveys show that people use CAM because they want to increase their options, or because they are philosophically aligned with the marketing image created for CAM (holistic, etc.). CAM users, however, do not turn to CAM because they are dissatisfied with their doctors or mainstream medicine. In fact in one survey CAM users were more satisfied with their primary care doctors.

No one claims that mainstream medicine is perfect, or that science-based medicine has all the answers. As with science in general – medicine is a flawed human endeavor. The rational response to the deficiencies in medicine, however, is to strive to improve our knowledge and practice, not to turn to an alternative simply because it’s there. CAM therapies need to stand on their own merits (which they can’t – that’s why they are not accepted as science-based). Proponents, however, promote CAM therapies as if they are the default choice when SBM is imperfect.

Tu quoque

A similar strategy to the false choice is to justify the failings of CAM by pointing out the failings in mainstream medicine – the tu quoque logical fallacy.

In the comments to the above article commenter “shotinfo” (which, I am told, is a common pseudonym for Meryl Dorey, who heads an anti-vaccine organization in Australia) wrote:

According to articles published in both the British Medical Journal and the New England Journal of Medicine, between 85% and 90% of all mainstream medical drugs and procedures have never been scientifically proven to either work or be effective.

I love the fake references – of course no such articles in BMJ or NEJM exist, and no references were offered, but it certainly makes the fake factoid sound legitimate. I have already discussed this issue in detail. The bottom line is that surveys of medical practice find that about 78% of them are reasonably evidence-based. Yet again we have a factual misstatement used to support a logical fallacy (tu quoque). All medical practice should strive to be more science and evidence-based. Pointing out the deficiencies in one discipline does not justify deficiencies in another.

The commenter, however, also misses the real point of criticism of CAM. Mainstream medicine is based upon a culture and institution of science, and a science-based standard of care. The execution of this standard is flawed, but the principle is clear. CAM is not based on a science-based standard. It, in fact, seeks to subvert and even remove the science-based standard of care. And CAM proponents live in a culture of pseudoscience, not legitimate science.

To the extent that the science-base of modern medicine is not adequate the proper response is to improve the science (a never ending task), not to use methods that are even less science-based. CAM is largely devoid of science. CAM proponents, to borrow an excellent turn of phrase, use science as a drunk uses a lamppost – for support rather than illumination. Tom Harkin gives us the best evidence for this when he stated (talking about the NCCAM):

One of the purposes of this center was to investigate and validate alternative approaches. Quite frankly, I must say publicly that it has fallen short. It think quite frankly that in this center and in the office previously before it, most of its focus has been on disproving things rather than seeking out and approving.

The purpose of science is to validate, not disprove, according to Harkin. This, of course, is the opposite of the truth, but reveals a key logical failing of the CAM community.

Conclusion

There are many more examples of poor logic and dubious facts common to the CAM community (“what’s the harm,” for example), but the above arguments are the most common in my experience. After discussing and debating this issue for years it is clear to me that the above arguments will not go away simply because we point out that they are false and logically invalid. So we will have to keep pointing it out, over and over again.

Posted in: Science and Medicine

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76 thoughts on “Defending CAM with Bad Logic and Bad Data

  1. cervantes says:

    Well okay, but since we keep pointing it out, over and over again, and it doesn’t seem to be working, we’re probably misdiagnosing the problem. Quackery proponents obviously aren’t persuadable by the arguments that persuade me and Dr. Novella. Just repeating ourselves is missing the point.

    I’d start by saying there’s a supply side problem and a demand side problem. The supply side problem is that there are people who make money, and perhaps gain other benefits such as the prestige of claiming to have a professional credential or expertise, and the satisfaction of imagining that they are helping people, off of these nonsensical constructs. It’s a lot easier to becoming an ND than it is to become an MD, after all. And since there’s money to be made, there’s money to be spent on marketing and propaganda. You’re never going to stop that by rational argument.

    The demand side problem is, first, that most people have very limited grasp of science and the inescapable fact is that biology is complicated, as are the rules of scientific inference and the technical challenges of making appropriate diagnosis and selecting the most appropriate treatment. Quackery relies on metaphors and simple ideas that people think they can grasp, that seem intuitively satisfying. So they are easily persuadable.

    Second, there are perfectly good reasons why people distrust the medical institution. As you say, the right answer is to improve it, not to run away toward even more flawed practices. But the deficiencies of medicine are well publicized, often directly experienced, and it’s going to be a long road to ameliorate them. These include not only such safety issues as a flawed drug approval process and inadequate systems for preventing serious errors, but also the very common and mundane experiences that people have such as showing up on time for an 8:30 appointment and seeing the doctor at 11:00; or encountering a physician who is brusque, unsympathetic, and doesn’t listen. All of our protestations about the ineffectiveness of acupuncture or naturopathy are of no avail against that.

  2. DugganSC says:

    Quite honestly, I think a lot of it does have to do with marketing and image. Personability is a big one. My fiancee goes to a chiropractor regularly for her hip and shoulders. When she makes an appointment, she shows up and is immediately attended to by the doctor in charge. For patients who show up regularly, they waive the co-pay, only taking the insurance payment. I compare that against every physician visit I’ve had in the last three years where I’ve shown up on time, had to wait for half an hour to an hour, been attended by a nurse for the majority of the time, and only briefly been seen by the doctor. From the human perspective, she’s getting better care than I am, certainly more personal and attentive care. Frankly, this seems to be reflected in articles on this site. They mention how CAM practitioners are putting themselves forward as being accessible and personable, how almost all of the beneficial effects of things like massage and acupuncture are due to this standard of personal care, and yet the same practices of the doctor never being on time and spending a minimum amount of time with the patient is so much the standard that it seems unusual to show up for your appointment and get ushered right in.

    I know that part of the problem is that medicine is hard, and therefore we only have so many doctors to spare. Furthermore, practicing actual medicine no doubt takes more time than “adjusting vertical subluxations”. Lastly, vagaries of college tuition, malpractice insurance, and hospital cartel legbreakers means that it’s virtually impossible to be a doctor and not charge high rates. Still, it seems like there’s a lesson to be learned in all of this.

    Kind of makes me wonder how many people would go to their CAM practitioners even if they did know that it did nothing from a medical point of view. Reminds me of the old joke about the guy who put up his car as collateral for a loan and gladly let the bank hold onto the car while he paid the minimum amount. When asked why he followed that practice, he said that the interest on the loan was cheaper than finding parking in New York.

  3. thatguybil81 says:

    ” – if a treatment were backed by solid logic and evidence it would not be CAM, it would just be medicine.”

    Which is a point I try and hammer home with friends and family when CAMish stuff comes up.

    “Big pharma does not want to cure things like Cancer*… they want to make it a chronic disease so that they can sell drugs to people for their entire life and make money”

    Look if there were a “cure for cancer” they would be happy to sell it and charge a giant fee equal to ~ the amount of what 6 cycle of chemo would have cost to treat it prior to the break through invention. Thus they would Gross the same amount of money. Their profits would be much higher because they could stop wasting money on all this R&D and marketing. No need to market a cure for cancer… it kinda sells it self. :)

    Sadly that argument rarely works.

  4. nybgrus says:

    vis-a-vis the “false choice” and “what’s the harm” aspects I would also argue that it is, in fact, also physicians that further promulgate this.

    pmoran continually offers us examples of this, and I have also experienced it myself both with other medical students and seasoned attendings.

    Of course, the exact meaning and rhetoric is different than your typical CAM apologist. It generally takes the form of “Well, we don’t have an effective science based option for [particular subset of patients] and why would we deny them the opportunity to potentially feel, or actually get, better?”

    My feeling on this, which I very well could be wrong about, is that it stems from the physician’s passionate desire to help his/her patients. I haven’t been in the exact position myself, but close enough to at least appreciate that when a physician has tried every option to no avail it becomes extremely frustrating and often times felt as a personal failure (in fact, this latter point is something taught in my medical school). So when such a physician evaluates the evidence for or against certain modalities, they can often reframe the question and evidence. Suddenly acupuncture goes from something that has no evidence of efficacy and the admittedly small amount of complications and adverse effects do not ethically justify its use to, something that has placebo responses to pain and in conjunction with actual medical care the small adverse effects rate is justifiable in otherwise intractable patients.

    Of course, as Dr. Hall has pointed out the discussion often transitions seemlessly from population level discussions to individual patient level as if they were the same, using whichever set of arguments is most convenient at the time as though they were interchangeable.

    To me though that seems rather Machiavellian and nearsighted. I’ve found that if you have to argue that the ends have justified the means, then they probably didn’t.

  5. Jan Willem Nienhuys says:

    Hahnemann, the inventor of homeopathy, had one line of arguments based on what he called ‘involuntary homeopathy’. He claimed that many instances of cures in the literature were actually illustrations of the principle of homeopathy. His examples elicited from Oliver Wendell Holmes Sr. (1809–1894) in Homeopathy and its kindred delusions the following:

    It is stated by Dr. Leo–Wolf, that Professor Joerg, of Leipsic, has proved many of Hahnemann’s quotations from old authors to be adulterate and false. What particular instances he has pointed out I have no means of learning. And it is probably wholly impossible on this side of the Atlantic, and even in most of the public libraries of Europe, to find anything more than a small fraction of the innumerable obscure publications which the neglect of grocers and trunkmakers has spared to be ransacked by the all-devouring genius of Homoeopathy.

    But Hahnemann really claims by direct quotation that Hippocrates was the first to state the main principle of homeopathy. I wrote an article about it: http://www.skepsis.nl/homeopat.html . So many homeopaths claim that already Hippocrates was doing homeopathy, and their authority is the great master. I doubt if these claimants really examined the Hippocratic wrtings carefully themselves.

  6. Dje1123 says:

    This is a very interesting article; I find myself strongly agreeing with some aspects and disagreeing with others. As a Licensed Massage Therapist, I do consider myself to be a medical/health care professional and hold myself accountable to the standards set forth by my profession as well as NYS. I strongly believe in science-based or evidence-based care and am very clear with my clients about what works, and if I can tell them, why it works.

    Sadly, my profession suffers from a lack of evidence as to effectiveness of treatment (although this changes almost daily), and certainly an even deeper lack of research on why certain conditions exist, or why some treatments work. However, this is of course not unique to manual therapies; “traditional” medicine is always seeking deeper understanding of the body and effective treatment through scientific study as well. I will say, just because we haven’t yet proved something scientifically doesn’t necessarily mean that it doesn’t work, it just may not yet have been studied. Conversely, just because we have studied it doesn’t mean we really know what’s going on, particularly since the primarily pharmicological-surgical model of medicine as we currently know it is also still in its infancy (even penicillin was only used in large quantities since D-Day- just 70 years ago!)

    As to the idea of making money providing service– any successful business (that includes MDs, CAM practitioners and of course all of the folks at “big Pharma” and other major medical organizations) is certainly in the business of making money. The argument that we tell people certain things in order to make money is part of doing business. Its up to the consumer to make sure that they question what they are being told as being based in some kind of evidentiary result– and that includes what their MD tells them. A good MD or other allied health professional will tell you quite frankly that most of the human body remains a mystery and that they just have more tools and a bit more education in their bag of tricks to fall upon when needed. And really, thank heavens for antibiotics, and insulin, and other lifesaving drugs. But I still question their decisions and the drugs that are suggested, as should all of us.

    As for science “proving” things– the pharmaceutical companies spend a great deal of money proving that drugs work… they can afford to test on large populations, and their revenues depend on proving themselves to be correct. The drugs don’t always work, and they certainly do not work for everyone either, and are never without side effects. However, some side effects are tolerated despite the danger factor, and there’s also the serendipity factor in the drug world too (a huge part of the reason Viagra was discovered, much to Pfizer’s financial delight!). Alternative medicine has not utilized such a cut and dried scientific research method and has spent far too little time proving treatments to be effective. This is a failing on our parts. We must work harder at proving what does work, and spend a bit less effort defending and sharing essentially ineffective treatments (some of which certainly have more basis in myth and spirit than fact) at all costs.

    As for being disenfranchised with the medical field, I love my DO and my OB/GYN for their ability to look at all methods of treating whatever ails me, and I work with plenty of clients who also like and respect their health professionals, and in fact are often referred to me by them for treatment. However, lots of docs do not listen to their patient’s needs and just “give another pill” and traditionally have little patience with conditions that are difficult to “fix”, particularly if they are more likely to effect quality of life than present as life or death situations. These folks often come running to CAM practitioners for support and answers, which they generally receive from us. This is “good medicine” too, and may do as much or more to provide relief than any pill could ever do.

    That being said, I also fall on the side of science if given a push, and am a big show me kind of person. I’m the first to ask for references when I see or hear something that makes me go hmmmmmmm, and regularly debunk myths about alternative health care in my posts and with my clients (like the massage releases toxins myth… there’s a good one!). That being said, there is more to heaven and earth than we can see or quantify, so I honor those who practice and believe otherwise, but I do urge my clients to use their heads and if something feels wrong, don’t do it. If it doesn’t work for them or provide relief, stop doing it. I don’t care who is providing their treatment, MD or CAM practitioner.

  7. WilliamLawrenceUtridge says:

    Bookmarked.

  8. Vera Montanum says:

    I really think that CAM owes its successes to failures of medical professionals and the healthcare system. Case in point, the treatment of chronic pain in America, which, by the latest count, may afflict nearly half of all adults (116 million persons, the accuracy of which can be debated separately).

    In the state of Washington, which may be a harbinger of what’s to come in other parts of the country, new rules for opioid therapy go into effect next month. Already, 70% of public health clinics in the state are turning away patients with chronic pain, and 10% of those remaining refuse to prescribe opioid analgesics altogether. There appears to be a cavalier attitude toward the treatment of chronic pain that should be frightening to us all.

    Meanwhile, who do suppose will be welcoming those patients with open arms? That’s right… chiropractors, homeopaths, acupuncturists, massage therapists, hypnotists, psychologists…. you name it. Some may have worthwhile therapies to offer for pain relief, many do not. What choice do patients have? Suffer in silence or seek whatever options are still available to them.

    So, while it may seem entertaining to poke fun at modalities that have little if any scientific evidence to support them, this is no joke for desperate patients. It is one thing to have scientifically valid medical treatments available, making them accessible and affordable for patients in need is another matter. And, consider this: you, me, and our loved ones could easily be the next victims of some chronic pain disorder — how would want to be treated?

  9. weing says:

    @DugganSC,

    “For patients who show up regularly, they waive the co-pay, only taking the insurance payment.”

    Very interesting. If I did that, it would be considered fraudulent billing. I guess different standards apply to medicine.

  10. showmedadata says:

    “Different standards apply to Medicine”. Exactly.

    As an emergency physician, if I know that a medicine is no better than placebo (say, honey for a cough), yet present it to the patient as something that works, I’m being dishonest and thereby violating the fundamental ethical pillar of “Respect for Patient Autonomy” which carries with it the expectation of full disclosure. However, giving my patient something that is relatively harmless (unless its the botulism-ridden honey sold at a “health food store” as unpasteurized and holistic) to treat a symptom may give them the expectation of improvement and thus take advantage of the placebo effect which we know is real. As such, I would still be aligning myself with the principles of Beneficence and Non-Maleficence, but not Respect for Autonomy / Full Disclosure.

    However, in our current model of medicine, respect for patient autonomy trumps all, and knowingly using or selling the placebo effect is unacceptable – Unless you’re a CAM provider. No doubt in my mind, especially with vague, subjective, chronic conditions, the therapeutic relationship and employment of the placebo effect by CAM practitioners works to some degree in some patients. It’s not better than placebo, it IS placebo, which works sometimes!

    CAM practitioners feed their families on profits from the sale of placebo. If we were to do this in medicine, it would be outright fraudulent and grounds for dismissal. Yet, if these patients do benefit in anyway, is it still the “Greater Good” to withhold this placebo effect from them, maintaining Respect for Autonomy and the possible expense of Beneficence?

    I think it’s criminal when homeopaths and their ilk sell patients their placebos as alternatives for serious issues like cancer or vaccination. However, in the setting of ruled out major medical disease and ongoing troublesome symptoms (such as chronic pain), perhaps we should, as a society, allow more liberal employment of placebo.

    Whichever way we decide, physicians and CAM practitioners ought to be held to the same standard. If selling placebo is deception, we should enforce and penalize those who continue to do it. We cannot expect patients to sort through the boatloads of data, information, and misinformation to come to their own conclusions.

  11. wreichert says:

    “”74% of medical practice is “reasonably” evidence based”.

    That is the most hilarious statement about medicine I have ever heard. Where is the “evidence” for
    this claim?Please cite a reference.
    I have been in medicine a long time and I would argue that perhaps 10 percent is evidence based
    especially when you consider all the things we do without even awareness of what we are doing.
    FOR EXAMPLE, in neurology some treat hypertension in the setting of acute stroke but what
    evidence is there for deciding 1 whether to treat in the acute setting 2 if treating, when to start treatment 3. what is the best drug to use 4. what is the goal
    of treatment 4 how often should the patient be seen to have the blood pressure checked 5 what tests if any need to be done to follow the BP treatment and so forth. These aspects of treatment are all decided but the evidence for them is where exactly?
    If you consider carefully all the decisions you make daily and are aware of the literature you realize how little is evidence based.
    Of course if you add the modifier “reasonably” to the term “evidence based”, you can probably justify almost any thing you do…….just like alternative medicine. ( not that I endorse the latter) . You could probably “reasonably”
    endorse the use of heparin in the acute stroke setting. How ever the evidence is at best best conflicted, no matter how reasonable it seems.. I am surprised that a neurologist could look inside himself and make the claim
    that he practiced “evidenced based” medicine. That is really a hard to fathom.

  12. Harriet Hall says:

    A question for all:
    Do you think it might be ethical to offer placebos as “comfort measures” in the same class as back rubs and plumping pillows? For instance, “Honey won’t do anything to change the course of your illness, but some people think they feel better after using it. You might want to consider trying it, if only to get a placebo effect, and it’s safe as long as you use pasteurized honey.”

  13. DrRobert says:

    Is there any surprise that CAM practitioners use bad logic and data? These people are susceptible to absolutely ridiculous beliefs, and these beliefs are backed up with a complete lack of knowledge and understanding of science, medicine, and human physiology.

    http://www.skepticalhealth.com/wp-content/uploads/2011/12/480432-copy.pdf

    Here’s a great study that was performed by homeopaths and published in a CAM journal. This study examined the knowledge of HIV/AIDS among homeopathic practitioners. They were asked extremely challenging questions such as “Is AIDS caused by a virus?” and “Can you get the AIDS virus by having sex with someone who has it?” In total, they were asked 21 such simple questions and they scored rather poorly.

    To them, the poor arguments faulty logic they present are intelligible. They simply don’t know any better.

    Another example:
    http://www.ncbi.nlm.nih.gov/pubmed/18564960

    Homeopathic study says that it’s unscientific to reject claims that aren’t proven by science. (Yes, you read that correctly.)

  14. DrRobert says:

    Dr. Hall:

    A colleague keeps a bottle of B12 and gives the shots for free if a patient wants it. He tells them he doesn’t think that they need it. Usually he said they won’t feel any improvement and wont ask for it again, but it at least alleviates their concern that they are low on B12. So it’s kind of a treatment, it’s kind of a diagnostic test, and kind of a placebo. Of course, if people get several B12 shots he’ll start working them up for a deficiency. I do believe what he does is absolutely harmless, he doesn’t claim it will help with anything, and he gives it for free. Is that ethical? I think so. The doctor does not claim that it will help with anything, but it is a (slim) possibility that the patient needs the shot.

    On plenty of occasions I wish I could just prescribe a placebo. For example, an unruly patient who was only recently released from jail started raising hell with our front desk clerk because we wouldn’t write them “the good pain meds.” The patient became belligerent, etc. In that case it would have been nice to just write her for placebo and send her on her way. But is it ethical? No. I don’t think so. In this case, if I had tried to get rid of the patient by prescribing placebo, I would be lying to them and therefore unethical.

    As nice as it would be to sometimes “shut someone up” with placebo, I do not think it is ethical.

  15. jhawk says:

    “The bottom line is that surveys of medical practice find that about 78% of them are reasonably evidence-based.”

    From Bob Imrie’s article I presume. Of this 78% only 37% is proven effective via RCT. So 41% has “compelling” evidence via observational studies. Is this 41% more effective than placebo? Is it possible that 67% of medicine is either not effective or no more effective than placebo?

    From Imrie’s article; “95% of surgical interventions in one practice”. n=100 in a single teaching hospital. Is this generalizable? Makes me question the rest of his references.

  16. Harriet Hall says:

    @jhawk,
    Compelling evidence includes things like appendectomy for appendicitis and like setting broken bones. Some things are clearly more effective than placebo but can’t ethically be tested with RCTs.

  17. @Dr Robert, that was an interesting study of Pune and New Delhi India Homeopaths, conducted to get an overview of their knowledge of AIDs to support (or at least not undermine) HIV prevention efforts.

    It appears that most of the questions were answered correctly by 88 to 97 of participants. There were some questions with lower scores, like ‘can a person be infected with the AIDS virus and not have the disease’ (35 and 53%).But that’s kinda a funny question, usually one would say a person is infected with HIV, but has not developed AIDS, correct?

    Pretty low scores on ‘does AIDs effect the brain.’ and ‘is there an AIDs vaccine’. Wonder what’s up with that, looks like there might be some AIDs vaccine homeopathy myth or just an urban legend going around that needs addressing.

    But, I couldn’t find what language the questionnaire was presented in, English, Hindi, Punjabi and Urdu…the four language used in new Delhi, I’m not looking up Pune. Although, that probably wouldn’t effect the results, to much, only 4% of the participants were not Hindu.

    Do you have the results of the same questionnaire given to medical doctors and nurses in Pune and New Delhi? Seems that you would need that before concluding that Homeopaths there, are inferior to medical doctors or nurses in HIV transmission and symptom questions.

    Or are you concluding something about U.S. Homeopaths based on a survey of Pune and new Delhi Homeopaths? Or are you in India? Or are you suggesting that Americans shouldn’t fly to India for HIV prevention education from an Indian homeopath? That certainly seems like a bad idea.

    Maybe I’m missing your point.

  18. DrRobert says:

    @MIM, I believe that the strange wording of AIDS in place of HIV is a hint of HIV denialism in the study. The average score was 87% overall, which is simply unacceptable. Those questions are on par with difficulty that should be given to a child in middle school. Those aren’t difficult questions. Keep in mind these are people that are purporting to treat and cure HIV/AIDS, and yet they don’t know the basics of the disease. To me, the study is appalling. Instead, they should be investigating the efficacy of homeopathy on HIV/AIDS. But of course, I’m sure we can all already predict that outcome.

    I see no reason to believe that U.S. homeopaths would fare any better on the same set of simple questions. Given their complete lack of scientific reasoning capabilities, I’d be surprised if they could figure out how to sharpen their pencils in order to take the test.

  19. Dr Roberts, could you point me to the section of paper where the homeopaths claim to have a cure for AIDS. Because in my reading the paper clearly says there is no cure. It also says that since AZT drugs are so poorly supplied in India, prevention efforts are important. They go on to say that, since Homeopaths treat millions of people in India, it’s important to get a clear understanding of their knowledge of AIDS prevention and infection, to see if they are adequately educating their patients.

    Sorry for the lack of quoting, you linked to a PDF.

    I agree with you that 87% is not adequate. But that test could give public health folks an idea of where to direct education of homeopathic practitioners in HIV/AIDS issues. Or you could ignore the homeopathic practitioners and do nothing to prevent them from spreading misinformation to millions of people.

    Or you could try to convince millions of Indian people to stop seeing their homeopathic practitioners. Good luck with that.

    Also, WTF? You want someone to study the efficacy of water for HIV/AIDS? I’m only a BFA, not a doctor like you. But I can tell you the efficacy of homeopathic remedies for HIV/AIDS. Zip, nada, zero, nil… Feel free to send me a check for my “research”.

    Believe what you like in the AID’s denialist front. But you won’t get me to agree unless you present some sort of evidence that is not entirely based on your subjective interpretation of the wording of a test give in a other country, that may have been translated into another or several other languages.

    But of course that doesn’t seem to be the point. The points is singing to the choir. Everyone who is FOR science should ignore the flaws in your “evidence” and says how lovely your voice is.

  20. DugganSC says:

    But of course that doesn’t seem to be the point. The points is singing to the choir. Everyone who is FOR science should ignore the flaws in your “evidence” and says how lovely your voice is.
    Oy… I thought I got away from New Education when I left Kentucky… KERA

    Whenever it comes to surprising survey results, I always find myself itching to see how questions were phrased. Well-designed survey questions can reveal fascinating truths. Poorly designed (or worse, purposefully badly designed) questions produce results that are a 180 against reality. This goes double for a survey where the circumstances indicate that it may have been translated in the process.

    I actually hadn’t realized that waiving a co-pay was illegal. Huh. I saw it as the equivalent of the restaurant owner who offers a free meal for a repeat customer, but I suppose things are different when you’re charging an insurance company for each visit. True, there’s a fixed number of visits per year covered by her insurance, but making said visits “free” to the consumer does encourage over-use.

    That said, there’s enough comments above over the bedside manner and presentation of modern medicine that I think the point’s come across that modern medicine has an image problem, and that’s somethings which is extremely hard to try to combat with cold hard facts when patients are looking for a warm reception.

  21. weing says:

    @DugganSC,

    A warm reception is ALL that CAM offers. Hookers also offer something similar. If you need something more than just a warm reception, then you can see a real MD. Depending on how busy they are, you may even get a warm reception.

  22. Calli Arcale says:

    I actually hadn’t realized that waiving a co-pay was illegal. Huh. I saw it as the equivalent of the restaurant owner who offers a free meal for a repeat customer, but I suppose things are different when you’re charging an insurance company for each visit. True, there’s a fixed number of visits per year covered by her insurance, but making said visits “free” to the consumer does encourage over-use.

    Exactly what is wrong with it depends on the patient’s coverage and the provider’s contract with the insurer. Sometimes, a co-pay can be covered by a second insurance plan or some sort of coupon, and there may be an arrangement in place at that chiropractor which creates the contractual framework for that. Depends on the specific policy. Usually the co-pay cannot simply be waived as a matter of course, though, and many policies will actually explicitly state this. Indeed, if you are making claims to two insurers for the same thing (with the intent of getting the copay covered by one), then you have to disclose this to both insurers or you may be committing insurance fraud — there’s usually language to that effect in the policy and in the regular statements your insurer sends to you.

    It’s always an exception, not the rule. If the co-pay is being waived as a matter of course, then what’s happening is the chiro has effectively reduced his rates by $20 and is still billing insurance for the full amount. This becomes even more obvious if your policy has you pay a percentage rather than a flat copay. That’s where it might become insurance fraud, depending on the policy. In general, the point of a co-pay or co-insurance is to make you more involved in price decisions and more aware of how much things cost, with an eye to reducing the number of unnecessarily claims by helping remind people that it isn’t really free health care. A chiro who consistently waives the copay is defeating the purpose of a copay.

  23. nybgrus says:

    Huh. I saw it as the equivalent of the restaurant owner who offers a free meal for a repeat customer, but I suppose things are different when you’re charging an insurance company for each visit… but making said visits “free” to the consumer does encourage over-use.

    Beyond that it is a violation of ethical principles in medical practice. By the very nature of the physician-patient relationship, the physician is the one in authority and power. Providing free services, while in many cases may be completely moot, does set up a situation wherein the patient may feel indebted to the physician and thus become more willing to surrender their autonomy in future interactions. i.e. – the doc states that treatment [x] is what he would recommend, and the patient doesn’t want to for whatever reasons. However, because of the previous favrotism the patient aquiesces either for fear of reprisal (no more free services) or simply to appease the physician that has been so “extra” nice to them. A more sinister example would be that the physician gets into a new product he wishes to sell and begins to hawk it to a patient. Same results.

    The point is that such measures and ethical principles are in place not for the majority of patients who would be otherwise unaffected, but as a recognition of the extra step we must take as physician to ensure protection and advocacy for our most vulnerable patients and everyone else at the same time.

    So when sCAMsters do it, it completely and intentionally circumvents that protection of autonomy and, in many cases, beneficence. The patient feels indebted to the CAM practitioner (or at least like they “owe” him a favor in return) and so when the time comes to hawk more services (which may or may not be called for at all) the patient becomes placed in a tough position.

    If it is a restaurant wanting me to come back and spend more of my money on food – well, there is no ethical dilemma there. Of course a pure business wants me to buy its product, and if I decide that such treatment warrants my continued patronage, then so be it.

    But the very fundamental basis of the relationship between restauranteur and diner is completely and wholly different from that of physician and patient.

    And that belies the true nature of CAM – selling a product, not providing actual medical care. The danger and the inherent problem is they claim to provide the care and yet act in a manner inconsistent with that.

    That said, there’s enough comments above over the bedside manner and presentation of modern medicine that I think the point’s come across that modern medicine has an image problem, and that’s somethings which is extremely hard to try to combat with cold hard facts when patients are looking for a warm reception.

    I fully agree and there are myriad reasons why. For my small part I attempt to combat it at every opportunity I get. Whenever I teach (which I did every week this year) I made it a point to stress that science is the necessary basis for all that we do, but science delivered compassionately and with genuine care is vastly more effective and should be the goal we aspire to at all times, even when it means extra work and time.

    As my step-father has said, “Homeopathy is a symptom of the failings of modern medicine.” (He is a critical care physician). I don’t think his statement encompasses the totality of the reasons for CAM and homeopathy, but it is certainly a valid point and a nice sound byte.

    Which of course brings us right back to the beginning; the answer is to improve medicine and our delivery of it (as well as physician bedside manner). Not to turn to CAM as something worth “integrating” into actual medical practice. For me, that means practicing what I preach (haha, no pun intended) and calling out others who do not. I get quite an interesting mix of spite and respect for that, because I do not hesitate to call someone out when I have good reason to.

    Well, back to wrapping up endocrinology and then heme/onc. Check back with you guys later in the day!

  24. jhawk says:

    @ Harriet Hall

    “Compelling evidence includes things like appendectomy for appendicitis and like setting broken bones. Some things are clearly more effective than placebo but can’t ethically be tested with RCTs.”

    I agree with you here but in Imrie’s article he says

    “it would appear that ‘compelling evidence’ may occasionally be obtained from uncontrolled case series in science-based medicine….”

    Compelling evidence may occasionally be obtained. Then he doubles and sometimes much more than doubles the effectiveness shown from RCT’s (37%) to RCT’s plus compelling evidence (78%). This seems drastically more than occasionally obtained.

    Also, From Imrie’s article; “95% of surgical interventions in one practice”. n=100 in a single teaching hospital. Is this generalizable? This article also only says 24% is effective via RCT then claims 71% is “compelling” evidence. Once again, much more than occasionally obtained. It makes me question the rest of his (Imrie’s) references.

  25. Harriet Hall says:

    @jhawk,
    You are quibbling about semantics and details, but Imrie is undeniably correct when he says that RCTs are not the only acceptable evidence and that critics underestimate the percentage of medicine that is based on good evidence.

  26. pmoran says:

    Also, Jhawk, as I think daedalus2, or was it Nybgrus?, pointed out, you will not find the mainstream using extremely plausible treatments as thought they were proven. Of course, plausibility is a bit subjective, and scientists sometimes gets things wrong, but it is not likely that they would be far wrong about about dozens of matters and methods all at once.

    So the evidence is actually very strong that close to a hundred per cent of alternative treatments “work”, to the extent that they work, via placebo and other non-specific nurturing effects of medical attentions.

    The science is mainly not yet complete as to what that means for the individual patient i.e. certain aspects of the science may be pretty clear, and place limits upon what is possible, but there is still room for some kinbds of practical medical benefits in cost/risk/benefit terms.

    We also now know that the RCT is not as reliable an instrument as we once thought when it comes to assessing the subjective effects of interventions, and there is even more murkiness in the science when it comes to difficult-to-blind procedural treatments. So we should certainly make some adjustments to the traditional sceptical belief that there will always be a clear divide between what works and what doesn’t .

  27. DrRobert says:

    Question: When we say “only X%” of medicine is actually proven, does that include stuff that quack M.D.s utilize?

  28. pmoran says:

    Nybgrus:vis-a-vis the “false choice” and “what’s the harm” aspects I would also argue that it is, in fact, also physicians that further promulgate this.
    pmoran continually offers us examples of this, and I have also experienced it myself both with other medical students and seasoned attendings.

    OK, I’ll play, but for brevity ignoring the implication that I have EVER supported bad logic or science.

    I suggest that these intellectual flaws are mainly post hoc rationalizations, not the primary drivers of CAM.

    It is possible to explain the existence of CAM through three simple influences: unmet or poorly met medical needs, the power of the personal testimonial, and a human tendency towards compulsive consumption of medical treatments when ill. These factors would sustain CAM without anyone ever sitting down and considering its provenance or scientific basis.

    The “threat to medical science” is thus largely an illusion drawn by the preoccupations of the scientific mind, as is largely also the notion that people can ever be easily educated into an “our way or no way!” attitude towards medical treatment even when the mainstream has nothing to offer itself.

    I am not supporting CAM, bad logic, or bad science. I merely want to be sure I understand it all to my own satisfaction, without bias and especially without any potentially counterproductive distortions of the reality.

  29. nybgrus says:

    @pmoran:

    the implication that I have EVER supported bad logic or science.

    I apologize if that was the implication. I actually do not think you have either.

    However:

    I suggest that these intellectual flaws are mainly post hoc rationalizations

    That is more or less what I am saying you (and others) are doing. My primary “accusation,” if you will, is that you tend to torture the utility of placebo and hide in gray areas of the science. You do not support bad science, nor do you support bad logic, but you continually challenge the steadfastness of ethics regarding placebo use (by finding ways in which you can deem it justifiable) and simultaneously systematically err on the side of preserving the potential power of placebo. You tend to frame the discussion from the point of view of maintaining strict scientific ambiguity (i.e. the science has not fully described the placebo effects and their utility), but at the same time you support utilizing the placebo of acupuncture for LBP and certain chronic pain issues.

    The counter from myself and others here has been one of realizing that whilst not fully settled, indications are that placebo is not useful in isolation, but very useful in conjunction with actual medical care. That statement alone allows for the use of acupuncture by a physician, for example. However, the basic ethics of our practice dictate that pure placebo cannot be ethically prescribed to a patient by a knowing physician.

    So in the first case you find that beneficence is maximized by inclusion of such pure placebo, but that impinges on autonomy. And that is where my argument on the matter rests.

    Of course, CAM has no such compunction and the likes of Kaptchuk and Moerman are striving mightily to demonstrate that there is some intrinsic and distinct utility to placebo effects such that they can justify a swath of CAM as not only “useful” but ethical to employ in practice. They have failed repeatedly.

    , not the primary drivers of CAM.

    I agree. I was merely adding to the conversation. I did not intend for my statement to indicate I thought such physician based promulgations were significant contributors, let alone sufficient.

    It is possible to explain the existence of CAM through three simple influences: unmet or poorly met medical needs, the power of the personal testimonial, and a human tendency towards compulsive consumption of medical treatments when ill.

    Stated as is, I agree.

    The “threat to medical science” is thus largely an illusion drawn by the preoccupations of the scientific mind,

    This is one part of your rhetoric I find particularly interesting and simultaneously befuddling. The reality is that pseudoscientists and CAM apologists, by in large, have an agenda. As has been pointed out innumerably here, CAM and indeed pretty much any pseudoscientific or denialist agenda is politically and/or ideologically motivated. I hope that we can at least agree on this (with exceptions, of course – but it is an accurate descriptor for most of what we are talking about).

    So then the actual scientists out there are faced with two options: do nothing, or do something. In a competition of ideas, the group that does nothing will inevitably lose out to the group that has an active agenda.

    Look at the evolution “debate” in America as a prime example. Almost nothing is more settled in the scientific world than evolution. In fact, it was after the Scopes trial that the collective thought was that evolution was established and creationism was done and we could move on. In other words, we did rather little. And now we have states passing laws to protect the teaching of creationism, Presidents proudly denying its veracity, and a distinct majority of the American population absolutely certain that it is a lie promulgated by scientists.

    Translate that to medical science and we see that in general, most physicians and scientists don’t care much. They think little of CAM and its errant ways. And yet somehow we now find ourselves with “Integrative Medicine” departments at medical schools, undergraduate institutions teaching CAM as a viable and valuable alternative to “Western” medicine, and prestigious medical centers offering Reiki and reflexology to its cancer patients. How you fail to see the parallel here is beyond me.

    In the sense that sCAMsters won’t be able to expunge the corpus of medical and scientific knowledge from humanity, of course there is no “threat to medical science.” But in the sense that an unattended and ignored garden grows weeds which detract from the beauty, utility, and function of the garden, so does an unattended and ignored CAM movement do the same.

    No matter what happens, I personally and others like myself will not find our own education and research hindered. But our practice might. And our patients might. It is not sufficient to simply keep the best ideas. You must also get rid of the worst as well. That goes for individuals and societies.

    as is largely also the notion that people can ever be easily educated into an “our way or no way!” attitude towards medical treatment even when the mainstream has nothing to offer itself.

    Yet another common rhetoric of yours that I cannot fathom. Of course, there will always be some small segment of the population doing and thinking very strange things. However, in general we can see a very clear historic precedent and progression of general scientific knowledge and understanding. Even an average child (in a developed nation) has more scientific knowledge and critical thought than the average adult of just a couple hundred years ago. There was a time when everyone thought disease was caused by miasms and evil spirits and blood letting and trepany were considered very obvious treatments. Chances are much less you’d encounter the same thing these days.

    Which is odd for me to say, since I have typically been the cynic amongst my friends and family. But I cannot deny that with concerted and genuine efforts such things are indeed possible and inevitable. It just takes time. Certainly longer than my lifetime.

  30. pmoran says:

    Nybgrus, I am not sure that my position on many matters is as settled as you suggest.

    I am sure that we could be applying more scientific rigour to the questions that CAM raises e.g. why do people do it and what do they get from it?

    Extreme bias is warranted against many aspects of CAM, but at other times it can be both unconscious and unhelpful. Here are some opinions from your last response that you might think further about.

    As has been pointed out innumerably here, CAM and indeed pretty much any pseudoscientific or denialist agenda is politically and/or ideologically motivated.

    (Politically? — that is surely rubbish. Ideological?, other than that some think the methods really might work? Writers indeed may say such things on these pages, to avoid having to think deeper about the true reasons for CAM, but to what extent are they really true?)

    The counter from myself and others here has been one of realizing that whilst not fully settled, indications are that placebo is not useful in isolation, but very useful in conjunction with actual medical care

    (Hardly worthy of comment. What “indications” support these assertions? There is much against it. )

    However, the basic ethics of our practice dictate that pure placebo cannot be ethically prescribed to a patient by a knowing physician.

    I think that is fine as a general policy for doctors. That you consider this as settlling anything is a reflection of the intense, instinctive, proprietary attitude that we doctors have towards medicine in general. We like to feel that medicine is our province, that what we offer should be enough for patients, and we are resentful if they find that wanting and want to try something else.

    We have an implied contract to do certain things for our patient and for the general public, but in order to fulfil that contract adequately we need to know for sure what people get out of CAM. Some truths are worth knowing for their own sake, but this one has additional significance.

  31. Harriet Hall says:

    @pmoran,

    “the basic ethics of our practice dictate that pure placebo cannot be ethically prescribed to a patient by a knowing physician.That you consider this as settlling anything is a reflection of the intense, instinctive, proprietary attitude that we doctors have towards medicine in general.”

    It could also be a reflection of our desire to be able to trust our own doctors.

  32. pmoran says:

    @pmoran,

    “the basic ethics of our practice dictate that pure placebo cannot be ethically prescribed to a patient by a knowing physician.That you consider this as settlling anything is a reflection of the intense, instinctive, proprietary attitude that we doctors have towards medicine in general.”

    It could also be a reflection of our desire to be able to trust our own doctors.

    Oh, yes. I agree. This is part of the reason for the bit of my response that you cut out i.e ” I think that is fine as a general policy for doctors.”

    People do come to “proper doctors” expecting scientifically sound treatment and advice and we must do that to our best ability and say so if we are ever for any reason departing from that.

    But we need to also understand that this commits us to an extremely Type 11 error-averse standard of practice. Nothing is given any benefit of the doubt. If it doesn’t work exactly as claimed it doesn’t work at all, according to the narrow meaning for “work” EBM operates from.

    We more or less have to base mainstream medicine on such an approach, but it clashes starkly with what patients may be prepared to try out for themselves when life is significantly impaired by medical problems and science-based plans A, B, and C have not worked for them. There is at minimum a “not wanting to die wondering if it might have helped” aspect to this which we should respect.

  33. nybgrus says:

    a little break from neurology to stimulate some other brain cells…

    Politically? — that is surely rubbish

    Senator Harkin, DSHEA, Bravewell collaboration.

    Ideological?, other than that some think the methods really might work?

    Thinking something works and striving mightily to prove it is one thing. That is not what a lot of CAM is about. Ideology can be easily identified by persons not actively trying to prove their ideas true, but by proving other ideas false. Creationism is one fine and crisp example.

    In my own personal experience in undergrad, this was the case. As I have said many times before, I actually hold a degree in medical anthropology (magna cum laude). My courses focused on explaining what CAM was and how “evil Western reductionist science and medicine” was destroying it. Never once do I particularly recall anything resembling an attempt to actually proffer positive evidence of efficacy beyond the standard logical fallacies Dr. Novella recently wrote about.

    Is the entirety of CAM such a political and ideological movement? Of course not. Is the majority of the consumer base similarly motivated? I would not be so silly to think so. But is a distinct and reasonably large segment thusly motivated and actioned? Absolutely. And that is what the focus here is. I think most of the authors here would agree that we would care little about the wayward hippie trying to make a few bucks doing Reiki and reflexology. But that contingent that is so motivated is certainly a worthwhile focus of effort and attention.

    Writers indeed may say such things on these pages, to avoid having to think deeper about the true reasons for CAM

    Perhaps this nuance bears further exploration. It is my impression that the volumes written here have two main foci (at least in regards to CAM).

    1) To demonstrate which modalities are ludicrous and why
    2) To demonstrate the existence of and combat the type of CAM you claim doesn’t exist

    In other words, very little of the actual verbiage here is devoted to the discussion of why consumers use CAM. In fact, I’d reckon that we’d all reasonably agree with your assertion as to the reasons in your previous comment.

    So the question he is not why does CAM exist at all. But why is it proliferating in venerable scientific spheres and how does one combat that?

    So when you follow that up by saying:

    but to what extent are they really true?

    I would say you are asking that of the wrong question.

    Hardly worthy of comment. What “indications” support these assertions? There is much against it.

    We’ve had this discussion before, extensively. Lets chalk it up to a difference in interpretation of the data betwixt us and leave it at that.

    We like to feel that medicine is our province, that what we offer should be enough for patients, and we are resentful if they find that wanting and want to try something else.

    Maybe that is how you feel. It is most certainly not how I feel. I do not feel resentful for people seeking CAM in addition to or in lieu of any medical care I may be in a position to offer. I would feel that I need to step up my game and do a better job with my patients. It has yet to be demonstrated that there is anything a science based physician can’t do just as well as a CAM practitioner, at least in principle.

    The only arena left is, as you have accurately pointed out, when the science runs out and there is nothing left to do within our current capabilities and understanding. That is also a time I can fail my patient by inadequate education.

    And as you say:

    There is at minimum a “not wanting to die wondering if it might have helped” aspect to this which we should respect.

    Of course. And I would never denigrate someone for making such a choice in the face of their own mortality. I’d like to think I have the strength to face my own death with the magnanimity that Hitchen’s just faced his, but who knows until you are actually there?

    But once again – you have shifted frames of reference. Your arguments are sound and correct… from the perspective of the average consumer of CAM. But they do not apply to the arguments proferred here which are in reference to the purveyors of CAM and the concerted ideological movement behind it that you claim doesn’t exist.

    You claim that there isn’t a concerted infiltration of patently ridiculous CAM into actual medical practice. So why then would the electronic charting software I used when working in a modern ER force me to pick from the following choices for pain relief after asessing a patient:

    () Opiod analgesic administered
    () Non-opiod analgesic administered
    () Therapeutic touch administered

    Interestingly enough, if I ever assessed a patient and (s)he rated his/her pain at 4/10 or higher, the system would not allow me to file my progress note without checking one of those boxes. I had no other options. And since my license did not allow me to administer drugs to patients, I always had to say that I gave them therapeutic touch.

    Or would you like to argue that unmet patient needs, the power of testimonial, or compulsive treatment seeking led to the architects of the software deciding that the only reasonable choice outside of pharmaceutical analgesia for pain was magical hand waving? Because I certainly don’t think that the average lay consumer was the one informing the software engineers about the standard of care, procedures, and therapies to include in the EMR.

  34. JPZ says:

    @pmoran

    “But we need to also understand that this commits us to an extremely Type 11 error-averse standard of practice. Nothing is given any benefit of the doubt. If it doesn’t work exactly as claimed it doesn’t work at all, according to the narrow meaning for “work” EBM operates from.”

    *distant applause is heard in the background*

  35. Harriet Hall says:

    @pmoran,
    “Nothing is given any benefit of the doubt. If it doesn’t work exactly as claimed it doesn’t work at all, according to the narrow meaning for “work” EBM operates from.”

    Oh really? If a CAM claim is tested and shown not to work, what would you have us do? Give it the benefit of the doubt and use it on patients because it might still work, just not exactly as claimed?

    Science ALWAYS gives the benefit of the doubt: scientific conclusions are always provisional and can be overturned by better evidence. But without such better evidence, how could we rationally choose treatments for our patients? It sounds like you’re making an argument for using any treatment you want just on the basis that we haven’t absolutely proven that it can’t possibly work.

  36. weing says:

    “But we need to also understand that this commits us to an extremely Type 11 error-averse standard of practice.”

    Not sure what you mean by that? I see us as constantly poised between type 1 and 2 errors. If you’re not removing an occasional healthy appendix, then you are probably leaving an occasional gangrenous one in. CAM has nothing to do with this. This does not stop us from being compassionate and respectful to patients. We all know that a drowning man will clutch at straw, or a razor. We need to provide the patient what gives them the best chance of survival. Wasting our limited resources on nonsense is not the way to help them or future patients.

  37. pmoran says:

    Those are not the kind of errors that those terms refer to, Weing, and as usual everyone misunderstands my intent. But I will keep plugging away.

    The mainstream HAS to be error-averse, setting a reasonably high bar for the treatments that it is prepared to use and recommend funding for. It must do so, because such is the misleading content of medical outcomes that, the number of intrinsically ineffective treatments being proposed as treatments will always vastly outweigh those that actually do “work” in a “better than placebo”, cost/risk/effectiveness sense. As Harriet implies, without those standards medical systems would be chaotic and closer to bankruptcy.

    What I am trying to point out is that while we doctors have this entirely valid, internally consistent approach to use of medical treatments, it is determined for us by responsibilities and obligations that are highly specific to the members of our profession.

    Members of the public don’t have the same obligations, although part of my push would be try and explain to them why they might take on some.

    It is not even entirely clear what standards should apply when, as with most use of CAM, the mainstream does not have an entirely safe and effective solution for medical distress. Do we assume, basically upon past form suggesting high odds against, that everything else will probably be useless (we doctors have to within our own practices, really, don’t we, Harriet? No giving the benefit of the doubt there.) What level of implausibility might preclude a trial of a dubious treatment, and who is to judge? What level of desperation might merit a trial of acupuncture for pain?

    So I am saying that the CAM user may have their own reasonably valid and internally consistent world-view, simply a different one — not “post-modernly” different, merely one that makes some sense for their own personal practical medical purposes and according to their own lights.

    But they don’t know enough about medicine to be able to explain why their situation is rather different. So they come up with these silly, defensive, post-hoc rationalizations. We latch onto those and laugh at them, revelling in our feeling of intellectual superiority and reinforcing our lazy, evidence-inconsistent perception that “if we could just educate these people with a bit of science and logic —- !”. We don’t grasp that these folk may on some level respect science just as much as we do. Science has simply, in a way, already done its dash for them.

    Does this help? Note the hint of despair in Steve’s last paragraph. This is why I think we should reexamine some of our basic assumptions about CAM (why they do it and what they get out of it) and check that they really do hold up. Being good scientists in other respects does not guarantee us an instant understanding of such a complex human activity.

  38. Harriet Hall says:

    @pmoran,
    “What level of implausibility might preclude a trial of a dubious treatment, and who is to judge?”

    We are not to judge. We are to inform, to give patients information about what is known scientifically. We should try to protect them from harmful treatments, but we needn’t discourage patients who want to try a harmless treatment, no matter how ridiculous it seems to us. If a patient brings up a CAM treatment and wants to try it, the doctor can respect their wishes, condone the trial, and keep managing the patient’s overall care. That’s OK, and I don’t think anyone here has suggested that it isn’t. But if a doctor is the one to bring up an unproven treatment and he recommends it to the patient in a way that leads the patient to think it is more effective than placebo, that is not OK.

    I think you are creating a straw man: the idea that science-based doctors fail to understand their patients’ psychological needs and automatically ridicule everything in CAM and do everything in their power to deny it to their patients.

  39. jhawk says:

    @pmoran

    “Also, Jhawk, as I think daedalus2, or was it Nybgrus?, pointed out, you will not find the mainstream using extremely plausible treatments as thought they were proven.”

    I hear this on SBM often . Here are three examples that say otherwise: debridement and lavage for knee OA, surgery for uncomplicated LBP, and injections for LBP.

    “Of course, plausibility is a bit subjective, and scientists sometimes gets things wrong, but it is not likely that they would be far wrong about about dozens of matters and methods all at once.”

    So you are saying if an allopathic procedure is difficult to study but has good plausibilty it works beyond placebo but a CAM procedure that is difficult to study and has good plausibility works only by placebo?

    “So the evidence is actually very strong that close to a hundred per cent of alternative treatments “work”, to the extent that they work, via placebo and other non-specific nurturing effects of medical attentions.”

    I am not sure you can make that argument (via placebo) if the teatment has not been or can not be studied via RCT especially when the treatment is extremely plausible.

    “We also now know that the RCT is not as reliable an instrument as we once thought when it comes to assessing the subjective effects of interventions, and there is even more murkiness in the science when it comes to difficult-to-blind procedural treatments. So we should certainly make some adjustments to the traditional sceptical belief that there will always be a clear divide between what works and what doesn’t.”

    Agreed, these failures of the RCT have been known for many years.

    @ HH

    “You are quibbling about semantics and details,”

    The devil is in the details and Imrie’s devils are conflation, overestimation, and citing poor studies.

    “but Imrie is undeniably correct when he says that RCTs are not the only acceptable evidence”

    I fully agree with this and have since my first research methods class back in undergraduate.

    “and that critics underestimate the percentage of medicine that is based on good evidence.”

    This may be true but Imrie overestimates.

  40. pmoran says:

    HArriet: I think you are creating a straw man: the idea that science-based doctors fail to understand their patients’ psychological needs and automatically ridicule everything in CAM and do everything in their power to deny it to their patients.

    Where did I say that? I am mainly suggesting that the more public face of medical scepticism might benefit from a face-lift, or a bit of a rethink. I have pointed out how viewpoints expressed here, in public, that normally go unchallenged, often DO necessitate a highly oppressive bent towards CAM in its entirety.

    And everyone here admits that present approaches are not working. even with our own kind!

    Even without the urge to oppress, if our arguments are even a little off-kilter, responsive to our own slightly distorted perceptions rather than how CAM really mainly operates, then we will not be listened to by those we wish to influence. For that is how most of the debates here pan out, even the ones with me. The method is to sift through what is said until you find something that looks weak, and in countering that imply that everything else that said can’t be worth thinking about or even worthy of response.

    As an example of off-kilter attitudes, some WILL see us as screwy, paranoid extremists if we regard medical science as being under a serious organized, political or ideological threat that includes CAM. Perhaps the universities giving CAM the hearing that we wish to forbid it have a more mature and secure sense of the inevitability of scientific progress, and know we have nothing to fear from it in that way.

    Is there any SCIENCE that says otherwise? Did the persistence of homeopathy into present times stop the Germans being amongst the most sensible people on earth?

    1. Harriet Hall says:

      @pmoran,
      “Perhaps the universities giving CAM the hearing that we wish to forbid it have a more mature and secure sense of the inevitability of scientific progress, and know we have nothing to fear from it in that way..”
      And perhaps not. Did you really manage to say that with a straight face?

  41. pmoran says:

    JhawkAlso, Jhawk, as I think daedalus2, or was it Nybgrus?, pointed out, you will not find the mainstream using extremely plausible treatments as thought they were proven.”

    I hear this on SBM often . Here are three examples that say otherwise: debridement and lavage for knee OA, surgery for uncomplicated LBP, and injections for LBP.

    Apologies. That should have read “IMplausible”, as the next sentence in the original implied.

    You are quite right that plausibility does not guarantee good results.

    Those examples contain powerful lessons for CAM, because everyone believed that they worked well until they were properly tested in well-planned prospective studies. How were they misled? By the anecdotal and semi-anecdotal experiences that provide the main basis for CAM.

  42. weing says:

    ” I have pointed out how viewpoints expressed here, in public, that normally go unchallenged, often DO necessitate a highly oppressive bent towards CAM in its entirety.”

    I am not sure if “oppressive” is the right word here. Are laws against fraud, forgery, etc “oppressive”? I am pretty sure a forger would think so. If that is true, then society benefits from this type of oppression.

  43. weing says:

    @jhawk,

    Imrie was referencing an article in British Journal of Surgery 1997,84, 1220-1223. He was not overestimating, he was reporting the findings of the article. Please read and understand the article, if you want to criticize it.

    Here is some of what was considered convincing non-RCT evidence for the 100 cases described by the authors:

    1 mastectomy for breast cancer, 2 open cholecystectomies, 6 hernia repairs, 2 strangulated hernia repairs, 1 gastrectomy and 1 laparoscopy for gastric cancer, 2 amputations for lower limb gangrene, 2 bypasses for critical lower limb ischemia, 2 I&Ds of abscesses, urethral catheterizations for 4 acute urinary retention cases, 3 UTIs treated with antibiotics, 3 epididymo-orchitis cases treated with antibiotics, 2 cases of metastatic cancer treated with palliative care, 1 head injury treated with observation.

  44. David Gorski says:

    Where did I say that? I am mainly suggesting that the more public face of medical scepticism might benefit from a face-lift, or a bit of a rethink. I have pointed out how viewpoints expressed here, in public, that normally go unchallenged, often DO necessitate a highly oppressive bent towards CAM in its entirety.

    Help, help, I’m being oppressed!

    And everyone here admits that present approaches are not working. even with our own kind!

    Well, yes and no. What we “admit” is that there isn’t a lot of evidence either way. Lacking that, until there is strong evidence that one approach or another worlds better, we’re left to our own devices to try to muddle through. In any case, we also “admit” that you appear unable to articulate a convincing alternative or describe evidence that supports its efficacy. Your alternative, boiled down to its essence, appears to be simply not to criticize anything but the most egregious CAM or “alternative medicine,” with alternative cancer cures being about the only thing in CAM that is apparently deserving of your criticism.

    For that is how most of the debates here pan out, even the ones with me. The method is to sift through what is said until you find something that looks weak, and in countering that imply that everything else that said can’t be worth thinking about or even worthy of response.

    Interestingly enough, that’s exactly how CAM advocates attack EBM/SBM. They find a part of it that’s not so strong and then use that to imply falsely that the whole edifice is crumbling.

    Even without the urge to oppress, if our arguments are even a little off-kilter, responsive to our own slightly distorted perceptions rather than how CAM really mainly operates, then we will not be listened to by those we wish to influence. As an example of off-kilter attitudes, some WILL see us as screwy, paranoid extremists if we regard medical science as being under a serious organized, political or ideological threat that includes CAM. Perhaps the universities giving CAM the hearing that we wish to forbid it have a more mature and secure sense of the inevitability of scientific progress, and know we have nothing to fear from it in that way.

    What Harriet said. A more likely explanation is that ideology has trumped science, as it is wont to do sometimes in academia. Seriously, Peter. I can’t make up my mind if you really just don’t get it anymore or if you’re just being obstinate. “Urge to oppress”? Seriously, I call B.S.

    Is there any SCIENCE that says otherwise? Did the persistence of homeopathy into present times stop the Germans being amongst the most sensible people on earth?

    On what evidence do you base your claim that Germans are “amongst the most sensible people on earth”? Define “sensible.” Are you referring to just Germans now or throughout the 200 years since Hahnemann invented homeopathy?

    Seriously, Peter, you’re making less and less sense the longer you go on in this thread, and that’s even after my having tried for many months to bend over backwards to understand where you’re coming from.

  45. pmoran says:

    @pmoran,
    “Perhaps the universities giving CAM the hearing that we wish to forbid it have a more mature and secure sense of the inevitability of scientific progress, and know we have nothing to fear from it in that way..”
    And perhaps not. Did you really manage to say that with a straight face?

    Why not? I have previously opined that it is ridiculous to think that CAM represents a serious threat to the progress of medical science and acceptance of its basic validity by (nearly all) our profession. Have those who think otherwise been exposed to too much CAM propaganda?

    CAM carries within it the seeds of its own ultimate unravelling precisely because it is not based upon good science. It’s loose standards and lack of sound underpinning in the basic sciences will allow hundreds of false claims before a true one is likely to surface.

    That will not pass the notice of the public indefinitely. Even so, many may continue to try out these methods, but, as I have tried to point out many times, without regarding it as expressing a committed scientific opinion. It is a gamble they think is worth taking.

  46. David Gorski says:

    CAM carries within it the seeds of its own ultimate unravelling precisely because it is not based upon good science. It’s loose standards and lack of sound underpinning in the basic sciences will allow hundreds of false claims before a true one is likely to surface.

    You mean the way that creationism has unraveled and been rejected by the public because it’s not based on good science?

    I get it now. You have an amazingly optimistic and idealistic view of human nature and science. The problem, of course, is that science is difficult; much of what it demands goes against human nature. That’s one reason why pseudoscience and quackery flourish. Defenders of science can’t afford just to sit back and hope that CAM eventually implodes because of its lack of scientific underpinning. It might do so eventually, but we’ll be waiting a very, very long time.

  47. Harriet Hall says:

    @pmoran
    “That will not pass the notice of the public indefinitely.”
    As David points out, large sections of the public still accept creationism, ESP, astrology, and a lot of other nonsense. Do you envision some ideal future in which the human race will have evolved to become more rational? How long do you imagine it might be until CAM “unravels”? I’m not holding my breath! Meanwhile, do you think that creationism, astrology, and CAM should be taught in our schools until EVERYONE rejects them?

    “It is a gamble they think is worth taking.”
    Sure. Many people think risking their money in Las Vegas is a gamble worth taking, too. At least in Las Vegas the odds can be calculated, so people can consider that as they decide on whether to gamble. If a patient decides to gamble on coffee enemas in a Mexican clinic, we recognize his right to do so, but we think he should be given the information needed for informed consent. All too often, CAM baffles patients with BS: testimonials, pseudoscience, and false information.

    We get it, really we do: we understand why desperate people take risks with their health and grasp at any straw. I really don’t understand why you keep suggesting we are not sensitive to patients’ needs and thought processes. Surely, true compassion requires that we offer them realistic information to better deal with those needs. As for treatments that “might possibly work,” patients depend on us to provide guidance as to their degree of plausibility, to categorize unproven treatments as experimental, and to tell them when treatments have been tested and are almost certainly no better than placebo.

  48. pmoran says:

    Weing: ” I have pointed out how viewpoints expressed here, in public, that normally go unchallenged, often DO necessitate a highly oppressive bent towards CAM in its entirety.”

    I am not sure if “oppressive” is the right word here. Are laws against fraud, forgery, etc “oppressive”? I am pretty sure a forger would think so. If that is true, then society benefits from this type of oppression.

    I suppose “oppressive” has some unfair judgmental overtones but it is perceptions that really matter. There is already much wariness concerning our intentions and motives.

    The emphasis here is very much upon “the science”, rather than on the practical consequences of CAM for society, and “there are methods that work and methods that don’t” leaves little room for manoeuvre in legal and ethical matters. Thus relatively harmless uses of homeopathy will get as much if not more air time as life-threatening cancer quackery.

    In any case, it is the perceptions aroused in minds of readers that really matters. Paranoia already simmers away there as to our intentions and motives. The emphasis here is very much upon the science, rather than practical consequences for society. “There are methods that work and methods that don’t” leaves little room for manoeuvre in legal and ethical matters.

    In any case, it is the perceptions aroused in minds of readers that really matters. Paranoia already simmers away there as to our intentions and motives.

  49. pmoran says:

    Sorry for repeated content there.

  50. pmoran says:

    CAM carries within it the seeds of its own ultimate unravelling precisely because it is not based upon good science. It’s loose standards and lack of sound underpinning in the basic sciences will allow hundreds of false claims before a true one is likely to surface.
    You mean the way that creationism has unraveled and been rejected by the public because it’s not based on good science?
    I get it now. You have an amazingly optimistic and idealistic view of human nature and science. The problem, of course, is that science is difficult; much of what it demands goes against human nature. That’s one reason why pseudoscience and quackery flourish. Defenders of science can’t afford just to sit back and hope that CAM eventually implodes because of its lack of scientific underpinning. It might do so eventually, but we’ll be waiting a very, very long time.

    And no one is telling you to do nothing.. I am asking that we think about how to do it better, also that we set ourselves realistic and rational objectives.

    I am NOT deterred by present bullying from suggesting that we look both ridiculous and devious when we try to reinforce our legitimate objections to many of the claims of CAM by the fancy that science might crumble in front of them or that they are part of a sinister conspiracy against scientific medicine. Neither of those are supportable propositions, in my view, and I am prepared to argue that through with anyone who wishes to.

    Calling this a science-based enterprise does not immunise it from the tendency for like-minded groups like this to become accepting of ill-supported communal dogma, through constant incestuous reinforcement. I see that happening in CAM groups and don’t see any place for it on a suppsoedly science-based group.

  51. Harriet Hall says:

    @pmoran,

    “the fancy that science might crumble in front of them or that they are part of a sinister conspiracy against scientific medicine”

    This is an overstatement of the SBM position. I’m not afraid that science will crumble, just that more people will fail to appreciate it, that doctors will become less scientific, and that patients will suffer the consequences. I don’t imagine any sinister conspiracy, just a confluence of unfortunate influences and very human tendencies.

    As for thinking about how to do it better, we are constantly thinking. We are doing our best, and it seems to me your comments amount to carping rather than to constructive criticism. Do you have any concrete proposals?

  52. nybgrus says:

    I am asking that we think about how to do it better, also that we set ourselves realistic and rational objectives.

    As Dr. Hall said – have you anything better to offer? Besides critiques of the tone, tack, and a relentless claim that the science hasn’t completely and utterly proven placebo to be of little utility you’ve offered nothing else.

    You may indeed be right that the tack here, by myself included, is sub-optimal or even downright “wrong” – but unless you can come up with something actually better those words ring hollow and blow away in the wind.

    I am NOT deterred by present bullying from suggesting that we look both ridiculous and devious when we try to reinforce our legitimate objections…

    It has been my experience that when someone feels they are “bullied” it is because they simply have nothing to add to the conversation. Obviously those of us whom you accuse of doing the “bullying” have a set of ideas and beliefs about these topics. Obviously we (and I assume you would, at least to some degree, be including me in there) would lay down our reasons, rationale, and logic to support said ideas and beliefs. The fact that you continue to hear them does not mean there is an “ill-supported communal dogma” – it could just as equally be a very well supported evidence based stance. If you had anything substantive to offer in rebuke ideas and thoughts could change. But I am certainly not alone in thinking you have yet to do so.

    Dr. Gorski thinks you may have an overly optimistic outlook on human nature and some sort of utopian setting where we can just lean back in our chairs and this whole CAM business will settle out and we can be on our merry way. Perhaps some hundreds of years from now that will be more or less true. But it certainly won’t get there without a lot of hard work and concerted efforts at education along the way.

    I’ve said it before, but I think you are trying to find a reason to accept “harmless” CAM and never relegate yourself to professional helplessness whilst realizing that the worst of CAM must be dealt with. It is passing the buck and I have seen little evidence of anything else.

    Just as you rightly claim patients will cling to any straws (and even razors) in the face of their own imminent mortality, so too will some physicians cling to any straws so that they may never face an ill patient and be forced to say “I’m sorry but there is nothing more we can do.” Both are perfectly understandable, and both are also wrong. We cannot manage to always be right in this world, but we should strive to be.

  53. Harriet Hall says:

    “I’m sorry but there is nothing more we can do.”
    Change that to “There is nothing more we can do to cure or change the course of the illness, but we can still offer symptom relief, comfort measures, support, and we can realistically hope to maintain a satisfactory quality of life as long as life lasts.”

  54. nybgrus says:

    @Dr. Hall:

    Yes, I agree. But based on his arguments (which I am almost certain he will correct me and say that is not what he is saying) it strikes me that pmoran would think that either we can’t do/say that or that sCAMsters are, for some reason, so much more adept at it than we are that our attempts at it would be pointless. Hence, he feels relegated to saying “There is nothing more that we can do” because without tapping into the CAM modalities at our disposal (which I have yet to see a system for evaluating which ones are “OK” and which one’s aren’t) we are effectively doing nothing.

    I actually doubt that is really what pmoran is thinking or does with his patients. And maybe I really am missing something fundamental to his arguments to date. But from what I can gather so far, that is all I have been getting.

  55. pmoran says:

    Harriet:As for thinking about how to do it better, we are constantly thinking. We are doing our best, and it seems to me your comments amount to carping rather than to constructive criticism. Do you have any concrete proposals?

    I know I carp a bit.

    Most of my comments are responses to poor science in the sense of statements or underlying assumptions that lack a solid, certain, or general correspondence to reality.

    I don’t think I should need to justify those. People can argue otherise if they wish. The practical concern, if you want me to spell it out, is that they will be counterproductive whenever the reader is prompted to say “well the CAM I know is not really like that”. Remind yourself how we hate it when the mainstream is seriously misrepresented.

    At other times my comments are more directly to do with how to talk to CAM sympathizers. The safest bet is always a simple account of “this is what I think and why”. This is what you do, indeed most contributors do so when dealing with the basic scientific considerations– it is where some understanding of CAM use and users is needed that I have concerns).

    I have been listening to and talking to CAM users for a very long time. That has not changed my scientific opinions one jot (as should be obvious), but I think I have some valid ideas as to what buttons are best not pushed if you want them to reach a working understanding of us.

    I suspect that it is much easier to engage a little trust (or to lose it) than it is to convince people of scientific ‘truths’ via sophisticated analyses of the evidence. Every quack relies upon that.

    1. Harriet Hall says:

      @pmoran,
      When a patient mentions CAM we shouldn’t just dismiss it by saying “That’s all bullshit.”
      We should know enough about CAM not to misrepresent the facts in our criticism,
      We should recognize that many people believe CAM has made them feel better.
      We should try not to alienate patients by attacking their CAM beliefs, but rather should try to explain dispassionately why we believe otherwise and what the scientific evidence shows.

      If this is what you are trying to say, I heartily agree.

      But I don’t think any of us violate those rules, and I don’t understand why you think you need to carp.
      There are times when we make statements about evidence, and there are times when we offer personal opinions.
      If you think we have underlying assumptions that are not consistent with reality, it’s up to you to provide evidence that we are wrong. If we have opinions that are not consistent with your opinions, that’s a different matter.

  56. David Gorski says:

    Do you have any evidence to support your “valid ideas as to what buttons are best not pushed”?

  57. nybgrus says:

    @pmoran:

    Believe it or not, I wholeheartedly agree with you (well, everything save the 2nd sentence you wrote)! I have also spoken with many a CAM sympathizer. Rarely in a professional medical capacity (yet) but certainly amongst friends and aquantainces.

    But my point that I have made repeatedly and that you dodge incessantly is that such rhetoric is fundamentally different from what goes on here. This blog does not speak to the individual CAM sympathizer – it speaks to the world at large. There needs to be a hard stance based on the science somewhere and that is most certainly (here’s where I agree with you) not one-on-one in the exam room.

    This is where I feel my intelligence is insulted and I’d venture Drs. Hall and Gorski as well. We are not so dim as to think that one size fits all or that our sometimes bombastic rhetoric here is the best solution for dealing with individuals face-to-face.

    Yet you take our discussions and arguments here, and act as if we were doing exactly that. Hence my continued critique that you are mixing population level arguments with individual levels arguments. They are very separate things.

    And considering that I have personally convinced, through kind and gently worded rhetoric, to forever give up acupuncture and “immune boosters” like VitC and echinacea, I would say I have just as much evidence as you about “valid ideas as to what buttons are best pushed and not pushed.”

    But that is not what the fundamental discussion is about at this blog. Hence our continued confusion as to what your actual stance on such matters is. Especially because this is not the first time such things have been explicitly spelled out to you – and not just by me.

    I get that when a CAM aplogist or sympathizer shows up here and we unabashedly destory him/her with science, we have not made that person a convert and only likely hardned his/her stance. But for the onlookers, those on the fence, or those not quite so vested, they have an opportunity to see why that is the case and potentially convert themselves. Or, as is often the case, they learn why some CAM they don’t care about it s garbage and then when it comes around to their particular peccadillo they are actually more apt to alter their view seeing the exact same reasoned and hard stance taken.

    One mustn’t confuse with a holding a hard and reasoned stance towards the world at large with crushing the hopes and dreams of an individual person standing in front of you.

    I would be willing to bet my next year’s tuition that if one of Dr. Gorski’s patients came to him asking about using even the most flagrant CAM (Robert O. Young, anyone?) that he would be as calm, understanding, and supportive as possible in an effort to at the very least remain involved in the patient’s care to ensure the best possible outcome even if that meant continuing with the woo. Phrases similar to “I haven’t seen any good evidence that it will help you, but if you would very much like to try it just please keep me informed so we can make sure that our treatments don’t conflict and we can give you the best possible care” would abound. And most certainly, I could never in a million years envision Dr. Gorski saying anything remotely like “Well, that is complete and utter garbage and if you go that route I won’t be able/willing to take care of you anymore.” Neither would a sense of macabre happiness come about should a bad side effect lead the patient to completely abandon the woo and solely rely on Dr. Gorski’s treatments.

    I am speaking for Dr. Gorski a fair bit on this one, but in reading almost everything he has written for the last 2 years and watching him speak (plus, my friend at Chicago med has met him in person and we chatted about that as well), I think my tuition is safe.

    So carp all you want, pmoran. Tossing in constructive criticism would be appreciated along the way though. However, please, please, stop conflating the type of rhetoric found here with the type of rhetoric anyone here would use in the consultation room.

  58. nybgrus says:

    Hit send before re-reading… I really should stop doing that:

    I should clarify that the consultation room should be hard science, just not the hard-line stance on science that is seen here.

    Also:

    “And considering that I have personally convinced, through kind…”

    should be:

    “And considering that I have personally convinced many a CAM user, through kind…”

    (i.e. anecdote and personal communication skills, which is on par with what you have to offer here)

    I should also add that the hard-line stances here offer those (lay or otherwise) who know that certain CAMs are BS to understand why and give them a hard understanding that they can then tailor to use on their own family and friends (and we have seen them comment to that effect here).

  59. Quill says:

    Reason is reason, isn’t it? Having a “hard stance” isn’t necessary unless you think the ground you’re on is soft or the force of an onrushing argument may knock you over. If your argument is logical and sound, no amount of hard or soft things will matter. However the attitude a position is conveyed with certainly will affect how it is received by another person.

    It’s a truism but bears repeating: the teacher must speak in a language the student can not only hear but understand. This is also true for anyone trying to explain something to anyone else. SBM seems to do a good job of this even when presenting complicated information.

  60. nybgrus says:

    You are correct Quill and that was supposed to be implicit in what I said.

    The difference is here we can and should say “No, that is garbage and here is why” but in a consultation with a patient facing an illness, a different tack is warranted. Nothing has changed about the stance or the science behind it.

  61. Quill says:

    @nybgrus: Indeed, yes, the difference between a blog and a clinical setting should (hopefully!) be obvious to all. I think that is where CAM’s “personalized” medicine sneaks in places, by proffering a “caring, personalized and deeply respectful” attitude at all times even when that means they don’t engage in any arguments but simply just sort of ooze platitudes. For a lot of people, hearing a constant stream of caring noises goes a long way.

    Anecdotally, I was put off by more doctors than CAM practitioners based on their attitudes before I began to think not only more clearly but for myself. Now I have much more sympathetic understanding of MDs who get cranky than for the CAMer who never even frowns. ;-)

  62. pmoran says:

    Harriet (and Dr Gorski): If you think we have underlying assumptions that are not consistent with reality, it’s up to you to provide evidence that we are wrong.

    That’s another ploy. Let’s go back to my entry point into the discussion of Steve’s present piece about logical fallacies and check just how unreasonable I am being. I am clearly putting up ideas for consideration. This is what I said –

    I suggest that these intellectual flaws are mainly post hoc rationalizations, not the primary drivers of CAM.

    It is possible to explain the existence of CAM through three simple influences: unmet or poorly met medical needs, the power of the personal testimonial, and a human tendency towards compulsive consumption of medical treatments when ill. These factors would sustain CAM without anyone ever sitting down and considering its provenance or scientific basis.

    The “threat to medical science” is thus largely an illusion drawn by the preoccupations of the scientific mind, as is largely also the notion that people can ever be easily educated into an “our way or no way!” attitude towards medical treatment even when the mainstream has nothing to offer itself.

    I am not supporting CAM, bad logic, or bad science. I merely want to be sure I understand it all to my own satisfaction, without bias and especially without any potentially counterproductive distortions of the reality.

    I followed this up with what I think is also an important insight. It should be clear that I am talking about ways at looking at CAM that are very subtley but possibly importantly different to the prevailing sceptical ones. I perhaps should have refrained from the ad hominem slant fo the last paragraph although it is surely an accurate respresentation of common sceptical dialogue. We are only human.

    The mainstream HAS to be error-averse, setting a reasonably high bar for the treatments that it is prepared to use and recommend funding for. It must do so, because such is the misleading content of medical outcomes that the number of intrinsically ineffective treatments being proposed as treatments will always vastly outweigh those that actually do “work” in a “better than placebo”, cost/risk/effectiveness sense. As Harriet implies, without those standards medical systems would be chaotic and closer to bankruptcy.

    What I am trying to point out is that while we doctors have this entirely valid, internally consistent approach to use of medical treatments, it is determined for us by responsibilities and obligations that are highly specific to the members of our profession.

    Members of the public don’t have the same obligations, although part of my push would be try and explain to them why they might take on some.

    It is not even entirely clear what standards should apply when, as with most use of CAM, the mainstream does not have an entirely safe and effective solution for medical distress. Do we assume, basically upon past form suggesting high odds against, that everything else will probably be useless (we doctors have to within our own practices, really, don’t we, Harriet? No giving the benefit of the doubt there.) What level of implausibility might preclude a trial of a dubious treatment, and who is to judge? What level of desperation might merit a trial of acupuncture for pain?

    So I am saying that the CAM user may have their own reasonably valid and internally consistent world-view, simply a different one — not “post-modernly” different, merely one that makes some sense for their own personal practical medical purposes and according to their own lights.

    But they don’t know enough about medicine to be able to explain why their situation is rather different. So they come up with these silly, defensive, post-hoc rationalizations. We latch onto those and laugh at them, revelling in our feeling of intellectual superiority and reinforcing our lazy, evidence-inconsistent perception that “if we could just educate these people with a bit of science and logic —- !”. We don’t grasp that these folk may on some level respect science just as much as we do. Science has simply, in a way, already done its dash for them.

  63. Harriet Hall says:

    @pmoran,

    We are not laughing at the patients, we are laughing at the ideas. I, for one, do not have the perception that “if we could just educate these people with a bit of science and logic…” I do think that if we could better educate children from an early age about science and critical thinking skills, we might eventually make some headway.

    I don’t think we ”assume that everything else will probably be useless.” Rather, we recognize that without proper scientific evidence we are very likely to fall into error. Deciding what to study should not depend on how desperate patients are, but on medical standards that are consistent. When acupuncture for pain has been repeatedly studied and all indications are that it is no better than an elaborate placebo, why would we want to spend our research dollars there?

    It still sounds like you are saying that since science doesn’t have all the answers, we should relax our standards.

  64. pmoran says:

    And considering that I have personally convinced, through kind and gently worded rhetoric, to forever give up acupuncture and “immune boosters” like VitC and echinacea, I would say I have just as much evidence as you about “valid ideas as to what buttons are best pushed and not pushed.”

    All that may prove is that people can be very responsive to the opinions of others at a personal level — negative, as well as positive. It may be an example of an “anti-testimonial” effect, moreover at the very soft end of CAM use and of medical need.

    You may not have equipped them with the level of scientific sophistication needed to counter the next testimonial they encounter. Nor have you explained why a different approach will work better in more public arenas.

    What do we REALLY want? What we really want is to as far as possible ensure that people use effective medical treatments before they risk life or limb on “useless” ones. That requires that they trust us — that they truly believe that we value their welfare above everything else.

    Does your “hard line” on scientific issues support that? It probably does depend in part on how we present our case.

  65. pmoran says:

    It still sounds like you are saying that since science doesn’t have all the answers, we should relax our standards.

    Why was it not clear to you that I was referring to how the CAM user makes their medical decisions? I even spelt out why medicine has to adhere to the standards it has set for itself.

  66. nybgrus says:

    Why was it not clear to you that I was referring to how the CAM user makes their medical decisions?

    Why is it not clear to you that the vast majority of the content here has nothing to do with why the CAM user makes their medical decisions, but how the CAM providers set up their arguments to sound appealing and thus “integrate” themselves into actual medicine via popularity? That nice long post of self-quotes is supporting a discussion we aren’t having, yet you keep dragging us back to.

    You may not have equipped them with the level of scientific sophistication needed to counter the next testimonial they encounter.

    Very true. And as Dr. Hall pointed out (and I have been saying all along as well) it is proper scientific and critical thinking education as early as possible that is necessary.

    What do we REALLY want?

    I would argue that what we really want is to have a strong, unified, evidence based stance amongst our profession to project to the public at large whilst managing individual patient encounters as best as possible… such as anti-testimonials, as you say.

    That requires that they trust us — that they truly believe that we value their welfare above everything else.

    Why do you think those people believed what I had to say? Or would you say that my non-medical professional interpersonal skills won’t translate in a professional medical setting?

    Does your “hard line” on scientific issues support that?

    Yes. My hard line is always there. It is only a matter of when and how (much) to state it.

  67. Harriet Hall says:

    @pmoran,

    “Why was it not clear to you that I was referring to how the CAM user makes their medical decisions?”

    Because you did not make it clear. You keep saying things like “It is not even entirely clear what standards should apply…” and in previous discussions you have suggested that it is appropriate to recommend acupuncture to patients – that is the doctor influencing the patient’s decisions, not just trying to understand the patient’s point of view. I have said repeatedly that if a patient wants to try something unproven, no matter how ridiculous I think it is, I would condone it (as long as I don’t think it puts him in any danger) – I just wouldn’t recommend it in the first place. Why is that not clear to you?

    SBM is all about what the science says, and it is not paternalistic but respects patient autonomy. There are times when it is appropriate to offer experimental treatments, preferably in the context of a scientific study, and only if it is clearly explained as experimental. When scientific medicine doesn’t have an effective treatment, I think a doctor who recommends CAM just because he desperately wants to “do something” for the patient and because “it might possibly work” is grasping at straws, acting paternalistically, and trying to look good to himself and to the patient. Even when all the effective treatments have been exhausted, a good clinician can always offer comfort measures without disguising them as something more, and can work with the patient to improve his quality of life.

  68. pmoran says:

    Harriet and Nybgrus,

    @pmoran,
    Why was it not clear to you that I was referring to how the CAM user makes their medical decisions?”
    Because you did not make it clear. You keep saying things like “It is not even entirely clear what standards should apply…” and in previous discussions you have suggested that it is appropriate to recommend acupuncture to patients – that is the doctor influencing the patient’s decisions,

    Oh, Harriet! Really?!

    If my antecedent comments were not sufficiently indicative, my full sentence was ” It is not even entirely clear what standards should apply when, as with most use of CAM, the mainstream does not have an entirely safe and effective solution for medical distress.” — which clearly refers to the most common pattern for use of CAM.

    You both have raised a different matter — my supposed support of acupuncture — presumably because on prevailing sceptical mores that would place me well beyond the pale –” ’nuff said, folks!”.

    I have suggested once or twice that I cannot see asking a patient if they would like to try acupuncture when more evidence-based options have been exhausted as an ipso facto hanging offence. I still don’t. But that is as far as I have ever gone in support of acupuncture.

    I would agree that even that is unethical if the doctor was sure that acupuncture would do nothing at all for the patient and was giving the advice for his own ends.

    But everyone allows that there is a possibility that it might help the patient in some way and that is what we are supposed to be here for. Most patients would be grateful that we are prepared go to the very limits of our science-based constraints to try and help them, and they may in consequence be better liable trust us when we tell them they are running more serious risks.

    Let’s explore those “limits”. Acupuncture is an impure placebo because it is probably good at provoking endorphin release, it may have more counterirritant and distractant effects than a “purer” placebo, it prolongs medical interactions, and it enforces periods of relaxation during therapy. The RCTs show it still “works” even if some elements are missing but they don’t clearly answer the question “do acupuncture-like methods work or not?”. That can go either way depending upon how you choose define “work” and how you asnwer the question “what is important here?” .

    The use of acupuncture thus does not have to be seen as encouraging pseudoscience unless we sceptics insist so so as to make our lives simpler. Acupuncture has actually been available on the Australian Medicare system for a couple of decades and the sky has not yet fallen, just as homeopathy is still ubiquitous in mainland Europe without thoroughly corrupting those medical systems or stalling the progress of medical science there.

    So, while it’s not something I would feel entirely comfortable with, I neither see an absolutely clear ethical or practical medical conflict therein, nor am I am convinced by the slippery slope arguments employed in the usual heretic-branding ceremony. The public is not as stupid as we think. Most sense that CAM has a somewhat different relationship to science and regard it as a last resort, if used at all.

    Look, I don’t want these exhausting arguments either. I am merely asking that people take time to think more deeply about these matters. My real message is that medicine is a very complicated human activity and we should be careful about too much slinging off at those who for a variety of honest reasons have more moderate views — that’s usually not based upon sound science, and it will also be repellent to some kinds of reader.

    Ironically, I have no complaint with you Harriet, about the way you personally approach CAM. So it is weird to find myself arguing with you.

  69. Harriet Hall says:

    @pmoran,
    “But everyone allows that there is a possibility that it might help the patient in some way”

    I’m sure there is a possibility that acupuncture will help patients in some way, but if the evidence shows that it will almost certainly “work” only as a placebo, I have difficulty justifying a recommendation. If you interpret the evidence differently, and think there is a good possibility of a specific effect, I couldn’t fault your ethics for recommending a trial of it, but I would question your judgment about the meaning of the evidence.

    Valuing hope over scientific rigor is laudable as a humanitarian gesture, but history shows us it is likely to lead us astray. We have other options for things that might possibly help the patient in some way, from those that might also harm (like heroin) to safe and simple comfort measures. Our job is not just to “help the patient in some way” but to help him in a way that is consistent with his long-term best interests.

  70. nybgrus says:

    Acupuncture is an impure placebo because it is probably good at provoking endorphin release, it may have more counterirritant and distractant effects than a “purer” placebo, it prolongs medical interactions, and it enforces periods of relaxation during therapy

    And you scoff at my understanding of placebo effects? Talk about grasping at razors to justify something

  71. Nikola says:

    Regarding the claim of homeopathy dating as far back as ancient Greece…
    I came across that same argument a few months ago on a national (Croatia) program discussing homeopathy. The claim is pure nonsense, of course – it’s purely based on the fact that Hippocrates applied the law of similars in the 5th century BC.
    Of course, this is mere truthiness, an invalid argument.
    To claim that an appeal to an ancient disproven healing principle establishes homeopathy’s case, all the while ignoring homeopathy’s added bonus law of infinitesimals is scientifically indefensible.
    What has happened to academia in the past few decades? Who let it happen?

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