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Open Letter to Dr. Josephine Briggs

Josephine P. Briggs, M.D.

Director, National Center for Complementary and Alternative Medicine

Dear Dr. Briggs,

As you know, we’ve met twice. The first time was at the Yale “Integrative Medicine” Symposium in March. The second was in April, when Drs. Novella, Gorski and I met with you for an hour at the NCCAM in Bethesda. At the time I concluded that you favor science-based medicine, although you are in the awkward position of having to appear ‘open-minded’ about nonsense.

More about that below, but first let me address the principal reason for this letter: it is disturbing that you will shortly appear at the 25th Anniversary Convention of the American Association of Naturopathic Physicians (AANP). It is disturbing for two reasons: first, it suggests that you know little about the tenets and methods of the group that you’ll be addressing; second, your presence will be interpreted as an endorsement of those methods and of that group—whether or not that is your intention. If you read nothing more of this letter or its links, please read the following articles (they’re “part of your education,” as my 91 y.o. mother used to say to me):

Naturopathy: A Critical Appraisal

Naturopathy, Pseudoscience, and Medicine: Myths and Fallacies vs Truth

The first article is an introduction to the group to which you will be speaking; the second is my response to complaints, from that group and a few of its apologists, about the first article. It was a surprise to me that the editor, George Lundberg, preferred that I make my response a comprehensive one.

Thus the second article inevitably became the crash course—call it CAM for Smarties—that your predecessors never offered you, replete with examples of useless and dangerous pseudoscientific methods, real science being brought to bear in evaluating such methods, proponents’ inaccurate or cherry-picked citations of biomedical literature, bits of pertinent but little-known history, the standard logical fallacies, embarrassing socio-political machinations, wasteful and dangerous ‘research’ (funded—unwittingly, I’m sure—by the NCCAM), bait-and-switch labeling of rational methods as “CAM,” vacuous assertions about ‘toxins’ and ”curing the underlying cause, not just suppressing the symptoms,” anti-vaccination hysteria, misleading language, the obligatory recycling of psychokinesis claims, and more.

Please excuse me if this sounds preachy; I admit that it does, but understand that I’m writing in good faith. My own views of “CAM” did not dawn on me overnight, but were the result of years of research. My ‘internship,’ as it were, consisted of sitting on a state commission from the fall of 2000 until the spring of 2002, listening to AANP members (including at least one with whom you will share the podium), reading about ‘naturopathic medicine,’ and attempting (unsuccessfully) to engage its advocates in rational discussion. I began that task open to forming opinions based on whatever information became available; by its end it had become abundantly clear that the group is best characterized as a pseudoscientific cult, and nothing since has altered that opinion.

Regarding your presence at the convention being tantamount to an endorsement of ‘naturopathic medicine,’ this is so obviously true that it ought not be necessary to mention it. Previous experience, however, has taught me to expect an air of—please don’t take this personally—utter cluelessness whenever I’ve raised such an issue. If you’ve read the second naturopathy article linked above, you already know that according to proponents,

The validity of naturopathic medicine is demonstrated by its support in government (including accreditation of its schools and NIH-funded research), on medical school Web sites, and in other parts of the public domain.

An appearance at their annual convention by the most important “CAM” administrator at the NIH surely has the political arm of the AANP licking its chops. NDs, as they call themselves, are currently licensed in 14 or 15 states and a couple of provinces, and aggressively seek licensure throughout the U.S. and Canada. They appear to wield political clout well out of proportion to their numbers, no doubt thanks in part to the legislative language that created the NCCAM’s National Advisory Council for Complementary and Alternative Medicine (NACCAM):

Of the 18 appointed members…Nine…shall be practitioners licensed in one or more of the major systems with which the Center is involved. Six of the members shall be appointed by the Secretary from the general public and shall include leaders in the fields of public policy, law, health policy, economics, and management. Three of the six shall represent the interests of individual consumers of complementary and alternative medicine.

Thus there have been 1-3 NDs on the NACCAM since its inception in 1999, although their numbers in general are, by any measure, miniscule: I reckoned there were about 2500 in the U.S. in 2003; the AANP now places that number at 6000. By comparison, there are about 800,000 MDs and 50,000 DOs in the U.S.

NDs claim to be well trained to practice what most people think of as family medicine or primary care medicine, although their version of training is chock full of pseudoscientific nonsense and lacks a true residency program. They began by purporting to use only “natural medicines,” but in regions where they’ve become politically connected they’ve sought, and been granted, the license to prescribe numerous drugs. Predictably, they’ve recently begun to bump people off with such exotic choices as intravenous colchicine and disodium ethylenediaminetetraacetic acid (that pesky TACT drug), in addition to more folksy nostrums such as acupuncture, vitamin B12, and an “herbal tincture” for a teenage girl who would shortly die of asthma.

I see that your talk is titled “Complementary and Alternative Medicine: Promising Ideas from Outside the Mainstream.” I imagine that it will cover some of the material that you covered at the Yale Symposium, where you used the similar phrase, “Quirky Ideas from Outside the Mainstream.” Without reading more into that word substitution than is warranted, let me assure you that there are no promising ideas emanating from naturopathy, even if there are plenty of quirky ones, e.g., inflating balloons in the nasopharynx to effect a “controlled release of the connective tissue tension to unwind the body and return it toward to its original design.”

Regarding the implicit requirement of your office that you appear open-minded even to medical absurdities, you made that clear in your own account of our NCCAM meeting and of another that you’d had a few weeks earlier, involving a group of homeopaths and associated crackpots who called themselves “the leading scientists in the field”:

Recently, I hosted two meetings with groups that represent disparate views of CAM research. These meetings have given me a renewed appreciation for the value of listening to differing voices and perspectives about the work we do.

My NCCAM colleagues and I know there are differing views of the value of doing CAM research. On one side, we have stakeholders who are staunch CAM advocates, and on the other side, we have CAM skeptics.

Each group has its own beliefs and opinions on the direction, importance, and value of the work that NCCAM funds. The advocates would like to see more research dollars supporting various CAM approaches while the skeptics see our research investment as giving undue credibility to unfeasible CAM modalities and want less research funding.

As I’ve stated before, our position is that science must remain neutral, and we should be strictly objective. There are compelling reasons to explore many CAM modalities, and the science should speak for itself. (emphasis yours)

Certainly science must remain neutral in the face of not-yet-seen data from rigorous studies of plausible methods, but that is different from what you, in your dual roles as “CAM” Explicator-in-Chief and Steward of Public Funds, must remain. You typically face questions that are, for all purposes relevant to the NIH, to modern medicine, and to the American citizenry, already settled—whether by basic science, clinical studies, rational thinking, or all three. I’ve offered several examples in the two naturopathy articles linked above.

Consider homeopathy, a core claim of “naturopathic medicine” and the subject of your meeting with the “staunch CAM advocates.” It makes no more sense for you to remain neutral on that topic than it would for the NIMH Director to remain neutral on exorcisms, or for the NCI Director to remain neutral on Krebiozen. Edzard Ernst, a one-time homeopath whose own portfolio of “CAM” investigations dwarfs the entire output of the NCCAM, puts it this way:

Should we keep an open mind about astrology, perpetual motion, alchemy, alien abduction, and sightings of Elvis Presley? No, and we are happy to confess that our minds have closed down on homeopathy in the same way.

Science and skepticism, moreover, are not distinct. Good science involves, first and foremost, skepticism. This is true for the design of any experiment, in which the primary goal is to attempt to falsify the hypothesis, and also for scientific thinking in general. Bruce Alberts, the editor of Science, discussed this in a 2008 editorial titled “Considering Science Education”:

…society may less appreciate the advantage of having everyone acquire, as part of their formal education, the ways of thinking and behaving that are central to the practice of successful science: scientific habits of mind. These habits include a skeptical attitude toward dogmatic claims and a strong desire for logic and evidence. As famed astronomer Carl Sagan put it, science is our best “bunk” detector. Individuals and societies clearly need a means to logically test the onslaught of constant clever attempts to manipulate our purchasing and political decisions. (emphasis added)

I believe that you know all this at some level, but that your current job demands that you bend over backward to frame skeptics as extreme—distinguishing them from “neutral” scientists. Thus you, like many reporters, have placed skeptics of homeopathy or naturopathy at one end of a contrived belief spectrum, and “staunch CAM advocates” at the other. Please indulge me while I compare this version of ‘neutrality’ with others that exist in the popular domain:

  • Some people feel strongly that the moon landings were a collective hoax. Others feel just as strongly that they really happened.
  • Some people believe that the Holocaust didn’t happen. Others believe that it did.
  • Some people believe that the variety of species on earth is a product of Intelligent Design (ID). Others believe in the theory of evolution by variation and natural selection.

This could go on and on, but you probably get the point. The last bullet is more pertinent to your tacit endorsement of the AANP than you might imagine. What follows is a representative view of herbalism offered by Thomas Kruzel, with whom you will also share the podium at the convention (he will discuss “Emunctorology”; don’t ask). Kruzel is Past President of the AANP and the former Vice President of Clinical Affairs and Chief Medical Officer at the Southwest College of Naturopathic Medicine. He was selected Physician of the Year by the AANP in 2000, and Physician of the Year by the Arizona Naturopathic Medical Association in 2003:

Herbal Medicine: Naturopathic physicians have been trained in the art and science of prescribing medications derived from plant sources. The majority of prescription drugs are derived as well from plants but are often altered and used as single constituents. What makes herbal medicine unique is that plants have evolved along with human beings and have been used as non-toxic medications for centuries.

If there is any problem with herbal medicines it is that unless one knows how to prescribe them, they may not be effective. Herbal medications should be prescribed based on the symptoms that the person presents rather than for the name of the disease. Herbal medications are much more effective at relieving the patients symptoms when prescribed in this manner. When prescribed the medicines act with the body’s own innate healing mechanism to restore balance and ultimately allows healing to occur.

What’s nice about plant or herbal medicines is that because they are derived from the whole plant they are considerably less toxic to the body. The plant medicine has evolved to work in harmony with the normal body processes rather than taking over its function as many drug therapies do. Because of this herbal medicines may be taken for longer periods of time without the side effects so often experienced with drugs.

You are particularly impressed, I hope, by the magical, ID-like claim that “plant medicine has evolved to work in harmony with the normal body processes.” Other curious assertions include the conflation of herbal medicine with the core claims of either homeopathy or the non-existent ‘allopathy’ (we can’t tell which)—”…should be prescribed based on the symptoms…”—demonstrating that the author doesn’t know much about even the fanciful methods for which he claims expertise; and the dangerously false statement that medicines “derived from the whole plant are considerably less toxic” (than are well-researched and precisely dosed “prescription drugs”).

Dr. Briggs, please consider the possibility that you no longer must hide your considerable scientific prowess in order to be a good NCCAM Director. Your ‘stakeholders’ include not only very small numbers of naturopaths, homeopaths, and other fringe practitioners, but also far larger numbers of citizens who wonder about the validity of what those practitioners are peddling. It is to those citizens that you should be directing your efforts, which ought to begin with sober, objective, skeptical, scientific considerations of the various claims, the vast majority of which can, like balloons in the nasopharynx, be deflated in milliseconds by anyone with even a modest understanding of nature. They don’t require clinical trials.

Things are changing elsewhere. My colleague Steve Novella has just written about substantial efforts to deny insurance coverage for homeopathy in the land of its birth, Germany. In the UK, homeopathy has been far more popular than it is here, even to the point of its being funded by the National Health Service. One of the “staunch CAM advocates” who reportedly attended your meeting by teleconference was Peter Fisher, Homeopath to the Queen. Yet both the British Medical Association and the House of Commons Science and Technology Committee have seen through the ruse of pseudoscience that is homeopathy, the former declaring it “witchcraft” and latter making this statement:

The Committee concurred with the Government that the evidence base shows that homeopathy is not efficacious (that is, it does not work beyond the placebo effect) and that explanations for why homeopathy would work are scientifically implausible.

American citizens want and deserve, for their tax money, exactly that sort of definitive evaluation of such claims. Your first responsibility, Dr. Briggs, is to them—it is not to the AANP, other “CAM stakeholders,” Tom Harkin, Orrin Hatch, or Dan Burton, and certainly not to the members of the NACCAM. Yes, we “skeptics see [the NCCAM] research investment as giving undue credibility to unfeasible CAM modalities,” because the evidence is overwhelming that this is the case. We also see your appearing at conventions of pseudomedical pseudoprofessional organizations as giving undue credibility to unfeasible and dangerous claims.

Sincerely yours,

Kimball C. Atwood, M.D.

Skeptic

The Naturopathy Series:

  1. “CAL”: a Medico-Legal Parable
  2. Another State Promotes the Pseudoscientific Cult that is “Naturopathic Medicine.” Part 1
  3. Another State Promotes the Pseudoscientific Cult that is “Naturopathic Medicine.” Part 2
  4. Another State Promotes the Pseudoscientific Cult that is “Naturopathic Medicine.” Part 3
  5. Another State Promotes the Pseudoscientific Cult that is “Naturopathic Medicine.” Part 4
  6. Colorado is Nearer to Promoting Naturopathic Pseudomedicine—Aided by the Colorado Medical Society
  7. Naturopathy and Liberal Politics: Strange Bedfellows
  8. Open Letter to Dr. Josephine Briggs
  9. Smallpox and Pseudomedicine

Posted in: Homeopathy, Medical Ethics, Naturopathy, Politics and Regulation, Science and Medicine, Science and the Media, Vaccines

Leave a Comment (70) ↓

70 thoughts on “Open Letter to Dr. Josephine Briggs

  1. dangblog says:

    I sincerely hope she reads it, takes it seriously, and makes it a “part of her education.” Dr. Briggs has a serious responsibility and there’s a great deal at stake here.

  2. hat_eater says:

    Essentially, we (although I’m not from the USA, I include myself as a sceptic) expect her to turn off the lights at NCCAM. In other words, to place the public interests above the interest of the institution she’s heading. On one hand, that’s quite a reasonable expectation, on the other… call me cynical, but I’m not holding my breath.

  3. Dionigi says:

    Bravo.
    To the point and well put.

  4. windriven says:

    hat_eater has it exactly right. Briggs may be many things but the simple fact that she heads NC-SCAM demonstrates that first and foremost she is an apparatchik and can be expected to give first allegiance to the bureaucracy.

    It is difficult for me to believe that any self-respecting scientist would take this political appointment in the first place; impossible to believe that one would stay after the briefest survey of the science surrounding CAM.

    “Hmmm, shall I stay and give the appearance of respectability to a small rabble of snake oil salesmen who enrich themselves on the credulity and suffering of others, or shall I march up to Capitol Hill and testify that CAM is a stinking heap of rotting garbage that no pile of federal money can turn into a respectable discipline?”

    One defines one’s self in the decision, doesn’t one?

  5. Val Jones says:

    Terrific post, Kim. I sincerely hope that Dr. Briggs has the courage to admit that the Emperor has no clothes. If she’d like to distinguish herself as a scientific leader and free-thinker, that would be the best way to do it. I hope she strongly considers speaking out against pseudoscience. She has a great podium from which to do so… anything less is bowing the scientific knee to political correctness and Washington politics.

    Dr. Briggs, please take the road less traveled and pursue an honorable career legacy. Expose misinformation, outdated science, and modern day snake oil… We need strong advocates for truth in medicine!

  6. Jann Bellamy says:

    Wonderful post!

    I would add that in reading the statute creating NCCAM I see absolutely nothing that requires the Director of NCCAM to turn a blind eye to the realities of “alternative medicine.” NCCAM’s statutory mission is research and “dissemination of health information” and “other programs with respect to identifying, investigating, and validating complementary and alternative treatment, diagnostic, and prevention modalities, disciplines and systems” and requires “high quality, rigorous scientific review of complementary and alternative [medicine].” “Validating” is problematic, but it obviously can’t mean ignoring the evidence or saying straight out that there is none.

    And so what if Hatch, Burton and Harkin get mad — what are they going to do? Defund NCCAM?

  7. Dr Benway says:

    Dr. Briggs,

    You have a chance to do something amazing and heroic. You’re in a position to say, “I’ve reviewed the CAM literature, talked to those providing and using CAM treatments, and I must say, the effort to create an evidential double-standard in medicine has been misguided…

    You would take a lot of heat. But I would volunteer to help you out anyway I could. I bet there are a lot of other doctors who understand how science works and who would also cheer you on.

    The American people don’t want CAM; they want stuff that works. They pay for CAM because they’ve been led to believe it works. Remove that mistaken belief, and the demand will vanish (save for those making a mint off supplements and dodgy practices).

    I see autistic kids who’ve been made to take a bowl full of unregulated supplements and made to follow strict gluten-free, casein-free diets. They come with pages of expensive lab results filled with meaningless numbers. In one case, my patient lost about 20 lbs over 3 months after she was started on God-knows-what. Her doctor is a board-certified MD from a fine med school. That’s what shocked me the most. And that’s when I woke up to the dangers of this well coordinated, well funded political movement called “CAM.”

    The UK and Germany are getting wise. The US will follow soon. So join the winning team! Take a stand for science and leave a legacy within the house of medicine that will make you proud.

  8. windriven says:

    @ Jann Bellamy

    “And so what if Hatch, Burton and Harkin get mad — what are they going to do? Defund NCCAM?”

    No, they’ll simply replace the director with someone more … accommodating.

  9. Joe says:

    It would be interesting to obtain a list of what Dr. Briggs thinks are “Promising Ideas from Outside the Mainstream” and why.

    Mr. Kruzel: “herbal medicines … are derived from the whole plant [thus] are considerably less toxic to the body.” There are two reasons that may appear to be so, or may actually be true. First, there is no rigorous, organized scrutiny of the toxicity of herbs. Second, most herbs are probably no more pharmacologically active than lettuce (in the doses used).

    @hat_eater on 23 Jul 2010 at 7:04 am “Essentially, we … expect her to turn off the lights at NCCAM.”

    No scientific influence can do that- NCCAM is a political product. As I understand it, it is unique as a federal “scientific” institution in that it was not the product of a scientific need. At one point, when a Director tried to emphasize too much science, Sen. Tom Harkin (D, Iowa) held the whole NIH budget till the Director relented.

  10. Shelley says:

    Is there anywhere else (other than through Medscape) where I can access ‘Naturopathy: A Critical Appraisal’? I’d like to read this information.

  11. Shelley,

    You can access articles on Medscape by registering and logging in. It’s free and they don’t spam you.

  12. Dr Benway says:

    CAM proponents can’t win on evidence so they tend fight dirty. See Dr. Kreider’s account here:

    http://www.sciencebasedmedicine.org/?p=434

    We also have the recent example of a coordinated effort to get Dr. Gorski fired:

    http://www.sciencebasedmedicine.org/?p=5827

    The Scientologists call this “fair game.” I don’t mean to imply the Scientologists have any relationship with the two incidents above. But they do have a significant stake in the alt med movement and they do seek to influence “thought leaders” who are CAM proponents. So it’s no surpise to me that the standard fair game ritual gets played out against public enemies of CAM.

    Were it not for the FBI raid on Scientology headquarters in the 1970s, we’d never have learned of Operation Snow White, “the single largest infiltration of the United States government in history with up to 5,000 covert agents.” Nor would we have learned of the coordinated effort to weaken the AMA, known as “Operation Sore Throat.”

    I’ve spent the last several months following the Anonymous protest movement and have witnessed several fair game scenarios unfolding. It really sucks to be a target. To give a taste, here’s a link to Dr. Lilly von Marcab’s story:

    http://forums.whyweprotest.net/24-fair-game-reports-personal-experiences/ive-got-remove-myself-60056/

    I share Dr. Lilly’s example simply because she (or he) is so damn cute.

    If Dr. Briggs dares to say critical things about alt med in public, the bad guys will go after her and she will need back-up.

    I want Dr. Briggs to know that Dr. Anonymous is legion and will appear everywhere when the need arises.

  13. @ windrivenon
    @ Jann Bellamy

    “And so what if Hatch, Burton and Harkin get mad — what are they going to do? Defund NCCAM?”

    No, they’ll simply replace the director with someone more … accommodating.

    They’d have to at least think twice about trying to force out someone for advocating the best science, reasoning, and methods available in what is supposed to be a scientific institution.

  14. windriven says:

    @ Karl Withakay-

    “They’d have to at least think twice …”

    They’d have to think once before they could think twice.

  15. Scott says:

    They’d have to at least think twice about trying to force out someone for advocating the best science, reasoning, and methods available in what is supposed to be a scientific institution.

    This seems overly optimistic. After all, what they’ll really be doing is forcing out an insubordinate closed-minded obstructionist who’s probably in the pocket of Big Pharma.

  16. cervantes says:

    The fact is that — as far as I know this is still true — 100% of the trials funded by NCCAM so far have had negative results. There could be social value in an enterprise that subjected treatments on which people are already spending money to legitimate testing, and then aggressively publicized the results if they were found not to work. And of course if some herbal remedy or whatever does seem to show promise it should be pursued.

    But what we have instead is a predisposition to legitimize nonsense. It appears that NCCAM does apply criteria of solid study design to reviewing proposals; what it does not seem to use are reasonable criteria regarding what interventions are worthy of study.

  17. WilliamLawrenceUtridge says:

    Better science, with each project having an experienced methodologist (is that really a title) to rigorously test the interventions, is the biggest favour any of them could do for the public. That is where Briggs could have the greatest benefit – consistently rejecting applications that have a low methodological rigour, and publicizing the results irrespective of outcome. Advertise the good and the bad of high-quality science and the results will speak for themselves.

  18. wales says:

    “American citizens want and deserve, for their tax money, exactly that sort of definitive evaluation of such claims.”
    Really? It appears that “American citizens” want choice, and many “American citizens” turn to alternative medicine because allopathic/western/science based medicine (paid for with their tax money and out-of-pocket money) has not adequately addressed their chronic conditions. With all due respect, I doubt that KA is representative of “American citizens”.

    “The Committee concurred with the Government that the evidence base shows that homeopathy is not efficacious (that is, it does not work beyond the placebo effect) and that explanations for why homeopathy would work are scientifically implausible.”

    The placebo effect can be quite powerful. I recommend “Placebo Effects: Understanding the mechanisms in health and disease” by Fabrizio Benedetti (OUP 2008)

    What is scientifically implausible today, may not be tomorrow. Scientists don’t yet completely understand the structure of water. http://home.slac.stanford.edu/pressreleases/2008/20080630.htm

  19. qetzal says:

    As I’ve stated before, our position is that science must remain neutral, and we should be strictly objective.

    Science should only be neutral when the available evidence is neutral. We must always strive to be unbiased, but if the objective evidence is strongly against a claim, remaining ‘neutral’ is exactly the opposite of what science demands.

  20. mikerattlesnake says:

    “What is scientifically implausible today, may not be tomorrow. Scientists don’t yet completely understand the structure of water.”

    “we don’t know everything, therefore we can’t claim to know anything”

    Lame. We certainly know more about water than the man who created homeopathy out of whole cloth a couple centuries before people knew what germs were.

  21. Scott says:

    Really? It appears that “American citizens” want choice, and many “American citizens” turn to alternative medicine because allopathic/western/science based medicine (paid for with their tax money and out-of-pocket money) has not adequately addressed their chronic conditions.

    More accurately, American citizens have been lied to by alternative medicine practitioners who can’t adequately (or indeed at all) address any condition, and as a result of that fraud believe that they want choice.

    That’s not even getting into the fact that neither “western” nor “allopathic” medicine exists except as a strawman useful to the massive fraud that is CAM.

    The placebo effect can be quite powerful. I recommend “Placebo Effects: Understanding the mechanisms in health and disease” by Fabrizio Benedetti (OUP 2008)

    Nobody denies that the placebo effect is effective, but that doesn’t give anybody the right to lie and commit fraud by bilking people out of their hard-earned money for “treatments” they’re TOLD are more than placebo but aren’t.

    What is scientifically implausible today, may not be tomorrow. Scientists don’t yet completely understand the structure of water.

    This completely misunderstands the nature of the implausibility. In order for homeopathy to work, the entire body of physics, chemistry, and biology would have to be completely wrong. Not just wrong in minor details, but bearing no resemblance to reality. Dropping an object and having it fall up is more likely to become plausible in the future than is homeopathy.

    “Science doesn’t have all the answers. But that doesn’t mean you can fill in the holes with whatever fairy tale most takes your fancy.”

  22. mikerattlesnake says:

    @wales (as was the previous)

    “The placebo effect can be quite powerful. I recommend “Placebo Effects: Understanding the mechanisms in health and disease” by Fabrizio Benedetti ”

    Proper medicine, when applied correctly, also shows a placebo affect on top of it’s actual efficacy. Why replace this with just a placebo? If people don’t need medicine, why not point them towards not taking medicine instead of taking fake medicine?

  23. moderation says:

    Well said. I am standing and applauding …

    Thanks.

  24. windriven says:

    @ wales

    You always have an interesting take on the blogs. I mean that genuinely.

    “It appears that “American citizens” want choice, and many “American citizens” turn to alternative medicine because allopathic/western/science based medicine (paid for with their tax money and out-of-pocket money) has not adequately addressed their chronic conditions. ”

    I think that isn’t quite complete. Some of the woo-drinkers I know simply distrust science and prefer the healing touch of mother earth. Others hear prognoses from MDs that are unpleasant and turn to the promise of easy answers from quacks.

    “What is scientifically implausible today, may not be tomorrow”

    That is occasionally true. But those rare cases simply demonstrate that science may not be fast but it is sure. One shouldn’t give credence to some scientifically implausible nonsense on the dim hope that some heretofore undiscovered principle will turn the nonsense into truth. It might someday be shown that acceleration on earth isn’t always 32 ft-sec^-2. But in the meantime I’m not going to jump off any tall buildings.

  25. wales says:

    Thanks windriven. What I’d like to see more tax dollars spent on (as an “American citizen”) rather than trying to disprove CAM is proving up (or disproving) the efficacy of existing allopathic or “science based” treatments. As this opinion piece articulates so well, negative study results are valuable.

    http://www.washingtonpost.com/wp-dyn/content/article/2010/07/22/AR2010072205267.html

    “Many drugs and treatments routinely used by physicians can have specific results, such as opening an artery. But these “improvements” don’t always translate into the expected benefit for patients’ overall and lasting health. That’s why it is important to also conduct trials that focus on strategies that are in use but are not fully tested — and to confirm that they improve patients’ quality of life or survival.”

    “It’s simply the case that many popular medical strategies have little or no rigorous scientific evidence of their effectiveness regarding patient outcomes. Realizing the potential for negative studies to change practice remains a challenge. Because negative studies often contradict conventional wisdom, they can undermine corporate-marketing messages and the pet theories of academics. Although no study is perfect, the flaws of the negative studies are often magnified by detractors to deflect the message that we can achieve more by doing less — or spending less.”

  26. wales says:

    In the Washington Post opinion piece cited above, the author cites multiple studies showing the failure of standard treatments to improve the health of diabetics. That is what I mean by people turning to alternative medicine when expensive “science based” treatments have failed in treating chronic conditions. “American citizens” are voting with their feet and dollars, that’s why they turn to CAM. Many of them feel they have been “lied to” and “bilked” by the failure of science based treatments. I don’t know what percentage feel this way versus those who just prefer “natural” treatments, as described by windriven. But I know a lot of people fed up with expensive, risky and failing science based treatments.

  27. @ qetzal

    “Science should only be neutral when the available evidence is neutral. We must always strive to be unbiased, but if the objective evidence is strongly against a claim, remaining ‘neutral’ is exactly the opposite of what science demands.”

    Well said. Science should always have a position, even if that position is that there is insufficient evidence to form a firm conclusion. In fact, the default position should always start out as not accepting any claim until it is sufficiently supported by quality evidence.

    Unfortunately, that position gets twisted by some (NCCAM) into a position that any claim needs to be tested, even those that have already been exhaustively tested or those that have no prior plausibility at all.

    Read the introductions to the abstracts to various acupuncture and homeopathy trails; they generally start out with an a priori assumption that X is effective and therefore needs to be studied. I haven’t seen hardly any that start out by discussing the basic science and physiognomy involved that lead to the reason to investigate the modality being studied. Rather than saying, “the basic science and medicine discussed here lead to a plausible hypothesis that X may be effective for Y,” they tend to start out with “lots of people have used X for a long time and have found it to be effective, so we’re going to try to prove X is effective.”

    Briggs seems to imply that science should remain neutral until and unless, of course, something is proven. Tom Harkin would be glad to know that the NCCAMs mission seems to be to never close the door on any modality and to keep investigating everything over and over until effectiveness is proven, which never seems to happen.

  28. daijiyobu says:

    Lovin’ it, Dr. A.

    Though I’m not a hopeless person, judging from what the State of Oregon — where that AANP conference will be — recently archived / enshrined at their ‘.us’ site, it seems ‘the big absurd naturopaTHICK stupid’ has thoroughly contaminated rational, ethical discourse now to the extend that government, as part of this racket, has etched it all in its full falsehood / irrationality into electronic permanency

    (see this Naturocrit post, http://naturocrit.blogspot.com/2010/07/enshrining-big-stupid-absurdity-state.html ).

    This is not ‘us’, though, by far.

    If by ‘us’ I mean: legitimate science, post-Enlightenment free-thought and rationality, high standards / professional ethics.

    -r.c.

  29. Foster Disbelief says:

    Before I fall off my chair in shock….

    Is this list of drugs, found at http://www.oregon.gov/OBNM/rules/850-060-0225.-0226_1.pdf , linked to in the main post, the list that ND’s can prescribe in Oregon?

    And if it is……Seriously? Oxymorphone? Oxycodone? Methadone? ND’s can prescribe this stuff? *sigh*

  30. FelixO says:

    Dr Atwood,

    did you send a copy of this via via postal service?
    Or are you hoping that Dr Briggs will read it here?

    I like what windriven wrote above:

    “Hmmm, shall I stay and give the appearance of respectability to a small rabble of snake oil salesmen who enrich themselves on the credulity and suffering of others, or shall I march up to Capitol Hill and testify that CAM is a stinking heap of rotting garbage that no pile of federal money can turn into a respectable discipline?”

  31. Scott says:

    What I’d like to see more tax dollars spent on (as an “American citizen”) rather than trying to disprove CAM is proving up (or disproving) the efficacy of existing allopathic or “science based” treatments.

    Absolutely. But that’s rather an independent question. And keep in mind that spending more money on “trying to disprove CAM” is exactly what Dr. Atwood is suggesting NOT be done – it’s ALREADY been disproven, and more spending on it is neither necessary nor appropriate.

  32. Joe says:

    wales on 23 Jul 2010 at 1:24 pm wrote “… What I’d like to see more tax dollars spent on … rather than trying to disprove CAM is proving up (or disproving) the efficacy of existing allopathic or “science based” treatments. ”

    Proper research is not aimed at proving or disproving, it is intended to find out. So far, NCCAM has found out that so-called CAM is as ineffective as (properly) educated people always thought it was.

    As for studying medicine, it has been, and is being, done; despite what you, or a journalist, may believe. The successes are too numerous to count, and I don’t know what to hold up as the best example.

  33. windriven says:

    @wales

    “What I’d like to see more tax dollars spent on (as an “American citizen”) rather than trying to disprove CAM is proving up (or disproving) the efficacy of existing allopathic or “science based” treatments. ”

    Truly science-based treatments don’t require quotation marks. There are, of course, treatments that have been embraced by MDs that lack rigorous proof of efficacy. Those of us who truly believe in science based medicine are just as eager to see commonly held mainstream Treatments debunked as we are woo. The point is understanding what work, how it works, why it works, and when it doesn’t work. When it comes to woo we have a pretty good fix on the ‘when it doesn’t work’ part.

  34. wales says:

    Joe, the Washington Post opinion was written by an MD, not a journalist.

  35. David Gorski says:

    It’s depressing to me that Kimball even feels the need to write such a spot-on criticism of Dr. Briggs. Having met Dr. Briggs, I left with the feeling that her heart is in the right place but that she really has no clue just how much fairy dust and pure quackery fall under the rubric of “CAM.” Her acceptance of an invitation to speak at a naturopathy convention is rather strong evidence of that.

    I also see Dr. Briggs as being in a near-impossible situation in that, as a distinguished scientist herself, she really does appear to want to increase the scientific rigor in NCCAM but how can you increase the scientific rigor of research that is studying pure pseudoscience? You can’t, particularly given that so many of NCCAM’s stakeholders don’t really want rigorous science (their claims that they do notwithstanding) because the more rigorous the science, the greater tendency to show how without a foundation in scientific evidence so much of CAM is.

    Depressing.

  36. windriven says:

    Dr. Gorski, I find it not so much depressing as disgusting. If Dr. Briggs is in a near-impossible situation she is there by her own choice. I don’t recall reading that she was forced to accept the directorship at gunpoint.

    Whether or not her heart is in the right place, her brain is not. The term ‘tool’ comes to mind. History is replete with intelligent, well-educated people who have allowed their talents to be used to loathsome ends.

    This is not a situation where a physician is prescribing a sugar pill to a hypochondriac, it is a situation where a Harvard MD and Yale Fellow is allowing herself to be used as the poster child for garbage science that all too often lures vulnerable people to early graves.

    There is simply no way for her to put a smiley face on that and pretend it is just a job.

  37. Joe says:

    @wales on 23 Jul 2010 at 3:29 pm wrote “Joe, the Washington Post opinion was written by an MD, not a journalist.”

    I stand by what I wrote:

    “As for studying medicine, it has been, and is being, done; despite what you, …, may believe. …”

    It was an opinion piece rather than a report; and you misunderstood it. He was saying that more credence needs to be given to negative results, resulting in changes in practice.

    As an intellectual exercise, explain to me how you can say research is not being done after reading an opinion describing the results of … research.

  38. windriven on motivations for unscientific medicine: “Others hear prognoses from MDs that are unpleasant and turn to the promise of easy answers from quacks.”

    Yep, and I’m about to join them. (Billy Joe, avert your eyes.) My beloved has been suffering abdominal pain for the past two or three years or so. It’s a lot like the pain from his vasectomy and the post-vasectomy surgery to remove a variocele apparently (?) caused by the vasectomy. He has various gut symptoms. It gets better and worse. He’s had various scopes and scans, seen a gastroenterologist and been referred to a surgeon. The surgeon told him that he’d had his million-dollar workup, that there was nothing wrong, that he’d probably torn a muscle or something and should be a big boy and stop bothering the doctors. (Or rather, that’s what he heard. I’m kicking myself: I should have gone with him.)

    Well, now I have someone at home, in pain, who has been told there is nothing to be done about the pain, and who [believes he] has been instructed to stop trying to find out what he can do about it. It’s bad enough that the pain itself puts a kink in our lifestyles (try being “intimate” with someone who can’t tolerate contact with his abdomen and who gets post-coital cramps), but now he is giving up hope that the pain will ever get better and he doesn’t want to live like that. He’s very depressed and wants to die. He doesn’t want to bother the doctors any more because they haven’t helped and they have told him to go away.

    (No, he does not now, nor has he ever, nor does he ever want to, take opiates. Except that he’s heard that heroin is a really nice way to go when the time comes.)

    So. Now, how am I supposed to offer him hope, exactly? The hope without which anyone’s life is unbearable? That’s going to be a complex journey, and (Billy Joe, stick your fingers in your ears, squeeze your eyes shut and start singing loudly) part of it will probably involve (really, Billy Joe, I mean it) trying various probiotic preparations and quack diets.

    This is not in defense of quack diets and absolutely not a defense of Dr Briggs and NCCAM. Just… what windriven said. When people don’t like what the doctor said, they’ll look for someone who says something more palatable.

    (Billy Joe, you can come back now.)

    Of course doctors can offer science- and compassion-based support and encouragement to patients with chronic conditions. It’s just that in this case… as much as we’d like to be, we aren’t there right now. (As a group, surgeons may not be the ones who have most developed this skill.)

  39. SloFox says:

    @ windrivenon
    @ Jann Bellamy

    I think the biggest concerns are that many of the congressmen that support NCCAM are also the biggest general supporters of the NIH and medical research. I don’t think that pissing them off will necessarily cause them to stop funding the NIH but it’s best not to put them in too defensive a position.

    Dr. Briggs did not get to be the director of NCCAM by being a renegade. There’s so much politics in that job it’s unlikely anyone given the job will be the one to turn off the lights. The institute is there by congressional mandate and only a congressional mandate is likely to close it.

    I’d recommend a grassroots campaign aimed at the members of Congress who have been the most vocal supporters of CAM. Ideally I envision a letter-writing campaign and/or petition from non-medical, non-scientific members within the Congressperson’s district. If you support CAM you really don’t care about what the experts have to say so I think it’s more effective if the effort is led by ‘lay’ people (with appropriate medical/scientific backing). It’s paramount that the effort start in the appropriate district because that will have the greatest impact on the Congressperson’s opinion.

    @ Dr. Atwood

    Great letter. I doubt it will have as great an effect as it should but still important that we educate our medical colleagues about how absolutely ridiculous CAM is and the inappropriateness of lending legitimacy to organizations such as AANP. Dr. Briggs may be bound to do wasteful research but that doesn’t mean she needs to lend credance to its proponents.

    Mike

  40. Joe says:

    @windriven on 23 Jul 2010 at 4:09 pm wrote “Dr. Gorski, I find it not so much depressing as disgusting. If Dr. Briggs is in a near-impossible situation she is there by her own choice.”

    Looking at Dr. Briggs CV http://nccam.nih.gov/about/offices/od/briggsCV.pdf it remains possible that she was naive walking into this. She may have thought she could do some good at NCCAM.

    This could be her big test- if she fails to heed this notice (I hope she got a copy directly) and/or comes away from a meeting of quacks without seeing the light, then she is certainly lost.

  41. daedalus2u says:

    Allison, what ii sounds like is low nitric oxide. This is somewhat speculative, but I suspect that the stress of the surgery, though minor to others wasn’t in the mind (gut?) of the beholder and that stress has become perpetuated. Not taking opiates for pain may have been a contributor. Pain signals are a stressor, and the usual response to stress is to lower NO levels.

    That is consistent with variocele, the morphology of tortuous, corkscrew-shaped vessels is characteristic of flow-mediated remodeling and which to me suggests low NO mediated remodeling, where the curved flow causes acceleration which moves red blood cells to the outside where they remove NO causing lower NO levels and causing the vessel to regress. Tortuous vessels are characteristic of many of the disorders characterized by low NO including diabetic retinapathy and leukoaraiosis. I have a write-up on the role of low NO on capillary rarefaction (which I think is the cause of the cramping, ischemia from insufficient vascularization).

    http://daedalus2u.blogspot.com/2008/10/role-of-low-basal-no-in-capillary-and.html

    This is consistent with depression which you mention, and very likely insomnia which you didn’t. I suspect that this is one of the mechanisms by which chronic fatigue syndrome occurs (which I think it due to low NO) and also PTSD but that is more complicated.

    The best method I know to raise NO levels isn’t generally recognized (yet). Another method that might help is to eat a high nitrate diet, lots of green leafy vegetables multiple times a day. They have a lot of nitrate in them, the nitrate is well absorbed, is concentrated ~10x on the tongue where it is reduced to nitrite. Nitrite in saliva is reduced to NO at the low pH of the stomach and has demonstrable effects on vascular physiology. You have to let your tongue have the right biofilm, which means not killing it off with mouth wash or high alcohol beverages. This method doesn’t have the same effects as the other. There is some cross-talk, but they are not equivalent. There is considerable thought in the NO research community that the nitrate in green leafy vegetables is the reason for their positive health effects.

    Something that does make low NO effects worse is Sildenafil. One of the signaling cascades that NO is involved in (but only one) is where it activates soluble guanylyl cyclase when then makes cyclic GMP. That cGMP causes smooth muscle to relax and is the mechanism for erections. Sildenafil inhibits the phosphodiesterase that removes the cGMP, so the level is higher in the presence of Sildenafil, which increases the gain for cGMP mediated effects of NO (such as erections). This can result in the feedback inhibition of NO release, which screws up the balance of NO mediated effects other than those mediated through cGMP. For example in obstructive sleep apnea, a single dose of Sildenafil does make it worse. This is because the pathways by which NO controls breathing are not mediated through cGMP (they are mediated through S-nitrosothiols which are not well understood).

  42. There we go — speculative diet number 1! No viagra, no alcohol, no mouthwash, but copious leafy greens for breakfast, lunch, supper and midnight snack. The stuff to avoid is going to be easy; the stuff to add… will take some doing. Will be very healthy, though.

    daedalus2u, what is the unrecognized method you’re referring to?

  43. JMB says:

    Either Dr Berwick or Dr Briggs could have a positive effect if certain principles are adhered to.

    #1 The government and insurance companies should not be expected to pay for a more expensive treatment unless the more expensive treatment is more effective.

    If CAM is no more effective than a placebo, then it should be reimbursed at the cost of a sugar pill.

    #2 All health tests and treatments should be judged by the same criteria, “are they effective?”. The scientific method is the unbiased method to prove effectiveness, the same scientific method should be used to judge all tests and treatments.

    #3 There is a separation of church and state. Any treatment or test based on a belief as opposed to objective evidence is allowing the state to pay for someone’s religious views.

    #4 If new methods for scientific analysis are introduced, they should be thoroughly evaluated by a multidisciplinary scientific community for validity before they are accepted as scientifically valid. Integrative medicine is rumbling about new methods of analyzing the effectiveness of alternative medicine combined with traditional science based medicine. They also tend to dismiss biostatisticians complaints about the proposed methods. Such new methods may give a scientific veneer to pseudoscience. I do mean scientific community, not political appointees.

    #5 If healthcare reform was sold to the American public as needed because, “we spend more per capita on healthcare, but don’t live the longest” then deliver on the promised fix. Don’t pay for unnecessary healthcare that won’t improve our longevity. Make healthcare more efficient, not woosey. No amount of homeopathy is going to extend our longevity.

  44. urodovic says:

    As always, excellent post Dr. Atwood, and I agree with Dr. Gorski in his frustration. Seem like Dr. Briggs is under a lot of pressure from many fronts and she wants to be, putting it mildly, “politically correct”. But she should seize this opportunity to clarify the role of science when dealing with implausible claims… you just don’t bother to continue looking into their “possible plausibility” specially when tax dollars are been used.

  45. daedalus2u says:

    Allison, topical application of autotrophic ammonia oxidizing bacteria to the skin. It is my hypothesis that these bacteria set the basal NO/NOx status in humans (and many other organisms) by converting the ammonia released as sweat into NO and nitrite and that modern bathing practices remove them faster than they can proliferate.

  46. Zoe237 says:

    I don’t see how anyone could possibly defend Briggs if she’s voluntarily giving talks at a naturopathic physician (is that an oxymoron) conference. Is that part of her job description or she is making money on the side? It sounds like she’s talking out both sides of her mouth to me. It’s certainly possible that brilliant people can be taken in by these issues. Now, I don’t have any basic issue against the idea of of a NCCAM, if it’s scientifically rigorous, and it sounds like it has been so far. However, if the bureacracy is spending money to publicize the “unlikely treatments bound to be successful,” then I guess SBM might have convinced me it needs to be disbanded. Either way, sounds like a conflict of interest, and certainly not a “neutral” stance.

    JMB, love the list, especially the separation of church and state and the sugar pill one.

    Should science be objective? Because there sure is a lot of passion on blogs from scientists, and i guess I was taught that it should be objective as well.

  47. daijiyobu says:

    Dr. G. said: “it’s depressing.”

    Luckily, you didn’t live through naturo. “cultic mystical weirdness” as I did. THAT’S depressing. Imagine people around you telling you that it is a scientific fact that the absurd is able to survive scientific scrutiny!

    Lucky for me, I suffer from ataraxia (see http://en.wikipedia.org/wiki/Ataraxia ):

    “robust tranquility that derives from eschewing faith in an afterlife [this is it!], not fearing the gods because they are distant and unconcerned with us [deism and much LESS!], avoiding politics and vexatious people [or else we'll bash their faces in with a PC's keyboard], surrounding oneself with trustworthy and affectionate friends [aka drinking buddies] and, most importantly, being an affectionate, virtuous person, worthy of trust [no matter the consequences].”

    Aka “virtue ethics.”

    -r.c.

  48. A very nice MD from Oregon confused about the status of NDs, and consequences for patients:

    http://allbleedingstops.blogspot.com/2008/12/how-would-you-handle-this.html

  49. BillyJoe says:

    Alison,

    I think it was pretty unfair to prick my balloon before I’d even had a chance to inflate it.

    (Still, I stand by my opinion that your support for SBM stands for nothing if it fails as soon as it is you who have the illness ;))

    regards,
    BillyJoe

  50. Alison – To woo or not to woo. That is the question…

    I feel for your dear friend. I have read that abdominal pain can be very difficult to diagnose. Possibly you have already told him this, but I would suggest that he go back to his GP or maybe the GE and say “look the surgeon told me this, but I still have these symptoms, what would you do if you were me?” If he feels they won’t work with him, find another GP. Which I know is a pain in the…neck.

    I think sometimes a specialist will basically drop a patient when they see their skills don’t apply to that patient. I had this happen with an endocrinologist once. Luckily, I eventually did go back to my GP when I was symptomatic and found that my symptoms were caused by a non-endocrine problem. In retrospect I realized that the endo probably did not mean to suggest that my symptoms didn’t exist and I should stop being a wimp (as I thought at the time.) just that they didn’t apply to her specialty. I do believe she could have communicated that better, though.

    I will now enter the complete pushy mother-in-law giving unsubstantiated advice mode (or perhaps you thought I already had) and suggest that if you are trying random diets, a few weeks lactose free might not be a bad idea. I have heard becoming lactose intolerant as you near middle-age is not that uncommon and, at least in my husbands case, the digestive reaction is not always obvious until you’ve been off lactose for a bit. That is assuming that you dear friend has some digestive symptoms and that they aren’t disappearing for weeks on end then reappearing. If they are disappearing for weeks on end, boy, any diet is going to be hard to judge.

    There, I’m not sure if that’s woo or just uneducated pseudo-medical, so take it for what it’s worth. Hope your dear friend finds a solution soon.

  51. Jann Bellamy says:

    @wales

    In your comments about ineffective “conventional” medical treatments v. ineffective CAM treatments, you fail to understand certain key differences:

    1. All medical treatments (to my knowledge) start with a plausible basis in science — they don’t even get to the study stage without that. To study treatments that have no plausible basis in science is, IMHO, unethical (if human or animal subjects are involved) and a waste of money.

    2. “Conventional” medicine stops using a treatment when it is proven ineffective, even though it is sometimes too slow to do so. I know of no case where proven ineffectiveness stops a CAM practitioner from using a treatment.

    3. The fact that medical treatments, even if effective, do not actually improve the patient’s quality of life is something medicine understands and works to improve. Hence this op-ed piece by an MD. I’ve never seen a similar critical self-assessment of one’s profession by any CAM practitioner in a newspaper or other public media.

  52. Wales “In the Washington Post opinion piece cited above, the author cites multiple studies showing the failure of standard treatments to improve the health of diabetics. That is what I mean by people turning to alternative medicine when expensive “science based” treatments have failed in treating chronic conditions.”

    Wales – Nice article, thanks for the link.

    I don’t think this was intentional, but the paragraph I quoted from you sounds like you are suggesting that standard conventional medical treatment fail to improve the health of diabetics.

    In the article linked the author is discussing some specific “more intensive” treatments for diabetics. The author says.

    “evaluate common, seemingly sensible but unproven strategies to treat blood sugar, lipids and blood pressure in patients with diabetes. In each case the more intensive approach, which used more medication to improve a patient’s risk-factor profile, failed to improve the health of patients. One finding, corroborated by two other trials, confirmed that the strategy of markedly lowering blood pressure was not effective for older patients with long-standing diabetes.”

    In fact one the authors links is a study of the “standard” blood sugar target and the “more intensive” one in which the “standard” offers better results than the more intensive.
    http://content.nejm.org/cgi/content/abstract/358/24/2545?ijkey=aeb1c3e34852a38032678268af78cfa395936d16&keytype2=tf_ipsecsha

    I don’t read the article that the author means to suggest that conventional medicine is failing in treating the chronic condition of diabetes, only that negative studies can sometimes show us that “less is more”.

  53. BillyJoe on solidarity: “I stand by my opinion that your support for SBM stands for nothing if it fails as soon as it is you who have the illness.”

    On another thread you put this as my not being “any better than other people.” Which is exactly my point. Yes, I am firmly behind SBM. No, I am not any better than anyone else.* If I have needs that are not currently being met by SBM, those needs do not disappear.

    My beloved needs to feel that he is not being blown off and that there are things he can do for himself. In an ideal world he would have a great relationship with a great SBM practitioner with all the time in the world, and this person would support him appropriately, using their knowledge of physiology, psychology and medicine to coach him toward appropriate goals. Both of us long for this ideal world. We do not live in it. (Hey, as long as we’re dreaming of ideal worlds, let’s dream of one without abdominal pain.)

    If I need to buy time for my beloved before he’s ready to go back to an SBM practitioner, then I need to buy time. I am left being the person who does not blow him off. I may encourage him to find a different SBM practitioner and next time I’m going with him. Right now he’s burnt out on doctors. In the meantime, while I do not want him flitting from naturopath to chiropractor to acupuncturist, I will be picking through the speculative stuff and selectively promoting it. Yoga, gluten-free and high-NO with a sprinkling of probiotics? Sure, if it’s good for bipolar vegetarian diabetics, why not? (We don’t use fresh milk – just soy milk and dairy cheese – so we’re already pretty much lactose-free.) I particularly like the yoga idea because it involves exercise and getting out and meeting people and would take time to work if it helps at all, which means that even if he doesn’t feel better immediately he can’t just shrug his shoulders and say See, nothing works.

    Another way of putting it: If I don’t root for him, who will? I don’t know what appropriate goals are for him – beyond developing a good relationship with a good SBM doctor – so I’m stuck inventing some so that I can root for him to achieve them.
    _________
    * By which I do NOT mean that SBM is not any better than woo. Of course it is, and woo is scary.

  54. windriven says:

    “I think the biggest concerns are that many of the congressmen that support NCCAM are also the biggest general supporters of the NIH and medical research. I don’t think that pissing them off will necessarily cause them to stop funding the NIH but it’s best not to put them in too defensive a position.”

    This is exactly the thinking that gets us a Congress with an 11% approval rating. NIH is not going to be defunded because those charged with running it insist on scientific rigor. Ducking one’s responsibilities as a scientist and manager breaks faith with the American people who pay for their expertise.

  55. “In an ideal world he would have a great relationship with a great SBM practitioner with all the time in the world, and this person would support him appropriately, using their knowledge of physiology, psychology and medicine to coach him toward appropriate goals. Both of us long for this ideal world. We do not live in it.”

    Ain’t that the truth! In the real world “conventional medicine” does not even necessarily equal SBM. I’m still pushing for a “SBM seal of approval” for doctor’s and hospitals, but no one seems willing to take up my idea.

  56. daedalus2u says:

    Allison, I have another write-up on chronic fatigue. What you describe is something that I think will eventually progress into CFS (if it hasn’t already). That is one of the end states of low NO.

    http://www.chronicfatiguetreatments.com/wordpress/treatments/chronic-fatigue-syndrome-nitric-oxide/

  57. mdcatdad says:

    I tried to read the first link, Naturopathy: A Critical Appraisal, but was taken to a Mescape page that requires a login or registration. Must one register to read it?

  58. urodovic says:

    @mdcatdat

    You can register for free and from there on access all past and future articles,,, no need to be a physician.

  59. wales says:

    Alison, this fascinating article about microbes (gut and otherwise) might be of interest. Good luck. http://www.nytimes.com/2010/07/13/science/13micro.html?pagewanted=all

  60. JMB says:

    @Allison
    Sometimes the fact that placebo effect works gets lost in our discussions of science based medicine. Placebo effect can be powerful, especially for chronic pain. In conventional medicine, there are guidelines for the use of placebo. When you seek an alternative medicine practitioner, just be aware of those guidelines to avoid certain undesirable results. Don’t stop any treatment regimen prescribed by the conventional practitioner. Placebo should be added on top of conventional therapy. Make sure any treating real physician knows the treatment regimen prescribed by the alt med provider. Any alt med treatment that is expensive is a sham. Watch the money you are spending. Many sources of abdominal pain have known delays in diagnosis, sometimes averaging over a year after the first tests are run. Some initial tests that were negative may become positive after the disease has been present for some time. So don’t abandon conventional medicine.

    We hope your beloved will be one of the lucky ones to benefit from the alt med. There is an old saying in SBM; it is better to be lucky, than to be right. But watch for those things that I have mentioned.

    Conventional science based medicine has always incorporated elements of dietary treatments, recommendations on lifestyle changes, and even the placebo effect. Unfortunately the placebo effect we were taught to use is the most difficult to achieve, rapport with the patient.

  61. Regarding Alison’s and BillyJoe’s comments (Sorry off topic to Dr Briggs.)

    We hear a lot of about the science associated with the diagnosis and proposed treatments for disease, but what is the science that supports how a patient is passed along through the medical system through referrals, tests and hopefully follow-up? Has anyone looked at what processes have better outcomes? Who should take responsibility of the “project management” associated with getting treatment? It seems the assumption is that the patient will. But is there science behind that decision?

    I do think “the process” is being thought about in medicine. Recently I heard an interview with Dr. Atul Gawande about his book The Checklist Manefesto: How to Get Things Right. There is also an article on this book here on SBM – http://www.sciencebasedmedicine.org/?s=The+Checklist+Manifesto

    Specific to this blog, I wonder if flaws in the process of patient management* may result in discouraging the patient and turning some toward woo. If that is the case, is it possible to come up with science based corrections to that process.

    *This may be the wrong term.

  62. daedalus2u says:

    JMB, I have written about the connection between nitric oxide physiology and the placebo effect.

    http://daedalus2u.blogspot.com/2007/04/placebo-and-nocebo-effects.html

    Because the placebo effect is largely mediated through the basal NO level, placebos are particularly effective in conditions that are characterized by low nitric oxide.

  63. Michelle B says:

    Yes, Alison, focus on not spending much money on anything alternative. Alternatives can run tests that are very expensive and since their practice is not based on science, there is no reason to take those expensive tests. If the alternative is more interested in psychologically and emotionally supporting her patients and doing basic stress reduction through massage, exercise, counseling, and diet, she will not pursue this if you do not want the recommended tests. If she does she is either focused on making pots of money and/or she really believes in woo. Finding this kind of decent alternative is as difficult as finding a decent practitioner of science-based-medicine!

    There is some scientific basis to probiotics, so I say start with your research regarding probiotics. If your beloved has gas, and not just a bit of gas here and there, but if it is pronounced and routine, even a bigger reason to pursue probiotics. Just do not spend much money on them! There is so much hype regarding available and expensive probiotics in bottles at health food shops. Buyer be aware, please.

    Perhaps if your beloved is treated with support both by you and any alternative practitioner, he will eventually try again with a science-based-practitioner as science-based medicine is not static nor or its practitioners.

    And tell your beloved that the medical doctor who implied that he should be a big boy and just bear the pain is an idiot. Your beloved is probably not imagining that, it is quite common. They really think that they have done their job, and that he is okay. Rather than saying, obviously you are not okay, but I was unable to find anything, perhaps suggest some stress reduction and a later visit, ruling out a self-limiting condition, they trigger such a strong reaction on the part of the patient, and they never learn from their idiocy.

    The good news is that the idiot doctor did not find anything egregious.

  64. “And tell your beloved that the medical doctor who implied that he should be a big boy and just bear the pain is an idiot. Your beloved is probably not imagining that, it is quite common.”

    The more I think about it…what baffles me is the “it’s probably a torn muscle get over it” routine. Even if it was a torn muscle, has this surgeon never met an orthopedic surgeon or physical therapist? Does he think all muscle tears are benign, cause mild discomfort and heal themselves without medical intervention? Why would he suggest a muscle tear without appropriate tests or a referrel?

    Sounds like that unlucky combination clueless and uncharming to me, but I can understand why someone would want to take a break from the medical hamster wheel for a bit.

  65. JMB says:

    @micheleinmichigan
    “Why would he suggest a muscle tear without appropriate tests or a referrel?”

    The most common method for treatment of a muscle tear is athletic training (and far more vigorous training than most people think). The most common method for diagnosis of a muscle tear is based on the history told to you by the patient, and the physical exam. An MRI is not necessary to diagnose a muscle tear. Most muscle tears involve only a part of the muscle, not the complete muscle, so that function is weakened, but movement still functional. It is considered to be cost ineffective if a patient with a partial muscle tear is referred to an orthopedist (other than a competitive athlete or manual laborer with inability to work).

  66. JMB,

    Right, so why doesn’t my beloved know which muscle he tore three years ago, or what vigorous exercise he needs to do? Without that information, “You’ve had your million-dollar workup, it’s probably just a muscle tear, deal with it” sounds like a blow-off, not a diagnosis and disposition. He did have some really fancy scans, and he was there in the office for her to push on and watch for grimaces, so she should have been able to tell him these things.

    Without further explanation of anatomy, to a layman “probably just a muscle tear” doesn’t sound like a plausible explanation for abdominal pain worsening over the past three years and too tender for cuddling for the past two years. So even if it is a muscle tear, he doesn’t believe her.

    If she didn’t know what was wrong beyond that she didn’t need to remove any bits of his anatomy, she could have said that. “Great news! You don’t need surgery! I’ll write a note for your GP and now that you know that you don’t need surgery, the two of you can start figuring out how to manage your pain. It might be IBS, it might even be a muscle tear, and there will be things you can do.”

    And since I wasn’t there, I don’t know what to think except that I know he’s going to “take a break from the medical hamster wheel for a bit” [thanks, micheleinmichigan].

  67. JMB says:

    @Allison

    I don’t mean to indicate that that a muscle tear is the diagnosis based on what you have described, only that when a physician is suspecting a muscle tear, he/she knows that with certain documented exceptions (based on evidence), all the powerful tests we have may not show the muscle tear. Thus, the negative result from the tests, combined with the history of exertion exacerbating the pain, may lead to the conclusion that it is a muscle tear. The muscle involved may be determined by location of tenderness and/or what movement tends to elicit the pain (a physical therapist is often the best one to identify which muscle is affected, and what exercise for treatment, if it is a muscle tear). Scar tissue can also be the source of pain, and is very hard to identify with our tests (unless it causes bowel obstruction). There are other things that may also account for the pain, even though the tests are negative. Any pain can cause nausea, and even vomiting.

    There are many things that cause abdominal pain that are never successfully diagnosed. Medicine is much more limited in its scope of knowledge than most would have you believe. Any test that is administered to a patient may effectively rule out 3 or 4 causes out of a possible 15 to 25 (those numbers will vary widely by the particular problem). For many of the possible causes, there are no tests that can reliably determine the presence or absence of the cause.

    Some have stated that we know more about cancer than about the common cold. Our status of knowledge on chronic pain is about at the same level as the common cold. We know more about cancer largely because of the dollars spent on research. The limitations of our knowledge is part of the reason it is unfortunate to have federal money spent on alternative medicine instead of on those boundaries of SBM for which much more needs to be learned. We know placebo works, why spend money for research on another variation of the sugar pill?

    There are many patients that medicine seems to abandon. Undiagnosed chronic pain is a major healthcare problem. There really is very little medicine can offer other than support. In the case of undiagnosed chronic pain, most specialists will sign off of the case because there is nothing their specialty has to offer. It is assumed then that the primary care physician is the provider of support, and monitor of the condition such that if changes occur, some tests may be repeated.

    The placebo effect is powerful, but it is difficult for a conventional healthcare provider to obtain the full effect in this type of situation, because physician-patient rapport has been broken by the frustration with the failure to diagnose and treat the condition. Alt med providers step in establishing rapport with the patient by denigrating mainstream medicine, and offering hope with an untried treatment. The 15 to 30% who may respond to the placebo effect then buy into it, hence the political support of NCCAM.

    I once had a not so close friend tell me how he went to a chiropractor, who diagnosed his problem by “laying on the hands”, without running a single test, and that impressed him. When he told me the details of the diagnosis, I reviewed his report from an xray test. The xray test had shown near verbatim what his chiropractor told him (chiropractors use different terminology, so there is some translation). The results had been checked out to the chiropractor, so the chiropractor may have simply read the report before or while seeing the patient. Whether it was a strategy to build rapport to imply that they could make the diagnosis without the expensive test, or if the friend had just misunderstood what the chiropractor had told him, I could not know for sure. I was not going to stir up any mistrust in the friend by questioning the order of events, I was going to let him benefit from the full placebo effect.

    I am not implying that everything a chiropractor does is just placebo. Manipulative therapy is very effective at relieving acute musculoskeletal pain, that goes beyond placebo effect, and has certain advantages over bedrest and medication.

  68. Dacks says:

    Allison,
    My husband developed abdominal pain the year that our first child was born, the same year that we began building our house. He was diagnosed with Giardia ( might be worth looking into) and treated.

    The real problems started to unfold when his symptoms continued. A stool sample showed the Giardia gone, yet he could not eat without producing diarrhea. He lost sleep, he lost weight, and things spiraled downhill.

    …(months pass) Finally, as problems mount, we looked for treatment for anxiety. With SSRIs and counseling, he was able to bring some balance back into his life, and the abdominal symptoms faded.

    This is only our anecdotal story, but way back at the beginning the grumpy old GP said “psychosomatic” and we did not want to hear it. So I’m putting it out there for you to consider.

  69. marcus welby says:

    Allison, I would add to what has been posted here on chronic pain. There are other complicating factors for careful MDs. Unfortunately, the legal and disability system has intruded on the world of medicine in sometimes troublesome ways. Physicians are somewhat wary of a straightforward reassuring attitude when they are not absolutely sure, whereas 50 years ago, reassurance and the placebo effect were one of the main methods for treatment possessed by physicians. There are also all sorts of individuals bent on a disability claim or lawsuit or drug-seeking which can add a subconscious conflicting aura to the situation. Caution has been a refuge for many physicians in chronic pain situations. Just to say “it’s complicated”.

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