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

A Brief Clinical Vignette

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

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

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

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

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

I expect better from an academic medical center like the University of Wisconsin. Unfortunately, increasingly I’m not getting it. Quackademic medicine is infiltrating such medical centers like kudzu.

A survey, a survey, my kingdom for a survey!

One of the most frequently used arguments by promoters of “complementary and alternative medicine” (CAM) or, as it’s more frequently called these days, “integrative medicine” (IM) has nothing to do with science at all. Actually, few of the arguments put forth for “complementing” or “integrating” quackery (which, let’s face it, is all the vast majority of IM really is) with science-based medicine actually have anything to do with science, favoring vague and fuzzy appeals to “holistic” medicine and the “whole patient,” as though it’s not possible to be holistic without adding a heapin’ helpin’ of magical thinking to medicine. It’s the classic false dichotomy: Either we inject a generous dose of woo into our medicine, or medicine remains “non-holistic” or, even worse, reductionistic, and we all know how evil “Western” reductionistic science is, right?

No, one of the favorite tactics used to market CAM/IM comes straight out of the Madison Avenue playbook. Indeed, I can imagine Don Draper of Mad Men cooking it up. It’s a classic argumentum ad populum, whereby CAM/IM advocates try to represent their “product” as being very popular and gaining in popularity every day. These sorts of appeals on the part of CAM/IM frequently emphasize the various subcategories of argumentum ad populum, such as the “bandwagon fallacy,” in which it is argued that, because most people believe something (or because large numbers of people; i.e., a sizable majority) you should believe it too, or at least consider it more seriously. Regular readers should be able to see the problem inherent in that approach. After all, many people believe in ghosts or astrology; the fact that such beliefs are popular does not make them true. The second form of argumentum ad populum is known as “snob appeal,” in which CAM proponents try to persuade you of a conclusion by appealing to what an elite or a select few (but not necessarily an authority) in a society thinks or believes. Of course, I view this variety of argumentum ad populum as more an appeal to authority than anything else, and, as I point out from time to time, an appeal to authority is not always a fallacy, which is why legitimate authorities need to be careful and responsible in what they say. What they say matters to non-experts.

We in medicine have apparently been failing in this respect utterly with respect to CAM/IM.

What led me to this conclusion yet again is a recent survey that’s being flogged in the CAM/IM blogosphere that reports to have found that CAM/IM programs are becoming more common in hospitals and medical centers. My first reaction was almost shruggie-like in that I just wanted to shrug my shoulders and agree with Steve Novella that pseudoscience sells. But then I decided to take a closer look.

What I’m referring to is the 2010 Complementary and Alternative Medicine Survey of Hospitals, a survey that was carried out by the Samueli Institute in collaboration with Health Forum, which is listed as an American Hospital Association Company.” Oddly enough, this survey was not funded by the National Center for Complementary and Alternative Medicine (NCCAM), but rather by the US Army Medical Research and Materiel Command under Award No. W81XWH-10-1-0938. With two wars going on, one would think that the Army would have better things to spend taxpayer dollars on. Apparently you’d be wrong.

For those of you who don’t remember the Samueli Institute, it’s one of the major forces, along with the Bravewell Collaborative, promoting the infiltration of quackademic medicine into academic medical centers. It even describes itself thusly on the cover page of its survey report:

Samueli Institute is a non-profit research organization investigating the safety, effectiveness and integration of healing-oriented practices and environments. We convene and support expert teams to conduct research on natural products; nutrition and lifestyle; mind-body practices; complementary and traditional approaches such as acupuncture, manipulation and yoga; and the placebo (meaning) effect. We support a knowledge network that assists in integrating evidence-based information about healing into mainstream health care and community settings and in creating Optimal Healing Environments.

The “meaning” effect“? Holy Dan Moerman, Batman!

Professor Moerman aside, in a couple of talks I’ve given, I’ve used the Samueli Center for Integrative Medicine at UC-Irvine as an example of just how egregious quackademic medicine can get. Indeed, right there on the SCIM website you can see a homeopath, along with acupuncturists and naturopaths. Some of these might well recommend something called FirstLine Therapy, which is basically a program marketed by Metagenics. Not surprisingly, dietary supplements are part of the program, as is “Ultrameal,” which is billed as “medical food” and takes the form of expensive drink mixes and bars. Yum.

But I digress. What about the survey itself? Let’s go to the Samueli Institute’s press release first:

Hospitals across the nation are responding to patient demand and integrating complementary and alternative medicine (CAM) services with the conventional services they normally provide, according to the results of a new survey released today by Health Forum, a subsidiary of the American Hospital Association (AHA) and Samueli Institute, a non-profit research organization that investigates healing oriented practices. The survey shows that more than 42 percent of responding hospitals indicated they offer one or more CAM therapies, up from 37 percent in 2007.

Note how this is a clever combination of the bandwagon appeal and an appeal to authority. After all, there is “patient demand,” and the authorities (i.e., hospitals) are responding. The unspoken subtext is the assumption that hospitals wouldn’t respond to such a demand if there weren’t something to it. They are, after all, health care institutions made up of health care professionals, right? Well, yes, but hospitals are also businesses, and many of these health care professionals have either bought into the myth that “holism” and improving the doctor-patient relationship requires woo, or they are shruggies.

Meanwhile, CAM/IM apologists and supporters are jumping all over this survey as “evidence” that they are winning. John Weeks of the Integrator Blog, for instance, crows:

The most significant data point here is that 74% say that “clinical effectiveness” is a top reason for inclusion. This growth took place in a down economy and despite the lack of good payment models for CAM. These findings will be interesting to view after new incentive structures that might support CAM inclusion kick in with the growth of accountable care organizations (ACOs).

“Clinical effectiveness”? Based on what? Certainly not science in most cases.

In any case, the story has gotten some traction in the mainstream media, such as the L.A. Times, which, tellingly, chose to report on the survey on its Money & Company blog under the title Alternative medical services growing at U.S. hospitals, quoting widely from the joint press release of the AHA and Samueli Institute.

But does the survey actually show what it claims? Let’s go to the report itself. The first thing I noticed when I read the report was that it’s full of the typical “bait and switch” language of CAM designed to inflate the numbers of people who apparently use “CAM modalities.” For instance, diet, exercise, and the like are represented deceptively as being somehow “alternative” when their utility not only can be studied by science but has been studied by science. None of this is surprising, but it is harmful in that it applies a layer of “mystery” and “danger” to modalities that physicians have been prescribing their patients for a long time, such as better nutrition and more exercise. These modalities are, in effect, “woo-ified.” Then, they are lumped together with the real woo, such as acupuncture, homeopathy, and “energy healing,” in order to provide legitimacy by association. For instance, if you look at Figure 2, you’ll see that natural products are the most commonly reported CAM modality, which tells me that the supplement industry’s marketing hype has been effective. More tellingly, other than chiropractic, all of the top nine modalities are nothing that couldn’t be considered SBM. True, homeopathy just barely squeaks into the top ten at number ten, but only 1.8% of adults in the U.S. have reported using it. (I suspect the number would be higher in Europe.) Where’s traditional Chinese medicine? Where’s acupuncture? Where’s “energy healing”? Apparently none of them made the top ten. For instance, if you go to the 2007 National Health Interview Survey Report, you’ll find that only 1.4% reported using acupuncture; 0.4% reported using naturopathy; 0.1% reported using Ayurveda; and 0.5% reported using reiki.

No wonder the bait and switch move is necessary, at least if CAM practitioners want to represent the popularity of their methods as being higher than single digit percents (or in some cases higher than 1%).

Here’s how the survey was done:

The 2010 Complementary and Alternative Medicine Survey of Hospitals, a 42-question instrument, was mailed to 5,858 hospitals from American Hospital Association’s inventory of opened and operating member and nonmember hospitals in March 2010. Respondents had the option to either complete the survey online or mail back a hard copy. A total of 714 responses were received for a response rate of 12%. Of responding hospitals, 299 (42%) stated that they offered one or more CAM therapies in the hospital—which could be either in the form of services provided to patients or employees.

Does anyone see the problem here? It’s fairly obvious, namely the response rate. It’s pretty hard to say much of anything based on a 12% response rate. Basically, all we can say is that 42% of the respondents have a CAM program of some sort or another, but we have no idea whether the respondents are a representative sample. Indeed, they almost certainly are not; there is probably major selection bias going on here, with respondents more likely to be the ones who have some sort of CAM program. Just the geographic distribution of responses makes me wonder, though, with 23% coming from the Midwest and only 11% coming from West Coast states. Later in the report, it is pointed out that “most of the hospitals responding to this survey would be considered ‘early adopters’” who are, apparently, adopting CAM “because they believe it’s the right thing to do or because it’s important to respond to the needs of their communities and patients.” Clearly, this is not a representative sample. Be that as it may, it can still be informative to examine this non-representative sample. For example, the “bait and switch” continues here, with the top six outpatient modalities being:

  1. Massage therapy
  2. Acupuncture
  3. Guided imagery
  4. Meditation
  5. Relaxation
  6. Biofeedback

And the top six inpatient modalities being:

  1. Pet therapy
  2. Massage Therapy
  3. Music/art therapy
  4. Guided imagery
  5. Relaxation training
  6. Reiki and therapeutic touch

The authors of the survey report conclude with amusing understatement:

Looking at the top modalities offered in hospitals it is clear that hospitals are “playing it safe” and starting with fairly conservative and non-invasive therapies to appeal to the broadest range of patients and consumers in the their community. Pet therapy has been growing in popularity. Massage therapy is provided predominantly for pain and stress management and for cancer patients, according to the American Massage Therapy Association’s 2007 Survey of Massage Therapy Utilization in Hospitals.

Other key findings include:

  • Majority of respondents offer wellness services for patients and staff, including nutritional counseling, smoking cessation, fitness training and pastoral care;
  • Massage therapy is in the top two services provided in both outpatient and inpatient settings;
  • The majority of hospitals that offered CAM were urban hospitals (72 percent); and
  • Seventy-five percent cited budgetary constraints as the biggest obstacle for implementation of CAM programs.

It is rather instructive, though, to look at the differences between inpatient and outpatient. First of all, who decided that “pet therapy” was in any way alternative? It’s not really “therapy,” either: it’s a great way to raise spirits among hospitalized patients, but lumping it in as a “CAM” therapy seems a major stretch to me. (If pet therapy is an “alternative” or “integrative” therapy, then sending hospitalized patients a card and flowers to lift their spirits must also be alternative or integrative therapy.) Secondly, it is interesting how reiki and therapeutic touch are major offerings in the inpatient realm but not in the outpatient realm. Very likely this is due to the decades-long infiltration of therapeutic touch in the nursing profession, leading too many nurses to come to believe that they can somehow realign a patient’s energy field to healing effect by waving their hands around. Reiki fits right into that, particularly given that reiki practitioners have been making a concerted effort to get into hospitals and offer their “services” to patients.

Money vs. ideology

It’s even more instructive to look at the reasons given for starting up a CAM program. Inevitably, financial considerations, plus popularity and a perceived demand among patients, are among the handful of factors that predominate:

Look at what comes in as number one: patient demand at 85%. None of this is surprising, given that in the introduction it is stated:

The American public is also demanding that their hospitals offer more than conventional allopathic health care and begin to integrate CAM therapies into the care they receive in the hospital. In response, hospitals have been looking to meet the needs of their communities. The demand for CAM services is significant, even though insurers may not cover all services or products, with the American public spending approximately $12–19 billion on CAM providers and a total of $36–47 billion on all services and products combined.

Which at first suggested to me that it’s almost all about the business. There’s a lot of money to be made in CAM, and it’s paid for out of pocket. It’s also instructive to look at the reasons given for choosing the CAM modalities offered:

There are, however, a couple of anomalies here. Most prominent, given that only 27% state that market research drove their decision to offer CAM, one wonders how all the others who didn’t do any market research (78%) knew that there was enough patient demand to justify spending the money to offer specific CAM services. In any case, I consider it also telling that the survey reports that 85% will use patient satisfaction as a metric to evaluate the CAM program while only 42% plan on evaluating health outcomes and 31% will evaluate quality. Don’t get me wrong, patient satisfaction is important, and we measure it for science-based medicine. However, there’s something wrong when twice as many hospitals with CAM programs will be looking at patient satisfaction as will be looking at health outcomes.

Perhaps the most interesting part of this study suggests that it may actually not be all about the money, despite the listing of how lucrative CAM can be. For example, only 57% of facilities will be using volume as a criterion for evaluating their CAM program. Is there a clinical program on earth (or at least in the U.S.) that doesn’t use volume as part of its criteria for evaluating it? It may be one of many, and it might not even be one of the more important criteria, but it’s usually a significant criterion. Adding to this, only 39% will use revenue; 20% will use profit; and 8% will use market share. To me these suggest that perhaps CAM is indeed more ideological than financial, particularly when coupled with the finding that 75% of hospitals reported that budgetary constraints are the biggest obstacle to implementing a CAM program, even though such programs can cost as little as $200,000 to start up. (One notes, in contrast, that only 43% reported that a “lack of evidence-based studies” was a major obstacle.) No wonder quackademic medicine is trying so hard to entice third party payers to reimburse for their services; if that were to happen, no doubt many CAM programs that are currently not financially viable will become viable. Perhaps, for as unrepresentative a sample as was surveyed, this survey serves the inadvertent purpose in providing evidence to suggest that the infiltration of quackademic medicine is not driven primarily by money, as skeptics and supporters of SBM (myself included) have on occasion speculated.

Maybe it really is about the ideology.

Posted in: Faith Healing & Spirituality, Medical Academia, Science and the Media

Leave a Comment (49) ↓

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

  1. daijiyobu says:

    To borrow from Monty Python’s Holy Grail,

    “but father, I don’ WANT to hop on a bandwagon!”

    Though, concerning the therapeutic value of being petted,

    I’m curious as to what operational definition of ‘pet’ is most employed.

    Perhaps ‘my pet woo’?

    -r.c.

  2. kathy says:

    I imagine ideology has a lot to do with it. However, if the hospital administration anticipated major startup expenses or serious risk, this would put the brakes on pretty sharply.

    But the actual setting up of many CAM modalities should be relatively cheap … perhaps some hospitals go into it on spec? You don’t need expensive equipment … things like X-ray machines are already available at the hospital. Otherwise what do most CAMs need? A padded table, some needles, a friendly filing cabinet and a nice sympathetic-looking desk with a warm and pretty desk lamp. Homeopathic pills and potions can be dished out by anyone, no need to pay a qualified pharmacist to do it. You don’t need to be an expensive MD to dish out St Johns wort or echinacea. A room for meditation just needs some candles, comfy chairs and a modest music centre … a water feature is optional and can be added later.

    That’s one of the reasons these modalities are practiced from home by so many members of the public. Take a cheap course or two, outlay a little on nice furniture, and you can start advertising. Low risk, potential profits.

    It would be interesting to know on what basis CAM staff are hired. Are they permanent staff or on some sort of contract? If, say, reiki, proves insufficiently popular, can the relevant staff be got rid of again?

    And apart from the risk being low and the potential profit good, it looks so good in the advertisements to say you are a people-friendly integrated hospital. Even if you have no special ideology, other people do, and it does a lot for your public image to fit in with it.

  3. nybgrus says:

    Well, this article actually buoys me a bit. It is nice to know that the real woo-woo of the CAM’s is still used by so few.

    On a side note, I looked the degree requirements for a local “naural health” college’s Bachelor of Health Sciences: Homeopathy. I couldn’t stop laughing when in the first semester you had to take Chemisty and Biochemistry, Foundations of Critical Inquiry, and then in the second Introduction to the Homeopathic Method and Foundations of Homeopathy and Materia Medica. Then in 3rd semester you take Pharmacology – “Understand pharmacology and Western drug treatment, awareness of potential interationcs with Western drug therapy” and Miasms and Chronic Disease.

    Oh yeah, and there was an advanced course later in the degree on research methods and ethics specifically for homeopathic medicine.

    The cognitive dissonance of the first year alone should be enough to make one’s head explode.

  4. cervantes says:

    Maybe we can turn this around and view it as evidence that science based medicine has a public relations problem. Let’s be proactive about saying that understanding people in a holistic way — as biological, psychological, and social entities — is entirely scientific, and that’s absolutely what science does. Sure, reductionism is part of scientific inquiry and there is research on very specific biological processes, but holism — putting the pieces back together — is just as essential. Not only diet and exercise but also social and emotional support are completely within the writ of scientific medicine, and scientists study human health and well being along every dimension. The most prominent movement in medicine and for that matter health policy right now is patient-oriented outcomes. We’re just as interested in whether people feel better and function better as we are in their lab tests, and yes, medical scientists study that and try to figure out how to achieve it. Say it loud, Dr. G: I’m holistic and I’m proud!

  5. Harriet Hall says:

    I agree with everything you said except “it’s not possible to be holistic without adding a heapin’ helpin’ of magical thinking to medicine.”

    cervantes is right. Good clinical medicine has always been “holistic” and we should not let CAM co-opt holism and pretend they are doing something unique.

  6. Very thought provoking article DG and I like the pop culture pics, fun.

    I have to say I’m a bit confused. On one hand you seem to say that most of the supposed CAM treatment are not really CAM, but fall into the categories of nutrition counseling (already part SBM) or shall we say, quality of life programs, such as pet, art and music therapy. On the other hand you seem to reprimand the hospitals for incorporating the programs on the basis on popularity instead of direct health outcomes.

    “. In any case, I consider it also telling that the survey reports that 85% will use patient satisfaction as a metric to evaluate the CAM program while only 42% plan on evaluating health outcomes and 31% will evaluate quality. Don’t get me wrong, patient satisfaction is important, and we measure it for science-based medicine. However, there’s something wrong when twice as many hospitals with CAM programs will be looking at patient satisfaction as will be looking at health outcomes”

    To me, it seems patient satisfaction would be a acceptable metric for quality of life programs such as pet therapy, music, art therapy, which seem to be the biggest hospital programs.

    Perhaps I’m misreading. But as a non scientist, I’m having trouble imagining the health outcome research for pet therapy.

    Sure I can think of an acceptable placebo for music (myzak) or art (Thomas Kincade) but I can’t think of an acceptable placebo for friendly, happy, doggie with soulful eyes. :)

    As an aside, if pet therapy is one of the most popular segments of CAM, perhaps we should stop calling it woo…

    and rename it “woof”

    so sorry.

  7. sorry not only for the bad joke, but the poor proof reading.

  8. HH, I took the magical thinking statement as irony.

  9. David Gorski says:

    I agree with everything you said except “it’s not possible to be holistic without adding a heapin’ helpin’ of magical thinking to medicine.”

    Except that I didn’t say that. (Or were you talking to someone else?) I represented that statement as a classic false dichotomy. Here’s what I said in context:

    Actually, few of the arguments put forth for “complementing” or “integrating” quackery (which, let’s face it, is all the vast majority of IM really is) with science-based medicine actually have anything to do with science, favoring vague and fuzzy appeals to “holistic” medicine and the “whole patient,” as though it’s not possible to be holistic without adding a heapin’ helpin’ of magical thinking to medicine. It’s the classic false dichotomy: Either we inject a generous dose of woo into our medicine, or medicine remains “non-holistic” or, even worse, reductionistic, and we all know how evil “Western” reductionistic science is, right?

  10. Harriet Hall says:

    @David Gorski,

    I apologize. I read too hastily. We do in fact agree.

  11. aeauooo says:

    “Dr. Rakel fell for the classic post hoc ergo propter hoc fallacy” “He also repeats the classic fallacy that I’ve written about time and time again in the context of cancer therapy”

    There’s a lot more where that came from. In addition to his Textbook of Family Medicine, Rakel’s Integrative Medicine can be accessed through MDConsult.

    FWIW (anecdote), a couple of months ago I needed to see a doc about knee pain. I specifically avoided the MD whose bio stated that he’s also an acupuncture practitioner.

    I wanted physical therapy, not voodoo.

  12. nybgrus says:

    @cervantes: Absolutely right. I have been making a habit of discussing these topics from the old “don’t treat the lab value, treat the patient” adage. I say that from an SBM point of view that is a false adage – you cannot divorce the two. You must always treat both the lab value and the patient. Period.

    @michele: First off, that cracked me up. Thanks. Secondly, the issue with using patient satisfaction is that many hospitals used that as the only metric for inviting CAM into the hospital. For things like pet therapy (and at my old hospital they used to have a harp player sit on a ward and play for 30 minutes – seriously – and it was quite beautiful and relaxing) patient satisfaction is of course the appropriate metric. But they are taking CAM as a wholesale item and not differentiating between such things as reflexology and pet therapy.

    I think Dr. Gorski’s point is that a hospital should use patient outcomes AND patient satisfaction as metrics.

  13. Saffron says:

    Really? The pediatric ICU team was stumped, so it “called for a consult with the Integrative Medicine Program”?

    Really?

  14. Saffron — maybe the parents of the child requested it and the ICU team gave in because they wanted the parents to stop hassling them and figured it couldn’t hurt? That’s my guess.

  15. weing says:

    Back in the old days when I was an intern, we had a Haitian lady who had seizures that were not responding to treatment. What I found on observing her was that she was having hysterical seizures. Could this be what happened here? By getting the accupuncture treatment the patient may have an out of his seizures. We would use similar “tricks” or, I guess could call them “placebos”, on patients in hysterical coma.

    1. Harriet Hall says:

      Or it could be that the drugs took effect and/or that the seizures resolved on their own.

  16. Enkidu says:

    Both my dogs’ Emergency Vet and my GYN have acupunturists/herbalists on-staff. Their presence makes me wonder about the doctors also employed there… what do they think?

  17. Terri C says:

    I work in a variety of settings with patients receiving hospice care. You’d be amazed (maybe not) about the end-of-life woo. There is a school of thought that certain music, played on the harp AND ONLY THE HARP, and only by persons trained at one particular place, is vitally “healing.” I can’t remember why, perhaps because I am not particularly fond of harp music. And of course the range of therapeutic touch/distance healing/flower essences… When one looks at the worldviews that underlie the woo, one finds a sense that there is a single “right kind of death” and a lot of pressure to make that happen. (Of course, not everyone agrees what that is, which makes it all the more fun.) What surprises me, though, is the number of otherwise very bright and rational medical folks who are susceptible to the allure of the woo, and do not bring to it anything like the level of critical analysis they bring to suggestions in their own fields from their colleagues. I don’t know if anyone has ever asked why this is so.

  18. lilady says:

    @ Weing: The patient who was in status epilepticus was a young boy…so I strongly doubt that he was having hysterical seizures.

    My son went through a horrific 15 month spell of many episodes of status epilepticus. We changed medication, titrated others up and down and he ended up on 4 potent anti-convulsants with no remission. After an episode of partial liver failure, I talked my way into an appointment with a neuro-pharmacology physician/researcher who was considered the foremost expert on anti-convulsants and their metabolism/interactions He offered some expert advice and also confirmed for me a certain theory that treatment of some cases of intractable seizures are a “crap shoot”.

    A short time after, the episodes of status epilepticus slowed a bit and within 2 months they ceased altogether. Was it the Dilantin and Mysoline that controlled them…probably…or maybe the episodes of status epilepticus ended because of the theory of “crap shoot intractable seizure control”.

    About twenty years ago, my son’s group home roommate developed an allergy to the anticonvulsant that partially controlled his seizures. He has a huge right hemisphere porencephalic cyst that results in Lennox-Gastaut seizures, for which there are few anti-convulsant treatments, which only partially control this type of seizure.

    This youngster went into status epilepticus and ended up in a world-renowned childrens’ hospital under the care of the “seizure team”. He experienced hundreds of seizures during his three day stay in the neuro ICU and the doctors had suggested general anesthesia with the hope (Hail Mary Play) that anesthesia would bring him out of status epilepticus. His mom and I “consulted” with the “team” and requested Mysoline…based on the unscientific theory of the medicine working for my son and the theory of “crap shoot control of intractable seizures”. Within 2 hours of the first dose, the child’s seizures slowed down considerably and stopped completely within 24 hours. He has never had another episode of status epilepticus.

    I am aghast that the Integrative Medicine doctor made a statement that acupuncture (or any other integrative medicine modality) might have stopped the boy’s status epilepticus. I bet the neurologists who treated the youngster feel the same way.

  19. cervantes says:

    Status epilepticus is pretty clearly distinguishable from an ataque de nervios or similar phenomenon. (That’s a culturally sanctioned way of expressing psychological distress in some Latin American cultures which resembles a kind of seizure.) An ataque might well respond to any sort of random intervention and indeed one culturally normative response would be a despojo, a ceremony to relieve the person of demonic possession. While physicians might, under rare circumstances, benefit from knowing about such phenomena it clearly is not what’s going on here. BTW what I am talking about are culturally normative ways of expressing distress and responding in a way that acknowledges the person’s pain. These are perfectly real as psychosocial phenomena. It’s worth acknowledging that some people do feel better after purely ceremonial intervention. That’s what church is for also, although I don’t go myself because I don’t happen to believe in it.

  20. nybrgus – thanks, I appreciate that there should be some rational balance between patient satisfaction and health outcomes. But it’s just very difficult to tell whether the hospitals are balancing those two factors rationally or not. When the top items for hospitals are pet therapy, massage therapy and music and art therapy, (items that would tend to be weighed more heavily on the patient satisfaction end of the spectrum,) then perhaps an overall “85% patient satisfaction, 42% health outcomes and 31% quality, makes sense.

    It just seems to me that overall it’s a bad survey that was done with the intent to make CAM appear popular. Trying to glean whether or not the hospitals are make rational decisions from such a survey seems an exercise in futility, to me.

    As an aside, I believe most pet therapy programs are all volunteer, so they cost the hospitals very little. The reason that pet therapy is sometimes described as “therapy” is that it is sometimes used as a motivator in therapies. I once traveled with a woman who volunteered as a handler with her therapy dog (golden retriever). She helped out a pediatric physical therapist. They would use petting the dog, brushing the dog or throwing balls for fetch, etc to work on motor control targets. Doggies can be good motivators, especially for children.

  21. nybgrus says:

    @michele:

    I think you make a very good point. But no matter how you slice it, the hard-ass in me still won’t be happy. I think I am probably happier thinking about it as your framed it, but I think that a hospital should always be looking at patient outcomes. Even if it is just a cursorial “making sure.” I know I may be stretching things a bit here, but what if the dog had fleas or the harp harbored some virus or bacteria? And wouldn’t it be nice to track patient outcomes receiving massage therapy? It’s just lazy is what that is. (Though do agree that drawing real hard conclusions about what is actually going on is quite tough – if not impossible – from this study).

    But you are right – it is an effort to make CAM seem more popular and more valid. It is all lumped into this hodge podge of “stuff.” And it seems that the definition of CAM is consistently one that is defined by what feels like a good definition. And I think the whole of it is just being lazy. It is much easier to say, “Yeah, yeah that CAM stuff it kinda sorta works and some stuff works better than others and theres a bit of crazy stuff” than to really get into the nitty gritty of it and be rigorous. And the damned sCAMsters take advantage of our laziness.

  22. pmoran says:

    Yeah. There needs to be some sense of proportion.

    Hospitals are places where important medical problems require intense, complex and risky interventions.

    We can almost always find ways of doing that better, and that should be looked at before introducing any CAM modality at hospital expense.

    One simple measure that would also have an enormous impact on patient morale is to increase the ratio of nursing staff to patients.

    Any extra patient round in a surgical ward will ALWAYS find problems that need to be dealt with, discomfort that needs to eased, concerns that need to be assuaged.

    This will impact on all patients, not just those into so-called “woo”.

  23. nybgrus says:

    We can almost always find ways of doing that better, and that should be looked at before introducing any CAM modality at hospital expense.

    I don’t think it should matter if it costs the hospital anything or not. The same standards and metrics should be applied, even if it is free – hell, even if the hospital gets paid to allow it.

  24. @nybrgus, It seems to me that cost should be part of any decision making metric.

    “It is all lumped into this hodge podge of “stuff.” And it seems that the definition of CAM is consistently one that is defined by what feels like a good definition. And I think the whole of it is just being lazy. It is much easier to say, “Yeah, yeah that CAM stuff it kinda sorta works and some stuff works better than others and theres a bit of crazy stuff” than to really get into the nitty gritty of it and be rigorous.”

    Warning stream of consciousness ramble.

    Yes this is what is bothering me. I keep hearing the CAM side say ‘this and that is CAM’ then the SBM side says ‘That’s not CAM, that’s acceptable.” He said she said. Reading both side I end up with a version of Justice Potter Stewart’s definition of pornography as “I know it when I see it.” Which I’m not fond of.

    Even when you define CAM as a therapy that has no proven benefit over placebo, you still end up including things like pet therapy, which people (beside Mark Crislip) seem to find unobjectionable when practiced safely. So what is the crux of the matter? How do we separate unproven activities that are basically harmless and may provide some emotional or mental value to the patient from unproven activities that may be directly or indirectly harmful. The most obvious answer is, well research should indicate that some activities are harmless or harmful. But does research at this point show that homeopathy is harmful? I’m guessing not.

    So if the issue isn’t the evidence showing benefit and it’s not evidence showing harm, then what is it?

    I’m guessing the crux of the matter is not only about science, it’s about ethics. It’s about whether the therapy or activity is honestly represented.

  25. Harriet Hall says:

    I propose a new division. Instead of conventional vs. CAM, why not classify treatments as proven, experimental, or comfort measures. Pet therapy would fall under comfort measures along with pillow fluffing and backrubs.

  26. nybgrus says:

    @michele:

    I didn’t say cost shouldn’t factor into the metrics. I said that the metrics should be the same regardless of the costs. In other words, whether it costs a hospital $100k/year to implement a reiki program or absolutely nothing, the way in which they evaluate it should remain the same. If it is pseudoscientific garbage, then free or not, it should not be used. Of course, if it is marginally useful but costs a lot, that also shouldn’t be used.

    I think Dr. Hall has a point here – the notion is that the definition of CAM is pretty nebulous. According to Medline Plus:

    Complementary and alternative medicine (CAM) is the term for medical products and practices that are not part of standard care. Standard care is what medical doctors, doctors of osteopathy and allied health professionals, such as registered nurses and physical therapists, practice.

    In other words, once it becomes used by medical doctors and is standard of care, it can no longer be called CAM. Which is what we have been saying this whole time – there is no need for this false division, except for the ol’ bait ‘n’ switch. The sCAMsters don’t want to give up yoga, diet, and exercise because those work. They want to add in prayer and faith healing because it appeals to religious people’s sentiments. Taken as a whole, it makes the entire category of CAM appear attractive.

    Besides the fact that some homeopathic medicine have been pulled for actually containing active ingredients that have harmed and killed, there is indeed harm from homeopathy. After the Haiti earthquake a group of homeopaths went there and gave out homeopathic vaccines. That is directly harmful – these people believed they were protected.

    But moreso, all this stuff is indeed about the ethics, as you rightly pointed out. The crux is the science telling us what has become unethical. If we had no reasonable way to discern that homeopathy or reiki were complete BS, then it would not be unethical to utilize it. But of course, we do, and since we know these modalities cannot and do not achieve effect beyond placebo responses it becomes unethical to make use of them in medical practice.

    I actually am in a drawn out discussion with a 1st year at the moment about Memorial Sloan Kettering Cancer Center’s use of reflexology and reiki in the integrative oncology department. A foot rub and massage is a wonderful thing for cancer patients. But calling it reflexology is unethical. If all it is is a foot massage, then you are giving false legitimacy and defrauding the patient who was expecting to get “real” reflexology. If you are employing “real” reflexology, then you are violating medical ethics because you are lying to your patients about the validity of the treatment they are getting.

    Pet therapy doesn’t fall into this problem because no one is claiming that the pet will channel energy into your chakras or shoot invisible doggy laser beams out of its eyes into your cancer or something. It is plainly states and clearly obvious that it is just a happy distraction to de-stress and help motivate people. And that is something I think any author on the forum can happily give their patients.

    I think cancer centers would be wise and perfectly within their rights and ethics to have a day spa associated with them. Charge people who can afford it (and want it) extra to get a foot rub, massage, or maybe do a full hour long massage with candles while getting your chemo infusion. But when you represent it as some pseudoscientific woo-woo mechanism of action, you cross the line and are no longer acting ethically.

  27. Harriet Hall, I like where you are heading. Would there be a separate classification for therapies that fall outside those three. Such as biofeedback. (Not 100% sure that’s a good example, but hopefully you get the idea.)

    Nybrgus – I think I’ve unintentional given the impression that I’m arguing with you. That is not my intention. I do think that your statements are accurate, but I am trying to find my way around the issue in a way that is more relevant to my experience, life and current knowledge base. For me, this is a process of poking and jabbing at statements until they sort click into relevancy. Please let me know if this is disruptive.

    You last statement sparks many thoughts, but unfortunately I’m under a production time crunch, so I can’t respond in depth.

    If I think loudly enough, do you believe you might hear me down under? :)

    Perhaps I can post later, but hard to tell. Thanks for the thought provoking discussion.

    1. Harriet Hall says:

      @micheleinmichigan
      “Would there be a separate classification for therapies that fall outside those three. Such as biofeedback”
      I think biofeedback would fall into either the proven or experimental categories depending on what it is being used for.

  28. nybgrus says:

    @michele:

    No worries. I do not feel like you are arguing against me. I think my feeling was exactly what you had described – ” trying to find my way around the issue in a way that is more relevant to my experience”

    In my discussion I have been attempted to expound as best as I can and hopefully you find something useful from it. Though indeed, some of it has been somewhat reflexive like the homeopathy stuff. I wasn’t quite sure how to read it and just had to throw in a little CYA, if you know what I mean. If it makes you feel any better, this is also how I discuss things with dear friends and colleagues over beers. Granted it does take on a slightly adversarial tone, but I hope you and I have interacted well and long enough that you would know it is a friendly adversarialism. I find that at the end of that sort of conversation both parties usually leave having learned something, and often in agreement.

  29. “Granted it does take on a slightly adversarial tone, but I hope you and I have interacted well and long enough that you would know it is a friendly adversarialism.”

    No problems or offense on my side. I enjoy hearing your side of things.

  30. JPZ says:

    @Harriet Hall

    “I propose a new division. Instead of conventional vs. CAM, why not classify treatments as proven, experimental, or comfort measures.”

    How about disproven? :)

  31. pmoran says:

    “I propose a new division. Instead of conventional vs. CAM, why not classify treatments as proven, experimental, or comfort measures.”

    JPZ: How about disproven?

    It depends on the precise question.

    The theories that CAM practitioners think they are applying can usually be dismantled using sham-controlled studies, but how do you prove that ANY well-meant, nurturing medical interventions is of no benefit at all to patients?

    CAM brings that question to the table, too.

    No simple clinical study design can entirely prove, disprove or accurately measure placebo and other non-specific “effects” of medical interactions. (Advances in neurophysiology may eventually help.)

  32. Harriet Hall says:

    @pmoran

    “how do you prove that ANY well-meant, nurturing medical interventions is of no benefit at all to patients?”

    No benefit at all? I don’t think you can ever prove that, and I don’t think that’s what science-based medicine is saying. It’s difficult to prove an absolute negative. What you can prove is that it is highly unlikely that a given treatment will offer any objective benefits to patients. You can’t prove that any quack or snake-oil interventions are of no benefit, either. Even the most fraudulent medical scam has victims who will swear they have been helped. But for crying out loud! You have to have SOME criteria for choosing a treatment.

    It sounds like you are arguing for a policy that would allow you to doubt all scientific results and pick treatments on the basis of your personal preference or guesswork.

    Science most certainly CAN measure placebo and non-specific effects. Benedetti is doing such studies. I’m planning to write a post about that next Tuesday. Stay tuned.

  33. # Harriet Hall
    “I think biofeedback would fall into either the proven or experimental categories depending on what it is being used for.”

    darn, then I think I used a bad example. I am looking for what you call something that can not or does not do what it is claimed to do. Such as hair analysis to evaluate a patient’s nutritional needs.

    Or are you suggesting that would fall under the experimental heading?

  34. Harriet Hall says:

    @Michele,
    “I am looking for what you call something that can not or does not do what it is claimed to do.”

    People will always claim that silliness like hair analysis and homeopathy do what they are claimed to do. And we can seldom absolutely prove that something doesn’t work. So I think “experimental” would avoid a lot of arguments with the true believers. It implies unproven: believers can interpret that to mean more studies should be done to prove it, while scientists can look at the experimental evidence and interpret it to mean no further studies are worth doing.

  35. HH “So I think “experimental” would avoid a lot of arguments with the true believers. It implies unproven: believers can interpret that to mean more studies should be done to prove it, while scientists can look at the experimental evidence and interpret it to mean no further studies are worth doing.”

    This is just wordsmithing, but when I think of experimental, I think of something that scientist think have great potential, but still need to study, such as stem cells for diabetes.

    I would be afraid that to an average laymen, “experimental” means ‘potentially great, early adopter phase.’

  36. pmoran says:

    Harriet, do you realise you are back to quoting selected half sentences of mine, and placing your own interpretation and context on them?

    I was responding to the word “disproven” which DOES place a certain onus on the claimant.

    I was allowing that science can readily prove some things, while suggesting that it does have a difficult task reaching finality with some of the questions that CAM raises. I have alluded to some of the reasons elsewherre.

  37. pmoran, In my reading your comment about disproven didn’t really take into account the context of the conversation. In my previous statement I was wondering at the somewhat arbitrary definition of CAM. HH, wisely propsed the catagories “proven, experimental and comfort measures”.

    I and (and I think JPZ) see a need for a category that says “does not provide benefit claimed, or ‘science has thoroughly examined this and finds no evidence that it provides the benefits claimed’

    JPZ suggested “disproven”. Do you have a prefered word, see all possibly therapies fitting into the three categories or have different categories in mind?

    It would be nice, from a laymen’s perspective to have a clear reasonablly objective way to group treatment options.

    I would enjoy hearing your thoughts.

  38. pmoran says:

    MM, there is nothing wrong with Harriet’s approach except that I would make it apply to specific claims and theories, rather than the treatment modalities themselves, and perhaps add a category of “highly dubious” to cover the kind of claim you mean.

    The problem with your desired classification of treatments is that a certain kind of chelation may help heavy metal poisoning, but not autism or CFS, spinal manipulation may help some kinds of back pain but probably not anything else except as placebo for placebo responsive conditions, therapeutic touch won’t cure cancer but it may help devotees feel more relaxed and less anxious.

    Depending on the results of future research into non-specific aspects of medical interactions, we might also need a slightly stronger word than “comfort”, for example if potent placebos did prove capable of getting patients with back pain back to normal function quicker, or helped terminate some kinds of psychosomatic illness. So far research into CAM has been mainly devoted to testing for intrinsic efficacy and we could use more data on real-life, longer term outcomes of it as non-specific nurture.

    People get the impression that I expect great things from placebo and CAM. I don’t actually, and certainly not such that the mainstream could exploit in any systematic way — any benefits are far too context-dependent.

    I just need to be sure in my own mind what is going on with CAM users and practitioners before I elect to trash CAM at every opportunity (as I once did, actually).

  39. Harriet Hall says:

    @pmoran,

    ” if potent placebos did prove capable of getting patients with back pain back to normal function quicker, or helped terminate some kinds of psychosomatic illness.”

    We can always dream… but I’m not holding my breath on this one.

  40. pmoran, “there is nothing wrong with Harriet’s approach except that I would make it apply to specific claims and theories, rather than the treatment modalities themselves, and perhaps add a category of “highly dubious” to cover the kind of claim you mean.”

    Yes, Good point, it makes sense to think in terms of claims and theories and I like the addition of “highly dubious”.

    For me, the focus on whether something is CAM (or not) creates a distraction that generates a lot of heat, but not light. I have been negatively effected by individual conventional medical doctors* enough to know that CAM doctors have not cornered the market on making dubious claims. I prefer a system that examines all therapies, claims, theories by their attributes rather than their source.

    *This is not meant as a general indictment of conventional medicine.

  41. Pman says:

    I’ve used acupuncture inpatient before for refractory status epilepticus in a pediatric patient. In this case it was a sad case in North Carolina for a patient in the ICU already on four anti-epileptic agents. Regrettably the consult came four weeks into her pharmacologic-induced coma, and shortly thereafter the decision was made to withdraw care.

    My guiding treatment principles were taken from a case report, which references a few studies from the 1980′s:

    http://www.medicalacupuncture.org/aama_marf/journal/vol11_2/poster.html

    There are a few institutes in Sri Lanka that have data as well, but it is not yet up to our standards (to my knowledge). It would be nice to run a controlled trial in this population, but would be tricky to pull off.

    The underlying physiologic explanation may not be to y’all’s liking as well. :-)

  42. Pman says:

    It bears noting that the next step would have been a corpus collosotomy by neurosurgery, and that the intent of the acupuncture would have been to preclude the aforementioned intervention.

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