Science-Based Medicine

A new year brings new opportunities for practicing the magic of legislative alchemy, the process by which state legislatures transform implausible and unproven diagnostic methods and treatments into perfectly legal health care practices, such as naturopathy, chiropractic and acupuncture. Different states have differentlegislative calendars, but many begin a new session soon after the first of the year. This gives “complementary and alternative medicine” providers a fresh opportunity to increase their scope of practice, insurance coverage and influence.

The state house doors have barely opened but CAM-friendly bills are already being docketed and sent on to health care and other committees for analysis. Unfortunately, legislators seem less than adept at critical thinking when it comes to perusing CAM legislation. To this point, I’ll start with an example from 2011: “Vertebral Subluxation Awareness Month” in Pennsylvania.

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When I graduated from Lincoln Chiropractic College in 1956, I had come to the conclusion that chiropractic’s subluxation theory, that misaligned vertebrae can cause organic disease, was not true. When I began my practice in Panama City, Florida, I limited my practice to care of mechanical-type back pain and related problems. Back then, that was not too much of a stretch, since manipulative services were not readily available in medical practices and there were a number of orthopedic and physical medicine texts recommending use of manipulation in the treatment of back pain.

In 1963, I published my book Bonesetting, Chiropractic, and Cultism, renouncing subluxation theory and recommending that chiropractic be developed as physical treatment specialty in the care of back pain. The book was reviewed by the Library Journal (February 1, 1964) and recommended for inclusion in medical and reference libraries. In 1965, I received a letter from the American Chiropractic Association (ACA) informing me that my application for membership in the ACA had been rejected. In the years to follow, I published many articles in an attempt to initiate an effort to change chiropractic from a subluxation-based practice to a legitimate physical treatment method that would fit in with mainstream health care. My suggestions were ignored and I was called a “chiropractic heretic.” Today, I find myself still saying some of the things I said in my 1963 Bonesetting book, still being rejected by most of my colleagues and still voicing opposition to subluxation theory.

There are now some chiropractors who do not subscribe to the theory that some kind of segmental dysfunction in the spine can cause organic disease, but they are overshadowed by subluxation-based chiropractors who publish their own journals, using scientific-sounding jargon to defend implausible theories and dubious treatment methods. Some of these chiropractors do not use the “subluxation” word, instead substituting some other vague description of a spinal lesion, such as “joint dysfunction,” alleged to have the same affect on the nervous system and general health as a “vertebral subluxation.”
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What do you think would happen if you gave a bunch of “complementary and alternative medicine” practitioners access to a big pot of money — say, up to $10,000 per patient — and let them treat patients virtually without restriction, hampered only by a fee schedule. No utilization review, no refusal based on a treatment’s being “experimental” — none of the usual foils which trip up CAM practitioners in the health insurance field.

Think they’d run up the bill? Yes, they would.

In fact, that’s exactly the scenario playing out in Florida right now with the state’s no-fault auto insurance.
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It is hard to Sokalize alternative medicine. The closest has been buttock reflexology/acupuncture, but that is a tame example.  Given the propensity for projections of the human body to appear on the iris, hand, foot, tongue, and ear, postulating a similar pattern on the buttocks are simple variations on a common SCAM (Supplements, Complementary and Alternative Medicine) theme. The buttocks?  Not really different from any of the other focal acupunctures.  Most of SCAM does not concern itself with application of reality  and physiology, anatomy, biochemistry, etc can all be expected to be ignored with virtually all SCAM modalities.

Every time I think the heights (or depths) of absurdity has been reached, I discover a Braco the Starer or Himalayan Salt Inhalers. This blog is not affiliated with the British Medical Journal in any way, and although this is being published near Christmas, I want no one think that what follows is a hoax.  I am not, I repeat not,  making up what follows. It is not fiction. Well, it is fiction, but not written by me and believed and practiced by some who really should know better.

Craniosacral Therapy
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Each of the 50 states and the District of Columbia require vaccination against certain diseases as a prerequisite to public and private school attendance, most commonly polio, mumps, measles, diphtheria, rubella, chicken pox, Heamophilus influenza type b, pertussis, tetanus, pneumococcal disease and hepatitis B. Unfortunately, mandatory vaccination for home-schooled children is rare. (1)

All states provide medical exemptions to vaccination mandates for those for whom vaccination poses a health threat. Indeed, it is doubtful that a state could constitutionally deny such medical exemptions.

Forty-eight states also allow exemptions based on religious beliefs. While it might be assumed that religious exemptions are required by the protection afforded religion under the First Amendment to the U.S. Constitution that is not the case. The opposite is true. Religious exemptions themselves are constitutionally suspect. In fact, to pass First Amendment muster, a state’s religious exemption statute may have to be so broad as to become, in essence, a “philosophical” exemption.

Vaccination mandates survive early challenges

Compulsory vaccination laws have enjoyed strong support in the state and federal courts for over a century. Early in the 20th century, the U.S. Supreme Court considered the constitutionality of a statute authorizing a municipal board of health to require and enforce vaccination, in this case during a smallpox epidemic. The Court found the legislation represented a valid exercise of the state’s police power. In a statement that proved prescient about the failed constitutional challenges to vaccination mandates which followed, the Court said that “we do not perceive that this legislation has invaded any right secured by the Federal Constitution.” Jacobson v. Massachusetts, 197 U.S. 11, 38 (1905).

In 1922, the Court specifically addressed the subject of school vaccination, holding that it is a valid exercise of the state’s police power to make vaccination a condition of attending public or private school. Zucht v. King, 260 U.S. 174 (1922).
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In November, the journal Pediatrics published an entire supplement devoted to Pediatric Use of Complementary and Alternative Medicine: Legal, Ethical and Clinical Issues in Decision-Making. The authors purport to have “examined current legal, ethical, and clinical issues that arise when considering CAM use for children and identified where gaps remain in law and policy.” (S150) Their aim is to “illustrate the relevance and impact of identified [ethical, legal and clinical] guidelines and principles,” to recommend responses, identify issues needing further consideration, and thus “assist decision makers and act as a catalyst for policy development.” (S153)

Unfortunately, as we saw in Pediatrics & “CAM” I: the wrong solution, the authors’ solution for the “issues that arise when considering CAM use for children” consist, in the main, of placing a huge burden on the practicing physician to be knowledgeable about CAM, keep up with CAM research, educate patients about CAM, warn patients about CAM dangers, refer to CAM practitioners, ensure that CAM practitioners are properly educated, trained and credentialed, and so on.

Limit CAM? Not happening

Curiously absent are recommendations placing responsibility on those who profit from the sale of CAM products and services — the dietary supplement manufacturers, homeopaths, acupuncturists, and the like — whose actions are directly responsible for the deleterious effects on patients’ health detailed in the supplement articles and described in the earlier post.

Apparently the authors’ view is that there is no accommodation to CAM too onerous to ask the practicing physician or the patient to bear. Even though they plainly locate the problems they describe — a missed diagnosis, ineffective treatments, drug therapy interactions, poor advice — in the CAM services and products themselves, suggesting that these services and products be limited or eliminated never seems to cross their minds.

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Steven Novella recently wrote about so-called “chiropractic neurology” and its most outspoken proponent, Ted Carrick.  In 2005 I published an article in The Scientific Review of Alternative Medicine (Vol 9, No 1, p. 11-15) entitled “Blind-Spot Mapping, Cortical Function, and Chiropractic Manipulation.” It was an analysis of a study Carrick had published.

Carrick read a shorter, popularized version of my critique in Skeptical Inquirer and responded with a diatribe that was inaccurate, distorted what I had said, and accused me of fraud, deception, and mis-representation.  He failed to offer a credible rebuttal of my specific criticisms; and, in my opinion, showed that he failed to understand some of my points. He referred to me as “Ms. Hall” and suggested that I was psychotic. He characterized my e-mail correspondence with him as “bizarre, rude, and offensive.” It was none of those, and I have copies of the e-mails to prove it. Carrick says he “forwarded it to the legal council for the American Chiropractic Association for review.”  Now that strikes me as bizarre.

I am re-publishing the entire text of my article here as an instructive example of what passes for science in the chiropractic neurology community. Readers can judge for themselves whether my critique amounts to fraud and whether I am showing signs of psychosis, whether Carrick is a good scientist and whether his reply to my critique was appropriate. Continue Reading »

Oh no!  Not again! The venerable medical journal Pediatrics devotes an entire supplement this month to Pediatric Use of Complementary and Alternative Medicine: Legal, Ethical, and Clinical Issues in Decision-Making.

We sense from the very first sentence that we are in familiar territory:

Rapid increases the use of complementary and alternative medicine (CAM) raise important legal, ethical, clinical, and policy issues. (S150)

“Rapid increases”? And evidence of these “rapid increases?” None cited.

We do, however, see the same shopworn reference to popularity deconstructed elsewhere on SBM. What we learned by actually examining “the large 2007 US survey” which purportedly “revealed that ~4 in 10 adults and 1 in 9 children and youth used CAM products or therapies within the previous year”(S150) is that

…most hard-core CAM modalities are used by a very small percentage of the population. Most are less than five percent. Only massage and manipulation are greater than 10 percent. These numbers are also not significantly different from 10 or 20 years ago — belying the claim that CAM use is increasing.

We also find this definition of “CAM”:

a broad domain of healing resources …other than those intrinsic to the politically dominant health system of a particular society or culture in a given historical period. (S150)

I’m not sure what it takes to become “intrinsic” to the “politically dominant” healthcare system. If it includes being legal, licensed or covered by public and/or private insurance, that would appear to disqualify dietary supplements, chiropractic, acupuncture, homeopathy, homeopathic products and naturopathy as “CAM” in some, or in some cases all, of the American states.

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Chiropractic is a diverse collection of beliefs and practices occurring under a broad regulatory label. The differences among various chiropractics are so stark that it is difficult to make general statements about chiropractic practice. At one end of the spectrum, however, are so-called “straight” chiropractors who adhere to the original philosophy of D.D. Palmer – that a vital force they call innate intelligence is response for health, and blockages in the flow of this magical force through the nerves are what cause illness. Such chiropractors believe they can influence non-neuromuscular conditions by restoring the flow of innate blocked by mysterious “subluxations” in the spine.

From chiropractors.org we have this definition of “straight” chiropractors:

Because straight chiropractors believe that nearly all diseases are caused by issues with the spine, they don’t believe they need any diagnostic tools. Traditional testing done by medical doctors and hospitals is not even considered by a straight chiropractor as being necessary. Diagnosis is done by finding the subluxations in the spine so that those can be corrected.

This particular version of chiropractic (by some estimates about a third of chiropractors follow this philosophy) is pure pseudoscience. It is, as indicated by the quote above, hostile to science-based medicine.  After a century of such belief there isn’t a bit of evidence to support the notion of innate intelligence, chiropractic subluxations, or health benefits from this approach.

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The very concepts of “complementary and alternative medicine” (CAM) and “integrative medicine” (IM), the former of which “complements” science-based medicine with quackery and the latter of which “integrates” pseudoscience-based with science-based medicine are all about slapping a veneer of scientific legitimacy onto something that has failed to achieve such legitimacy through actual basic, translational, and clinical science. The reason I start out by saying this is to emphasize that CAM/IM is all about using language to persuade that pseudoscience is actually science-based. It’s far more about marketing than accurately communicating concepts. In CAM, everything is “holistic,” and doctors “care for the whole patient,” while “Western medicine” is “reductionistic” and “allopathic.” At the very heart of this language is a false dichotomy: That you must either embrace pseudoscience or that you somehow can’t provide care as compassionate and caring as what the quacks supposedly provide, nor are you able to provide for the emotional needs of your patients. There are two false dichotomies, actually, in that there is also the not-so-subtle implication in CAM that you can’t be truly “holistic” without—you guessed it—embracing the pseudoscience that is at the heart of many CAM/IM modalities.

This use and abuse of language for propagandistic purposes in CAM/IM is not limited to just these examples. In fact, the misuse of language infuses the whole enterprise of CAM/IM to the point that its adherents, not content with being mere “practitioners,” are trying to claim the very title of “physician” for themselves. I learned this from John Weeks, the main force behind the Integrator Blog, a blog dedicated to issues of CAM and IM. He’s the one who first let me know about Andrew Weil’s attempt to put together a board certification in IM. In particular, his reporting on the reaction of CAM/IM practitioners, both physicians and non-physicians, to this initiative by Andrew Weil was most illuminating to me. What was most telling was how further propagandistic use of the language focused on “dominance” by MDs, which in this case struck me as actually being closer to the truth than the usual CAM-speak is. In any case, Dr. Weil’s initiative does indeed appear to be more about taking control of CAM for physicians, his high-minded language about “establishing standards” notwithstanding.

This time around, Weeks has provided me with an education about how alternative/CAM/integrative practitioners now covet the title of “physician”. In the process, he also uses and abuses language in the same way that Andrew Weil and CAM/IM advocates do. This time around, it’s all about co-opting the title of “physician” for non-physician CAM practitioners. It’s bad enough to me when actual physicians are seduced by the pseudoscience of CAM, but this effort appears to be an intentional strategy designed to confuse the public by proclaiming as physicians practitioners who lack the essential skills to be a physician, such as acupuncturists, chiropractors, homeopaths, and naturopaths.
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