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Please Don’t Define “Complementary and Alternative Health Practices”!

Since I have a master’s and doctoral degree in health education and since I’m a professor in a department of public health with an undergraduate curriculum that includes substantial attention to health education, I participate in the email discussion group of HEDIR, the Health Education Directory. On August 16th, I received a message to the discussion group from the American Association for Health Education inviting participants to complete an online survey from the Joint Committee on Health Education and Promotion Terminology with results to be analyzed at the Committee’s meeting in September 2011.

The survey items include various terms used by health educators, the currently approved terminology, and three choices followed by a type-in box:

  • This term should remain as defined
  • This term should remain in the report but modified in definition
  • This term is no longer commonly used in health education/health promotion literature

If modify, please provide the suggested wording and reference for that definition if you are citing it from a specific source.

For one of the terms, my preferred response would have be have been a fourth choice that was not offered: The term is commonly used in health education/health promotion and elsewhere, but it should not be used because its use only serves to distort our thought processes and promote quackery.

Here is the term along with the definition presented in the survey:

Complementary and Alternative Health Practices: These practices generally include natural substances, physical manipulations, and self-care modalities. These approaches often incorporate aspects of interventions derived from traditional practices. The approach in Western societies has been to select specific approaches from these systems and apply them to health maintenance, health enhancement, or disease management. Such approaches can be used to compliment[sic] conventional allopathic care (complementary therapy), or as an alternative to conventional approaches (alternative therapy). Many of these complementary and alternative approaches have not been validated through experiential research, but those that have, such as acupuncture for pain, are being integrated into conventional health practices (integrative medicine).

And here are my objections to the term and to the definition given:

“Complementary and alternative health practices” is marketing doublespeak that conceals how promoting (via advertising, publicity, direct selling, word-of-mouth, etc.) non-validated or invalidated practices is unethical. When a practice is science-based, it is simply part of good healthcare or health promotion. “Complementary and alternative” jargon is never necessary to describe validated practices in health promotion or health care delivery. Science-based uses of natural substances, physical manipulations, and self-care modalities are all part of regular medicine.

Science-based natural products medicine is called pharmacognosy. Labels like “complementary and alternative” are used to give the impression of legitimacy, not to pharmacognosy, but to superstitious and often ecologically destructive uses of natural products such as herbalism (particularly paraherbalism), gruesome extractions of bile from living bears, shark cartilage, and rhinoceros horns.

Physical manipulations with a rational basis such as many of those included in personal exercise programs and physical therapy do not require euphemistic labels such as “complementary” or “alternative.” However, the labels “complementary” or “alternative” are often applied to give the appearance of legitimacy to superstition-based or pseudoscience-based physical manipulation treatments such as those used in chiropractic. Many chiropractors falsely claim that the spine requires periodic maintenance “adjustments” of health compromising  “subluxations” that only chiropractors can supposedly detect. Such adjustments don’t complement anything else and they aren’t a viable alternative for health promotion or disease prevention.

Many of the manipulations promoted as “complementary” or “alternative” are actually non-physical; they are rooted in vitalism, which is defined as: “a doctrine that the functions of a living organism are due to a vital principle distinct from physicochemical forces” or “a doctrine that the processes of life are not explicable by the laws of physics and chemistry alone….” Different health cults have different names for the supposed vital principle. In anthroposophy, the names are the divine element in nature, astral body, formative force, or either body. In Ayurvedic medicine, it’s prana. In chiropractic, it’s innate intelligence. In Reichian psychotherapy, it’s orgone energy. In homeopathy, it’s vital energy. In naturopathy, it’s vis medicatrix naturae. In Traditional Chinese Medicine and acupuncture, it’s chi or qi or ki.

The vital principle was popularized in Star Wars as “the force.” But in the real universe, nothing like “the force” is reliably detectable and there are no Jedi-like masters who can manipulate anything akin to it for healing or any other purposes. In the movie Austin Powers: The Spy Who Shagged Me, the vital principle was called mojo. The idea that some people have skills as mojo detectors or mojo manipulators is as absurd as the movie, but “there are some ideas so absurd that only an intellectual could believe them.”

Self-care modalities have been promoted as “complementary” and “alternative,” but what useful distinction is there to be made between supposed “complementary” or “alternative” self-care modalities and those that don’t qualify and are therefore implicitly non-complementary or non-alternative? If the distinction is to be based on validation for safety and efficacy, why introduce euphemistic language like “complementary” or “alternative”? Categories such as validated, non-validated, and invalidated should suffice to give consumers useful information for deciding what modalities of self-care are worth trying out.

It’s true that many tradition-based practices are promoted as “complementary” or “alternative.”  Scholars who attempt to advance “complementary and alternative medicine” often like to emphasize traditional systems of care and ignore other practices marketed as “complementary and alternative.” Since it is often considered rude to be judgmental about traditions associated with particular cultures, fallacious appeals to traditional wisdom are useful in public relations. But numerous practices, products, and services marketed to consumers as “complementary” or “alternative” are promoted as “innovative,” “advanced,” “cutting edge,” “modern,” “scientific,” and the like, not as tradition-based. Examples include such so-called complementary and alternative medicine approaches (sCAMs) as metabolic therapy, chelation therapy, oxygenation treatments, insulin potentiation therapy, clinical ecology, anti-aging medicine, attachment therapy, various other mental health therapies, antineoplastons, cellular therapy, and syncrometers & zappers.

Referring to the selection of specific approaches from traditional systems in Western societies as “complementary” or “alternative” implies an East-West dichotomy that is simply false. Tradition-based systems and supposed whole-system care are not uniquely Eastern. Is it only in Western societies that approaches from traditional systems get used separately from whole-system care?

Medical anthropologists, medical sociologists, educated laypersons, health educators, and even physicians often make the mistake of describing standard medical practices of today and recent decades as “conventional allopathic care.” Allopathy is a term coined by Samuel Hahnemann (formulator of homeopathic treatment principles) as a label for medical practices of his day that were based upon ancient Greek humoral theory of disease such as bleeding and purging and blistering to manipulate the four so-called body humors: blood, phlegm, black bile, and yellow bile. As medicine became more science-based, it discarded treatment based upon the convention of manipulating body humors and progressed by developing healthcare consistent with progress in biological and physical sciences. Nevertheless, approaches to healthcare based upon humoral theory—what Hahnemann called allopathy—persist today in parts of India, Pakistan and elsewhere as Unani medicine, which, ironically, the World Health Organization recognizes as a type of “CAM.” Unani is an Arabic adjective meaning Greek.

Since modern medicine makes progress by relying on science, it is iconoclastic—the antithesis of conventional. By contrast, the real allopathy practiced today as Unani medicine is bound to its ancient conventions. Like much of what gets promoted as “complementary” and “alternative,” Unani medicine reflects conventional wisdom of healing traditions rather than the rigor of scientific testing and the iconoclasm of scientific discovery.

I have previously explained that calling an approach to healthcare “complementary” implies that it adds to the outcome when combined with some other treatment and that calling an approach to healthcare “alternative” implies that it can be successfully used in lieu of some other approach. However, this is misleading labeling. Simply calling an approach “complementary” doesn’t mean it actually complements anything else and calling an approach “alternative” doesn’t make it a viable alternative. The jargon “complementary and alternative” serves to distract attention away from questions of utility based upon scientific merit.

Professor Richard Dawkins has explained: “Either it is true that a medicine works or it isn’t. It cannot be false in the ordinary sense but true in some ‘alternative’ sense.”

Drs. John E. Dodes and Marvin Schissel put it this way: “Erythromycin is an alternative to penicillin, but a pogo stick is not an alternative to an automobile.”

Drs. Marcia Angell and Jerome Kassirer wrote: “There cannot be two kinds of medicine—conventional and alternative. There is only medicine that has been adequately tested and medicine that has not, medicine that works and medicine that may or may not work.”

Dr. George Lundberg explains it this way:

There is no “alternative medicine.” There is only medicine:

  • Medicine that has been tested and found to be safe and effective. Use it; pay for it.
  • And, medicine that has been tested and found to be unsafe or ineffective. Don’t use it; don’t pay for it.
  • And, medicine for which there is some plausible reason to believe that it might be safe and effective. Test it and then place it into one of the other two categories.

Although many people believe that acupuncture for pain is medicine that fits Dr. Lundberg’s first category,  the weight of evidence places it in the second category, especially considering the lack of a plausible rationale for acupuncture as a therapy. Few, if any, health practices that have been promoted as “complementary” and “alternative” also belong in Dr. Lundberg’s first category. More than ten years of research funding by the National Center for Complementary and Alternative Medicine has failed to contribute to medical progress.

The term integrative medicine is superfluous and should not be used by responsible health professionals. Palliative care and adjunctive care are meaningful and useful terms for efforts to provide rational modalities of humane care, comfort, and support addressing the diverse needs of patients. The term “integrative medicine” adds nothing to describe approaches strongly supported by scientific evidence, but serves as an income-generating mechanism for attracting patients to seemingly special modalities that typically lack support beyond cherry-picked evidence or tradition. The term “integrative medicine” is not needed to offer science-based psychological approaches for managing health problems, but it does help in marketing when you are offering modalities based on vitalism. “Integrative medicine” represents branding, not a meaningful medical specialty. It projects a misleading image of academic seriousness that serves only to obscure its hype and help secure funding for clinical research of dubious need.

Terms such as “alternative,” “complementary,” and “integrative” have become popular euphemisms for non-validated and invalidated approaches to health enhancement—especially approaches with farfetched rationales. The use of such euphemisms facilitates quackery: the promotion of health products, services, or practices of questionable safety, effectiveness, or validity for an intended purpose. Today quackery is a far less popular term than the euphemisms. In some circles, it is politically incorrect to refer to quackery. But if we cannot refer to quackery as quackery, we can expect it to persist as a neglected public health scandal. I suggest that there are better alternatives to using currently popular euphemisms of alt-speak.


William M. London is a professor in the Honors College and in the Department of Public Health in the College of Health and Human Services at California State University, Los Angeles. He co-authored the sixth, seventh, eighth, and ninth (in press) editions of the college textbook Consumer Health: A Guide to Intelligent Decisions. Since 2002, he has been associate editor of the free weekly e-newsletter Consumer Health Digest. Since 2005, he has been co-host of the Credential Watch web site. He tweets as @healthgadfly.

Posted in: Medical Academia

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51 thoughts on “Please Don’t Define “Complementary and Alternative Health Practices”!

  1. ConspicuousCarl says:

    “Complementary”, “alternative”, “integrative”, and other such words are the street drugs of medical language. They have no legitimate application and they have an abnormally high potential for abuse. They don’t need to be banned, but it is not appropriate to use or promote them in a professional setting.

  2. DBonez5150 says:

    Wow, what a fantastic piece! Thank you Dr. London. Sadly, I fear people who utilize the terms “complementary”, “alternative”, or “integrative”, either incidentally or actively, will not read your entire piece, or at least won’t respect (comprehend?) its message. It’s too bad. It should be required reading at all NIH / NCCAM hearings!

  3. pmoran says:

    I agree about the “word wars”, but labelling a field with such a complex mixture of causes, motivations and human behaviours with a loaded term like “quackery” could also be seen as seeking leverage from the use of language.

    The other worry is that CAM (such a handy abbreviation!) began to flourish during a period when this was standard practice. In fact, 200 years of calling homeopathy “quackery” have achieved what, precisely? So I see no clear basis for your But if we cannot refer to quackery as quackery, we can expect it to persist as a neglected public health scandal.

    I much prefer the term “alternative”, always in quotation marks so as to emphasize that these methods are not truly alternative to intrinsically active treatments when suitable ones are available.

  4. nybgrus says:

    does that mean I have to make air quotes every time I speak to someone about “alternative” medicine?

    I think quakery is a fine term. Though I agree it is loaded with emotional bias, so perhaps another word would be more suitable?

    Charlatanism, perhaps?

    I also think your questions is poorly framed. What did 200 years of calling homeopathy quackery accomplish? It kept it very fringe. What has 2 -3 decades of calling it CAM accomplished? Made it very en vogue and spawned Boiron.

  5. William M. London says:

    pmoran,

    I did not apply the label quackery to a “field” called “CAM.” I argued that the use of the term CAM sends the false message that it represents a meaningful field of health care. The first sentence in your reply [...but labelling a field with such a complex mixture of causes, motivations and human behaviours....] reinforces that false message.

    I argued also that products, services, and practices promoted as “complementary” and “alternative” tend not to complement science-based health care and tend not be viable alternatives. Referring to nostrums with euphemisms is a major feature of the semantics of quackery. The term quackery has a long history of use to refer to a persistent social pathology. All promotional activities of health products, services, or practices of questionable safety, effectiveness, or validity for an intended purpose are quackery. The label does not depend on whether terms such as alternative and complementary are used to label the products, services, or practices. The particular euphemisms change over time, but euphemistic semantics persist.

    Not all quackery involves use of “complementary” or “alternative” and not all uses of “complementary” or “alternative” involve quackery. But in recent decades, there has been considerable overlap.

    You asked: “In fact, 200 years of calling homeopathy “quackery” have achieved what, precisely?”

    Answer: You seem not to recognize how marginalized homeopathy became when it was still politically correct to refer to the promotion of such nonsense as quackery. Homeopathy has had a considerable revival coinciding with the growing popularity of euphemisms such as complementary and alternative. Homeopathy used to be regarded as quackery and the US Food and Drug Administration (FDA) used to discuss the term quackery in its consumer education efforts.

    In 1985, FDA took a firm stand against homeopathy. See http://www.homeowatch.org/history/fdac1.html But now that another agency within the US Department of Health and Human Services has Complementary and Alternative Medicine as part of its name, FDA no longer publishes anything with conclusions such as: “While the practice of homeopathy enjoys a long history in America, the public has a right to be protected from unsafe or ineffective drugs of any kind marketed in this country.”

    I’m not arguing that calling homeopathy quackery is sufficient to marginalize it. But if you want people to recognize the promotion of homeopathy and other nostrums seriously as a social and public health scandal, it helps to use clear, carefully defined, accurately descriptive language and to reject the preferred semantics of quacks, their disciples, and their apologists.

  6. weing says:

    Excellent post. This should be mandatory reading for all medical school deans, hospital heads, and health boards. We need to purge this nonsense from medicine.

  7. pmoran says:

    Answer: You seem not to recognize how marginalized homeopathy became when it was still politically correct to refer to the promotion of such nonsense as quackery

    I have lived through the relevant era. You refer to Dr Barrett’s research which shows that there was a resurgence of use of homeopathy in the US in the 1970s. I am sure that, as in Australia, there was no hint of any change in the attitude of the mainstream towards “quackery” in the US at that time. Far from there being any relaxation of mainstream attitudes over that period, you describe how the FDA saw fit to pronounce strongly against homeopathy in 1985. What, also, did that achieve?

    There are obviously other powerful forces afoot. We should try to understand them if we are not to inadvertently reinforce perceptions that tend to foster risky “alternative” medicine use in the susceptible. I know all the considerations that go into calling something “quackery” but we cannot expect that of many members of the public.

    The science is also not yet clear as to what subjective value “alternative” medicine use may be users in its most common context i.e. where mainstream measures are also used but are proving inadequate — via placebo responses, other non-specific influences and the satisfaction of other human needs and compulsions.

    What we want is to reduce the use of dangerous forms of “AM” and the risking of lives upon it when there are effective mainstream methods.

  8. weing says:

    The early 1970s was the era of the “Flower Children”, peace, love, drugs and drug-addled minds that found magical thinking acceptable. That may have something to do with the acceptance of nonsense as sense. Just look at the example of Steve Jobs. We need to categorically state that CAM is magic and has nothing to do with medicine and expunge from our midst. The placebo effect will still be there in real medicine as it always has. CAM is trying to pass off the smell and sizzle as the steak. Medicine has the steak, the sizzle and smell are still there.

  9. RichieS says:

    This is the definition I wrote for CAM ten years ago:

    Complementary and Alternative Medicine are the use of unproven methods and substances to diagnose and treat disease by persons who are unqualified to diagnose and treat disease.

  10. pmoran says:

    Weing: The early 1970s was the era of the “Flower Children”, peace, love, drugs and drug-addled minds that found magical thinking acceptable. That may have something to do with the acceptance of nonsense as sense. Just look at the example of Steve Jobs. We need to categorically state that CAM is magic and has nothing to do with medicine and expunge from our midst.

    Best of British luck with that.

    We as a species have had hundreds of thousands of years to learn how to respond to “pretend medicine”. It was the fall-back option when few effective medicines were available. Scientific medicine is gradually trying to supplant this all- pervasive, generic form of medicine, rather than resisting any likely serious incursions from it, as we sceptics like to assume in our more paranoid moments.

    As evidence for a society still pervaded with adult make-believe I tender the popularity of vampire, wizard and superhero movies, that most people believe in other supernatural beings and forces, and that we get violently passionate about sporting events that have no meaning outside of our own minds.

    Yet we expect the public to kow-tow to EBM-level rationality in relation to medicine! Come on! It just won’t happen. Sure there is fraud, and commercial exploitation and we have the right to expose that.

    But there is also much unmet medical need, the pull of the personal testimonial, the preparedness to try anything when desperate, and, of course, the seductive voice of the Internet.

    Let’s set realistic goals and try and work out how best to achieve them.

  11. nybgrus says:

    Scientific medicine is gradually trying to supplant this all- pervasive, generic form of medicine, rather than resisting any likely serious incursions from it, as we sceptics like to assume in our more paranoid moments.

    One of the few reasonable and rational points I’ve seen you make. So, how does one go about supplanting magical medicine with real medicine, if our stance is that some magical medicine is OK?

    As evidence for a society still pervaded with adult make-believe I tender the popularity of vampire, wizard and superhero movies,

    I absolutely love said movies. So does my partner. What are you trying to say?

    Yet we expect the public to kow-tow to EBM-level rationality in relation to medicine!

    No…. we expect them to realize that magical medicine is not valid or worthwhile. You always seem to think that we are adovocating teaching everyone on the planet physician level critical understanding of EBM. You also always seem to think that people are so stupid as to never be able to learn any level of critical thinking, including the minimal amount necessary to make such a distinction between magic and real medicine.

    But there is also much unmet medical need, the pull of the personal testimonial, the preparedness to try anything when desperate, and, of course, the seductive voice of the Internet.

    I always considering myself to be extremely cynical until I started reading your posts. I do believe the vast majority of people on earth are pretty stupid (most of them concentrated in the US – particularly the ones wishing to be willfully stupid). But with the right message and a firm stance, most people are amenable to reason. Part of that is making sure magic doesn’t get codified into law (because as we have seen, people think law = evidence of efficacy and safety). Part of it is to call magic what it is (oh no, I don’t use quackery… I use CAM and that’s OK because it is a great “alternative” to…). And part of it is to do everything we can to make sure that we ourselves don’t endorse CAM and magical thinking (no, reiki is legitimate! After all, the Memorial Sloan Kettering Cancer Center teaches it and offers it to patients.)

    Let’s set realistic goals and try and work out how best to achieve them.

    What’s the realistic goal then? Besides allowing for our profession to be OK with methods we know to be nothing but placebo and expectancy effects but we feel are “okay” (how do we define that BTW?) and sending patients over that way to meet that deep need you see us as incapable of meeting, you have outlined very little of what a “realistic goal” might be. You have only managed to advocate that we be wishy washy and turn a blind eye (or even refer!) to the less detrimental of the woos. But you cannot consistently define what those are and you ignore the very real dangers and problems with that (besides the ethics) that have been raised here repeatedly.

    So what are your realistic goals?

  12. pmoran says:

    Nybgrus, many orthodox sceptical stances including Weing’s desire that CAM should be “expunged from our midst” are so at odds with some realities of the “alternative” medical scene that I fear they do as much harm to our cause (whatever that is) as good, exciting paranoia, potentially eroding public trust, and seeming to lack compassion for the human misery and the foibles of the human condition that are amongst the main drivers of the CAM phenomenon.

    Stop any man in the street and he will understand that some people can think themselves into feeling better with imaginary treatments. Why on earth would we, against much of our own scientific evidence, want to regard the ability to that as somehow unworthy — an undesirable, disposable aspect of human nature, even when we have little to offer ourselves? “It might mask important illness” is weaseling, when most users will already have subjected themselves to mainstream diagnosis. Wanting to reserve those influences for ourselves is uncomfortably close to turf-protection.

    Most men in the street will already understand that CAM is a somewhat different category of medicine to that which the mainstream aspires to, while reserving the right to be able to try it out with minimal true intellectual commitment when there are no other options.

    He/she will find it utterly incomprehensible that we should wish to deny them that right when almost daily we are exposed as having gotten yet another bit of health advice wrong, and ourselves as not entirely immune to corrupting influences either. (Sceptics will deny that they want that, too, even as other aspects to common sceptical parlance require no other logical conclusion.)

    I suspect that the true frauds and quacks are delighted at every manifestation of the urge to suppress and “oppress”. Look at how they leap to exploit it at every opportunity: “what are they afraid of (if our methods are not better)?”.

    So one theme that we could look at is the possibly more mature, practical, well-informed, sensible, rational, science-based one of showing that we don’t have anything to fear other than that patients may come to real harm from relying upon dangerous or dubious treatments, via the approach I have suggested many times: ” these methods may help people feel better but they cannot be relied upon in the treatment of serious illnesses”. The public already understands about placebo influences. They already understand that CAM is carried on at a lesser level of scientific certainty. Why not treat them as adults and try to build on understandings that are already there?

    Another theme through this is that it has almost nothing to do with science in the normal sense. It has more to do with where people are prepared to invest their trust. Our task is, then, to inspire trust. I believe we may be able to do better, without sacrificing scientific rigour. In fact it is the evolution of the science of non-specific reactions to medical interactions that has made me rethink my own opinions on certain matters.

  13. nybgrus says:

    pmoran:

    many orthodox sceptical stances including Weing’s desire that CAM should be “expunged from our midst” are so at odds with some realities of the “alternative” medical scene that I fear they do as much harm to our cause

    That should be the goal – the aspiration. To rid the world of magical and fanciful thinking of all kinds. To educate people enough to have them realize it is simply not a valid form of thought and that the progress and comforts of society we revel in today are a factor of rigorous critical thinking. That can never be at odds with “our cause.”

    Stop any man in the street and he will understand that some people can think themselves into feeling better with imaginary treatments.

    Stop any man on the street some 160 years ago and he would have understood that miasms were the basis of disease and treating that would help some people. That’s not an argument for maintaining the poor understanding of medical care that can be supplanted by wishful thinking there there is “more” out there somewhere.

    You seem to think that if we tell people there is no santa claus they will be terminally depressed. “What… what do you mean acupuncture is just placebo BS? How can I go on living?” I disagree. By educating people with realistic understandings of how the world works it actually empowers them.

    Why on earth would we, against much of our own scientific evidence, want to regard the ability to that as somehow unworthy — an undesirable, disposable aspect of human nature, even when we have little to offer ourselves?

    You overblow and misconstrue the placebo effect. That has been clear from our extensive discussions on the matter. You also seem to believe that it is effective and valid as a standalone therapy – it is not, for more reasons than just the ethics involved.

    You also seem to consistently think that, for some unknown reason, only sCAMsters can adequately deliver placebo benefits to patients. I don’t think I will ever understand why you insist on that.

    Wanting to reserve those influences for ourselves is uncomfortably close to turf-protection.

    Turf protection? Now you are sounding like an apologist. No – we can and should augment our own practice with the known principles of placebo effects. But they are unequivocally harmful on multiple levels (to varying degrees, but always harmful) when used as standalone therapy. Especially when couched in magical thinking ritual.

    He/she will find it utterly incomprehensible that we should wish to deny them that right when almost daily we are exposed as having gotten yet another bit of health advice wrong, and ourselves as not entirely immune to corrupting influences either.

    And yet again, you utterly miss the point. Nobody wishes to deny anyone access to CAM or anything else. I don’t even want to make cigarettes illegal and yet I think you would agree with me that there is not one single redeeming facet to smoking. What our goal is (our “cause” if you will) is to make people not want the CAM. You keep arguing that people know CAM is BS and they still want to use it because it fills some need that we as physicians can’t. Yes, there are those people but they are the vast minority. Most people use CAM because they view it as having some level of legitimacy. Why would it be on pharmacy shelves if it weren’t efficacious? Why would it be advertised on TV if it didn’t really work? Why would it be offered at the MSKCC if it were quackery? Why would it be called “complimentary and alternative medicine” if it wasn’t medicine?

    The point is not to legislate it away. It is to clearly identify it as quackery, to prevent it from legislating itself to legitimacy, and to protect the consumer (i.e patient) from the scams that they are. When consume reports pans a product, they don’t want it forbidden – they want people educated so it can be avoided. It is as simple as that.

    Part of that is refusing to call it CAM – when a DOCTOR calls something MEDICINE it means something. Especially if that MEDICINE is being used in regular hospitals and taught as “integrative medicine.”

    I suspect that the true frauds and quacks are delighted at every manifestation of the urge to suppress and “oppress”. Look at how they leap to exploit it at every opportunity: “what are they afraid of (if our methods are not better)?”.

    You are absolutely right. There is a Streisand Effect in play, undoubtedly. But in the past, it was ignored and the physicians in their ivory towers just scoffed and thought nothing of this quackery. We have been shown that ignoring it allows it to grow and gain political momentum. That is plainly evident in the way the nomenclature for these practices has changed. Do you really think it started out as, “What are they afraid of?” No… it started out as “They are provincial and closed-minded and won’t look at this awesome woo.” Then we looked and said it doesn’t work and now they change they rhetoric.

    ” these methods may help people feel better but they cannot be relied upon in the treatment of serious illnesses”.

    I fully agree with you on an individual level – that is what I would tell my patients and what I tell acquantainces who ask. But it does not fly on a professional level.

    The public already understands about placebo influences.

    Hardly. I would argue that you don’t really understand placebo effects (not to say that I do either – but certainly more than your average lay person). People in general think of placebo as this awesomely amazing “mind over body” phenomenon. Hence “The Secret” and Deepak Chopra.

    They already understand that CAM is carried on at a lesser level of scientific certainty.

    No they don’t! They think that it has legitimacy and is gaining more. They like “other ways of knowing.” To them bickering and debate means there must be something to both sides. The way to win a public debate is not by being right and having the evidence – it is by being clear and confident. Look at any political or religious debate. The “winner” is whomever stated whatever stance they had with the utmost certainty. Science doesn’t afford us that since it makes us more humble – but that humbleness which you demand we employ is exactly our undoing. The sCAMsters are not humble nor uncertain. They know. The only recourse is to be firm in what is quackery and call it as such. The minutiae of it can be explained on an individual level, but on a public level and as a professional stance it is fair and reasonable to round that error and state that CAM is quackery of no value.

    Otherwise we should have advertisements that say, “Smoking is really bad for you. Except that for some people it will help protect them against ulcerative colitis and endometriosis. And really, the absolute risk for an individual smoker getting lung cancer is pretty small, but the aggregate effects are pretty big and even though you feel better when you smoke, you really shouldn’t.”

    That is technically what the science strictly says. Why don’t you demand we hold to that level of technical detail when it comes to smoking cessation programs?

    Our task is, then, to inspire trust. I believe we may be able to do better, without sacrificing scientific rigour.

    I agree. And people trust those who are confident. Our methods work and we have the evidence. Their methods do not work… and we also have the evidence for that. End of story.

  14. I feel as though the author and I are using the same vocabulary, but with a very different understanding of the meaning of the individual words. It makes me sad, but I suspect that the authors defining of many of those words is skewed in order to make his point.

    For instance, when speaking of the term conventional allopathic medicine you state you refute the description of conventional in this way.

    “Since modern medicine makes progress by relying on science, it is iconoclastic—the antithesis of conventional. By contrast, the real allopathy practiced today as Unani medicine is bound to its ancient conventions. Like much of what gets promoted as “complementary” and “alternative,” Unani medicine reflects conventional wisdom of healing traditions rather than the rigor of scientific testing and the iconoclasm of

    Let’s look up conventional in the dictionary. ”

    Main Entry: conventional  [kuhn-ven-shuh-nl]
    Part of Speech: adjective
    Definition: common, normal
    Synonyms: accepted, accustomed, button-down, commonplace, correct, current, customary, decorous, everyday, expected, fashionable, formal, general, habitual, in established usage, ordinary, orthodox, plain, popular, predominant, prevailing, prevalent, proper, regular, ritual, routine, square, standard, stereotyped, straight, traditional, tralatitious, typical, usual, well-known, wonted
    Antonyms: abnormal, exotic, foreign, irregular, strange, uncommon, unconventional, uncustomary, unusuale

    There is nothing to suggest that conventional is anti-science or progress, conventional in the context of medicine means the most established usage.

    Also, I’d like to point out that there is probably a reason that we often use words like “reasonable”, “good”, “bad”, etc the describe the word “alternative”, because the word “alternative” does not necessarily imply a good alternative.

    There are other areas that have the same problems, for me, but I’m not going to cover them all. I’ll just say that I would wish for a more skeptically eye in the editorial process.

  15. pmoran” They already understand that CAM is carried on at a lesser level of scientific certainty. Why not treat them as adults and try to build on understandings that are already there?
    Another theme through this is that it has almost nothing to do with science in the normal sense. It has more to do with where people are prepared to invest their trust. Our task is, then, to inspire trust. I believe we may be able to do better, without sacrificing scientific rigour. In fact it is the evolution of the science of non-specific reactions to medical interactions that has made me rethink my own opinions on certain matters.”

    I’m sorry to butt in on your discussion, but I feel compelled to offer some agreement. I find the emphasis of some poster here on banning CAM or punishing those patients who use CAM treatments by with holding standard care, disconcerting. The assumption that the public shouldn’t be exposed to even the option of making a decision that is not supported by conventional medicine comes across as highly paternalistic. And even parents know that in order to learn, one must be allowed to make mistakes.

    As to trust, relying upon doctors to point out the problems with alternative practitioners puts the doctors in the poor position of being similar to the window salesmen we’ve had around recently. They all bash each other’s products and service and you end up not trusting any of them.

    This is one reason that I’d like to see a patient advocate on SBM. One who approaches both SBM and CAM with a critical eye toward the patients needs.

  16. Scott says:

    I find the emphasis of some poster here on banning CAM or punishing those patients who use CAM treatments by with holding standard care, disconcerting.

    Did you have particular examples in mind? I don’t recall seeing such positions held on any regular basis here. The closest thing I can think of as a popular position is banning unsubstantiated claims about CAM efficacy.

  17. Of the top of my head…

    As least twice (that I have read), Windriven has suggested that patients who suspend conventional treatment to engage in alternative treatments should be banned from receiving conventional treatment later in the course of the disease on the grounds that treating diseases that may have progressed further must be more expensive.

    Also the article The Cure “One possible solution is that states stop further licensing of “CAM” providers. (snip)

    A second, simpler solution presents itself in the form of curtailing the use of implausible and unproven practices via legislation without directly repealing the “CAM” provider practice acts. The basic premise is that scientifically plausible health care practices can be used unless and until they are shown not to work. Implausible practices, however, must meet a higher standard. In other words, it is in essence “extraordinary claims require extraordinary evidence” fashioned into health care consumer protection law.”

    Curtailing the use of – through legislation, sounds a lot like banning the actual practice of rather than banning unsubstantiated claims. I don’t believe I read the whole comment thread, but I don’t recall anyone saying we shouldn’t ban the use of – the discussion was more directed toward feasibility of banning.

  18. @ Scott. As an aside, it doesn’t really matter if those positions are expressed on a regular basis or are representative of the SBM blog, editors, all writers, etc. My post was not a general indictment of SBM. It was an observation that I find those particular views disconcerting, along with the reasons why.

    nybrgus “The way to win a public debate is not by being right and having the evidence – it is by being clear and confident. Look at any political or religious debate. The “winner” is whomever stated whatever stance they had with the utmost certainty. Science doesn’t afford us that since it makes us more humble – but that humbleness which you demand we employ is exactly our undoing. The sCAMsters are not humble nor uncertain.” etc, to completion.

    This brought to mind that proverb. ‘Choose your enemy well for they are the one you will become.’
    Be careful.

  19. William M. London says:

    micheleinmichigan,

    A fair criticism of many practices within contemporary medicine is that they are too conventional: they rely too much on convention and not enough on scientific evidence. Unfortunately, much of medicine is based on tradition, orthodoxy, and convention. Sciencebasemedicine.org does a terrific job advocating for more science in medicine and not just what people label as complementary or alternative.

    But labeling medicine as a whole to be: conventional medicine, traditional medicine, orthodox medicine, etc.–the way alternativists (people who are devoted to the notion that “alternative medicine” is an actual field of medicine) do–is unfair, since standards of practice in medicine evolve based on scientific progress, technological progress, and clinical research. Overall, contemporary medicine really is better today than it used to be.

    The label “conventional medicine” misleadingly implies that what is done throughout the mainstream of medical practice is simply a matter of convention. Quacks often like to denigrate physicians by characterizing them as people who only do what they’ve been indoctrinated to do. Labeling medicine as “conventional” is one way they do this. They don’t tend to use terms like regular or modern to label mainstream practices because such terms don’t connote that physicians are stuck in the past. Use of the term “conventional” conveys that misleading message.

    It’s important to reject the preferred semantics of quacks in order to accurately characterize issues in the health care marketplace.

  20. William M. London, from a patients’s perspective, that’s me, conventional medicine is synonym with mainstream medicine. That is the most commonly used form of medicine, which is a mixture of science, convention, artistry, or ineptitude, depending upon the particular doctor or office you visit.

    Of course conventional medicine has progressed. If I say that my car has a conventional fuel engine. It does not mean that I am driving a model T. If I say my children attend a conventional school, it does not mean they are practicing their letters and arithmetic on a slate.

    Certainly it is important not to let your opponent’s language define you.

    But it’s also important not to let your opposition define you.

    Recently, I have been asking myself, is SBM becoming defined soully as an opposition to CAM. Is it about playing squirrelly words to oppose CAM for hours on ends,

    I guess I thought it could be about something else. I thought it could be about improving medicine.

  21. Scott says:

    So you have one example, windriven. You’ll note that The Cure article said (paraphrasing) “we could stop licensing, but that’s not really the best approach” so you’re mischaracterizing that. Hardly enough to justify the firmness of your original comment.

  22. Scott “So you have one example, windriven. You’ll note that The Cure article said (paraphrasing) “we could stop licensing, but that’s not really the best approach” so you’re mischaracterizing that. Hardly enough to justify the firmness of your original comment.”

    I read that to mean the best legal approach. But it’s fine if you disagree with me. I am giving my reading of the positions and telling folks how that makes me feel as a patient and parent to patients.

    I am saying those positions disconcert me, they make me feel as if someone has decided that they should protect me from making a poor choice and that feels paternalistic.

    I shared this in the hope of informing folks how the average patient may (or may not, I’m an individual, not the Borg) react to such positions. Hoping that it would provide proponents of good medicine some insight into the patient’s emotional reactions to the more stringent forms of CAM opposition.

    It’s IMO, If my firmness exceeded that, then my apologies.

  23. nybgrus says:

    @michele:

    The part of the quote you took makes it sound like I am advocating that we, in opposing CAM, focus on delivery and not content. I’m not sure if that is what you got from it, but I can assure you that was not the intent.

    We have the content. We need to work on our delivery. The point I was trying to make is that we need to accept rounding errors to make a message strong. The example I gave was anti-smoking laws and public health messages. Have you ever seen a public health message about smoking that was anything but negative? Of course not – they are firm and they are clear. However, the actual data do demonstrate that smoking has actual positive protective effects for at least two diseases – ones that are rather common and certainly affect quality of life. Also the individual risk from smoking in terms of lung cancer, heart attack, stroke, etc is actually very low. And people do make the argument “Well, my dad smoked for 50 years and never had lung cancer or heart problems. And so did my uncle.” Do we foible on the science there? Do we say, “Well, you’re right – the individual risk is actually very low, especially if you only smoke in your young adulthood and quit.” No – we push a solid, firm, message because the data tells us that overall, it is vastly better not to be a smoker than the be one.

    All I am advocating for in that above quote is the same sort of stance when it comes to CAM. Don’t foible over the minutiae of small effect sizes and placebo responses. Don’t give the “Well, maybe it will work for someone” attitude (which in the smoking example would be like saying “Well, you probably won’t get cancer if you smoke.”). Just be firm in stating the evidence – it doesn’t work very effectively, it is a waste of money, and it exposes people to additional risk which is not acceptable given the level of effect. And say it confidently and firmly.

    As for Jan’s legislative ideas – I think you miss the point here. No one is advocating legislation against CAM practitioners. The advocacy is to prevent unfounded and unearned legislation in favor of CAM practitioners. Since they are finding ways to get legislative approval to practice their ineffective “medicine” (which the public at large then views as a status of legitimacy) Jan is proposing putting legislation in place to prevent such false legitimization. If there were a way to include a clause that would affect medical doctors (like say, punishing those who prescribe antibiotics for viral illness) I would be for that as well. The idea is to have a completely level playing field where evidence is king, regardless of who is asking for the legislative legitimacy.

    And as for windriven – yes, he is much more harsh than even I am. But I believe that is in large part due to his brevity. You state that he made an assertion that patients who used CAM should be denied efficacious (how about using that instead of conventional for the time being?) medicine later on. That is actually a broader issue within medicine and the delivery of care – I actually had a class on exactly that topic. It is the concept of self induced disease. Do we penalize people who need medical treatment for knowingly harming their bodies? The class was in the context of smoking and alcoholism, primarily, but the overarching theme is the same. Personally I disagree with windriven, as do most people I know. But it is a valid question to raise when the resources for medical care are allocated publicly, if only for an academic discussion.

    As for the term conventional – I am not 100% sold on London’s ideas regarding it. However, I lean towards accepting it for the same reason I cringe when people refer to me as being trained in an “allopathic” medical school. Also, in my med anthro degree “conventional medicine” was a pejorative, often said with disdain. It was synonymous with “closed minded” and parroting an ideology. Perhaps you and the majority of patients don’t view it that way, but I can attest that med anthros and CAM apologists are using it in that way. It allows them to set up the false dichotomy that we here at SBM talk about so oftenly. Changing the term to “modern” or “efficacious” medicine is a branding tactic exactly like what CAM does to gain false legitimacy. The difference is that our tactic would be backed by evidence and reason and be a valid legitimacy.

    At least, that is how I see it.

  24. nybgrus says:

    @michele:

    I am saying those positions disconcert me, they make me feel as if someone has decided that they should protect me from making a poor choice and that feels paternalistic.

    I guess I am confused. Seatbelt laws, crash test ratings, and consumer reports all ensure consumer safety and prevent you from making certain poor choices like being able to buy a car that will disintegrate and blow up in a slow speed crash (Pinto anyone?) or buying a car that is overpriced for what you get. Are those notions overly paternalistic as well?

    Of course the car is just one easy example that came to mind, I am sure I can come up with many others, but I think you get my point.

  25. nybgrus, I didn’t even get to read or answer your first comment yet…And it’s halloween.

    It is my understanding that automobile accidents actual kill and disable a good number of people. In order to save many lives we often tolerate some paternalism.

    I asked this in the comments of The Cure article. Does anyone have the number of people killed, injured or disabled by CAM? How about the cost of CAM treatments to taxpayers.

    I suspect the numbers are much lower than car accidents. Are we going to legislate every safety hazard with an equal fatality, injury, disability rate to CAM…cause I suspect the rock climbers, skiers and horseback riders are going to be pissed.

    Consumer reports are not relevant. I don’t recall criticizing anyone for reporting. I did say it puts doctors in a bad position to be responsible for criticizing CAM. If Honda put out reviews of GM, it would hardly carry the weight that an decent consumer magazine would…Even if Honda was entirely correct in their criticism.

    I’ll try to get to your previous email tomorrow. But, in summary pmoran was suggesting what most men on the street feel/think. As a man (okay woman) on the street, I was saying, yeah, I pretty much agree with his summary in terms of my feelings. I am also saying that as a man on the street, I find any emphasis on laws as (opposed to education) by mainstream medical folks (or folks who make their living from mainstream medicine) to undermine rather than encourage my trust. I am not saying that undermining of trust is insurmountable, but if I was a doctor and I was going to put the argument concerning laws or punitive care options forward to mr or mrs manonthestreet, I’d have to be extremely, extremely, careful,* it doesn’t play as well on the street as it does on the SBM blog.

    *For instance I might find out how much CAM is actually harming people and get a sense of the what those risks are to the public compared to other risks, such as car accidents, drug use, poverty, lack of insurance, trampolines, dogs, bullies, guns, mosquitoes, education cuts, air, water and soil pollution, smoking, potholes, etc.

  26. William M. London says:

    micheleinmicigan,

    This seems to be your core point above:

    “There is nothing to suggest that conventional is anti-science or progress, conventional in the context of medicine means the most established usage.”

    I think it is true that people often use the word conventional with that intent. But I think you are ignoring common connotations of the word. What if I were to call you a conventional thinker? (I’m not calling you this. I would not call you this. I am presenting this scenario to you–and anyone else who might read this–in personal terms because I think doing so might make my point clearer.)

    Would you consider it a compliment to be called a conventional thinker? For example, would you think it simply means that you possess the best available wisdom?

    Maybe you would not go so far as to infer that you were receiving a compliment. Could you see the label as just a neutral description (as you characterized the notion of conventional medicine)? Could you see it as just a suggestion that your thoughts are similar to the thoughts of others? I would be surprised if your answer was yes.

    I think you would recognize that calling someone a conventional thinker is typically a put-down. It’s a way of suggesting that someone is not cutting-edge, innovative, original, progressive, trail-blazing, iconoclastic, open-minded, etc., etc. If you want to insult an artist, call her work conventional. It’s also insulting to health professionals. How often do you see practitioners brand themselves as conventional? How about this kind of self-branding: Al Lopath, MD, conventional physician? I don’t think so. (See the point I made in my post about allopathy as misnomer.)

    Many promoters of non-science-based medicine like to portray themselves as progressive mavericks rebelling at what they denigrate as orthodoxy (literally right doctrine) or conventionality of the “medical establishment.” They use language to imply that medicine is just a hegemonic ideology that is stale, staid, resistant to change, and simply turf protecting (e.g., the “allopathic medical monopoly” rhetoric).

    It appears that the notion that there is such a field as “complementary and alternative medicine” has emerged as conventional wisdom. Sometimes it makes sense to follow the conventional wisdom. This is not one of those times.

  27. nybgrus says:

    @michele:

    Sorry – I am by nature quite verbose. Get to my prior post whenever you have the time – and I won’t be offended if you don’t find the time either.

    As for your discussion about the harm… well, we’ve covered http://whatstheharm.net/ many times here before. I don’t think there is an accurate figure of everything – probably because it is very complex to do. But at 33.9 billion USD per year out of pocket, plus $10 billion dumped into the NCCAM, plus the immeasurable damage to people who are led to believe in energy fields, the naturalistic fallacy, and other magical thinking I’d say it is there. Also the infiltration into mainstream media as legitimate and into universities is harmful. I’m not sure what sort of threshold would be necessary to legislate, but for me it is met.

    I don’t think your analogy to skiers and horseback riders fits the bill – these people do these things FULLY aware of the risks they are taking and why. Plus, there is utility to those activities – much more so compared to the none or almost none of CAM.

    And as for GM criticisizing Honda – not a bad point. I must agree with that. However, GM’s do criticize Honda’s. But moreso, who else would you have criticize CAM? It may be perceived as a turf war – but it really isn’t. It is the people with the right knowledge to know to criticize. But I am indeed open to ideas on that one.

    I see that you are saying it is a perception of undue paternalism and you are giving us that feedback. I accept that. What I am trying to explain is that it really isn’t undue paternalism. So how do we manage to do what we need to, without the false perception?

  28. William H. London, I am gathering that many healthcare professional find the word conventional medicine offensive due to how it’s used by alternative practitioners. i did not realize this…the article described the phrase as such

    “Medical anthropologists, medical sociologists, educated laypersons, health educators, and even physicians often make the mistake of describing standard medical practices of today and recent decades as “conventional allopathic care.”

    So I did not realize that this was a label that had gained a negative connotation through repeated negative use by an outside party.

    Quite a while back a FB friend (who is actually a friend of a friend) posted a news article about a medical school that was having medical students work on healthcare outreach programs so that they got more experience treating people living in poverty, the homeless, etc. The “friend” made some snippy comment about how conventional medicine was finally thinking about getting some compassion. I responded that while medical students can sometimes be a little clueless in the bedside manner department and that training in that area was a good idea, that I’ve been amazed at how well the conventional medicine professionals work with my son to do exams, tests and surgeries to treat his cleft lip and palate and associated speech, hearing issues in a kind, gentLe, engaging way so that he can receive the care he needs without being scared or upset.

    I didn’t realize at the time that he was probably using the term as a derogatory, but he did seem a bit nonplus at my response. ;)

    So I will take back my comment that the author skewed his definition of conventional medicine to make his point. But I will defend my initial response, because I don’t think that any overriding derogatory connotation of “conventional medicine” due to common usage by CAM folks is mentioned in the article.

    Since conventional offends folks, I’ll use standard or mainstream or health care system instead. But, sorry I won’t use efficacious, innovative, progressive instead. In my mind, those are good subsets of mainstream medicine that should be used as complements to the professionals who earned them. The very broad term “mainstream” is general in the sense that it includes the good and the bad that exists in the system.

  29. nybgrus “As for your discussion about the harm… well, we’ve covered http://whatstheharm.net/ many times here before. I don’t think there is an accurate figure of everything – probably because it is very complex to do. But at 33.9 billion USD per year out of pocket, plus $10 billion dumped into the NCCAM, plus the immeasurable damage to people who are led to believe in energy fields, the naturalistic fallacy, and other magical thinking I’d say it is there. Also the infiltration into mainstream media as legitimate and into universities is harmful. I’m not sure what sort of threshold would be necessary to legislate, but for me it

    nybrgus, what’s the harm incorporates 365,000 South African AIDS patients in their figure of 368,379 people killed over an indefinite period of time. They AIDS patient’ premature deaths may have been prevented. if “the South African government had abandoned its President’s AIDS denialist policies and provided antiretroviral drugs”.

    What is the harm is very good anecdotal evidence for what can happen to you or your loved ones when you don’t think critically. But it is anecdotes, it does not give a clear picture of the extent of the problem or enable one to put that problem into perspective beside other modern problems.

    Is the number of people not treated due to Bush’s International Aid policies going to be corrected by regulating CAM practitioners in the U.S.

    What does the 33.9 billion USD out of pocket figure from? What is the definition of CAM that it covers. Does it include things like massage and pet therapy that I’ve seen in other figures.

    I would have thought that the infiltration of CAM into mainstream medicine and universities would have been under the oversight of state medical boards and university teaching doctors, administrators. What can State or U.S. legislators see that those organizations can’t? If Medical Boards and Universities don’t have enough teeth or guts to snub The CAM under their jurisdiction how do we expect the professions those entities represent to come up with standards guidelines for legal enforcement?

    I understand that your evidence is enough for you to support legislation. But most legislations come with risks and costs. What are the risks and cost? You may think the risks are minimal and the costs are worth it. But how can one know that without any real analysis of the risks, costs and it’s place in comparison to other government obligations.

    “plus the immeasurable damage to people who are led to believe in energy fields, the naturalistic fallacy, and other magical thinking”

    If we can’t or won’t measure it how do we know it’s doing more harm than good?

    To me, it comes across as haphazard. Which is not what I’d like to see from proponents of critical thinking and evidence or science based medicine.

    Also my apologies if I sound abrupt, overly firm or just darn contrary. Since I do regularly share my positive experiences with mainstream medicine with to my friends or acquaintances, I feel some kind of obligation to my self-credibility to speak up when I am bothered by a position that is put forth by a SBM advocate. If I don’t speak up I feel like a yes-man or toady. This does not mean I am particularly talented in, or even enjoy advocacy or dissent. It is more of a compulsion than a past times. Now I’m just kinda emotionally tired.

    Whoever likes can take the last word. I’ll read, but not respond.

    NCCAM is congressional budget thing, also not controlled by regulating CAM practioners or the like.

    NCCAM is

  30. nybgrus says:

    @Michele:

    My last post was indeed written in haste. It was late, I was tired, and my engineer was finally wrapping up her work and the lab and we needed to head out.

    You know I value your input and thoughts and I hope that has come across in my posts. I have to admit though that as of late the content and tenor of your posts is palpably different. Perhaps that is just a gut reaction on my part perceiving you as being contrarian. But we have disagreed in the past and I haven’t had that feeling. I make no judgements here – just telling you how I am perceiving things.

    I agree that the data is patchwork and incomplete. I don’t have a good set of numbers for a cost:benefit analysis. The WhatsTheHarm link was just a quick toss in since, as I said, I didn’t have time for anything more in depth. I was trying to make the qualitative point that harm does exist. I don’t think that can be denied. And it exists in a backdrop where there is evidence that tells us that what is causing the harm is entirely worthless. So comparing it to a car doesn’t work since cars have utility. Comparing it to skiing doesn’t work since skiers know the risks beforehand and there is utility there as well. When a person goes to a licensed acupuncturist they don’t know the risks full well, they don’t know there is evidence demonstrating it to be a worthless intervention, and they think they are getting an actual product. There is a history and precedent for legislating against fraudulent claims, which acupuncture and reflexology and much other CAM is. They are promising a service and charging money, when we know full well that said service is false. That seems like enough reason and threshold for legislation. What about if a company was selling diamonds but substituting cubic zirconium? Or how about the recent example of Power Balance bracelets being slammed for false advertising? I see no material difference between that and an acupuncturist saying he can cure your fatigue, a refloxologist saying he can fix your liver problems, or a chiropractor adjusting your subluxations.

    I also honestly do not have the firmest handle on the legislative aspects of these sorts of things – who says what to whom and what law affects what in which board and through what body… I’m simply not well versed in that sort of thing. So when Jan makes the assertion that this is where a law could/should go… I will defer since I view him as much more an expert than I. I assume London would be as well. Perhaps that is a bad assumption.

    But one thing I am reasonably certain about is that much of the harm from CAM comes from its credulity. That is entirely political and has no basis on evidence or reality. It is further reinforced by states licensing CAM, the federal government researching it “seriously,” academic institutions “integrating” it in with real medicine, and people seeing more supplements on pharmacy shelves than anything else. How many times have you seen the argument, “Well obviously there is something to my practice because the state licenses me to it?” I just had such an argument from a chiropractor. There is no evidence to back up their practice, so “I’m licensed” is equal to “I am legitimate.”

    Now my limited understanding is the state medical boards are professional entities created by the professionals they represent. In other words, the chiropractors and naturopaths have their own boards that they create for themselves. Voodoo practitioners could do the same. The thing is that the state then has to give legitimacy to those professional boards in regulate and govern their members and grant them privileges to practice in their state. Hence why a naturopath can be licensed in one state, but not another, even though naturopathic schools and the professional body representing naturopaths is nation wide. The Medical Board of California also cannot deny a chiropractor or naturopath licensure, regardless of what evidence we have – they get their legitimacy separately from the state.

    So the legislation would be to create a firm standard by which professional groups can seek legitimacy in the state. So when the naturopaths go there and seek the right to license, they can be held against that metric and if they fail, there is a simple way to deny them. If they make it, then great.

    At least, that is my understanding of the matter. Perhaps I am wrong.

  31. nybgrus says:

    ack, hit submit too soon.

    The closing statement I wanted to make is that CAM is an affront on all sides. This legislation idea and all these others topics are just handling one such thing at a time. I don’t think there is one single linch pin that if removed will make the bottom fall out. So dissecting one aspect and saying it alone isn’t worth it or appropriate is unfair, since each alone won’t have the dramatic effect we would all hope for and which would make the calculus easy. But when taken in concert with everything being suggested/done over here

    Oh, I’ll also add that I don’t think “mainstream” works very well in place of conventional as it has essentially the same negative connotions and is very vague:

    It is often used as a pejorative term by subcultures who view ostensibly mainstream culture as not only exclusive but artistically and aesthetically inferior.

    I agree that “progressive” and “innovative” would not be accurate terms to use either. However, “efficacious” seems quite apt – the medicine that we learn in medical school is efficacious. Not absolutely 100% of it, but the vast majority is. And just because an individual practitioner may not abide by it or is not very good at delivering it (thus lowering the efficacy of medicine her/she practices) that is not a reflection on the general efficacious nature of science based medicine as a whole. So in my mind, calling someone “progressive” or “innovative” is a compliment that an individual practitioner should earn. But the term “efficacious” is earned by obtaining your MD and is set as the standard in teaching.

  32. nybgrus says:

    please excuse my poor posts…. final exams are in 6 days and I am simultaneously studying for my USMLE board exam.

    But when taken in concert with everything being suggested/done over here… I believe the calculus adds up.

  33. JPZ says:

    @nybgrus

    “But the term “efficacious” is earned by obtaining your MD and is set as the standard in teaching.”

    Not everyone proving efficacy is a M.D. Having worked in pharmaceutical clinical research departments (doing GCP/ICH-compliant nutrition research), I can say it also includes PhDs, RDs, RNs, LPNs, MSs, BAs and BSs, et al. Creating scientifically-sound, efficacious treatments is not the province of a certain degree, it is based on the quality of the evidence.

    Go back to studying. No need to reply to my nit-picking here.

  34. nybgrus says:

    @JPZ:

    I spent the whole day studying. I can take a minute to respond. Besides, my girlfriend is writing her thesis and all my other friends are studying so what better do I have to do?

    I fully agree, BTW. I am sorry if my post made it sound like an MD is the only field that gets to be called efficacious. Absolutely not. But you point out the very good point that the reason why MD earns that moniker automatically is because the standard is evidence based. So just like any other evidence based discipline, efficacious is the baseline.

    So MD is just a subset of those proving efficacy.

    Of course, the integration of CAM into the curriculum is eroding that and that is precisely what we are trying to fight.

  35. nybrgus, I will mull on your posts.

    I’m afraid I’m still not pleased with efficacious. I think we are talking about different contexts. I’m thinking of a word for the current norm in the most commonly assessable medicine. In regions that have a huge amount CAM infiltration, that name should still apply.

    Let’s try a fill in the blank. (these are hypotheticals, not my real opinions or facts.)

    ———— medicine is Southern California incorporates alternative techniques such as acupuncture in about 25% of their patients

    ————- medicine has improved greatly over the last 16 years in it’s delivery of compassionate hospice care.

    ———— medicine needs to add more advance science training when training doctors.

    Sorry, I didn’t mean to reply, but I thought the fill in the blank might be worth a shot. Don’t feel you need to reply if busy.

    Best of luck on your exams.

  36. Also, I’m sorry but I can’t understand this statement.

    “And it exists in a backdrop where there is evidence that tells us that what is causing the harm is entirely worthless. So comparing it to a car doesn’t work since cars have utility. Comparing it to skiing doesn’t work since skiers know the risks beforehand and there is utility there as well

    Where is the evidence that acupuncture is entirely worthless? The evidence I have seen is that acupuncture works equal to placebo. The worth of placebo is a matter of opinion, not fact. Some evidence that I have seen (not sure if it’s here or on another skeptic site is that (in some people) acupuncture may cause a relaxation effect that is similar to massage. Once again, a relaxation effect may have worth to some people.

    The rational stated here has usually been that one should use massage instead of acupuncture, since massage is safer (citation needed). If one has decided that the benefit of rock climbing is exercise, then there are certainly safer ways to get exercise.

    The is why you and pmoran keep going around and around, because “worth” is not a something you can objectively measure. It’s subjective, a matter of opinion. I don’t disagree with your opinion, but I do wish that you realized that you were stating an opinion, not a scientific fact.

    “Comparing it to skiing doesn’t work since skiers know the risks beforehand and there is utility there as well. When a person goes to a licensed acupuncturist they don’t know the risks full well, they don’t know there is evidence demonstrating it to be a worthless intervention, and they think they are getting an actual product”

    How do you know that skiers, climbers and horseback riders know the risks before hand and a person going to an acupuncturist doesn’t? is that “in your experience”?

    In my experience as an occasional skier and rare climber who is related to an avid skier and world class climber, many people don’t know the risks of skiing or climbing before hand.

    Who’s experience is correct?

  37. That was to nybgrus, sorry to beleaguer you, guy.

    I really, really, really am going to drop it now. Or at least I’ll really try.

  38. weing says:

    @micheleinmichigan,
    We finally got our power back. A few thoughts after reading some of the comments. I have not seen any studies that show acupuncture to be anything but the sizzle without the steak. If you are happy with the sizzle, fine. It still won’t give you any nourishment. How is it being patronizing if you tell a grown man/woman that Santa is not real? Should we not treat them as adults? I still think we should expunge CAM from our hospitals and schools and stand for science. If you lived in a hippie commune, CAM would probably be your conventional medicine.

  39. @Weing – I am not trying to say that acupuncture has steak. I am trying to say that the WORTH of sizzle is a matter of opinion.

    You are not being patronizing if you tell a grown woman that the steak in acupuncture is not real and she is only getting sizzle. IMO you are being patronizing if you attempt to ban the sale of sizzle on the grounds that the woman may starve herself by not eating any steak. (Sorry, I couldn’t go with the Santa metaphor, since I couldn’t think of any Santa harms.)

    To some extent I would tolerate a patronizing legislation, if it’s going to save a reasonable number of lives for it’s expense. But where are the numbers? Lives saved, cost of legislation and enforcement?

    When budget cuts in our state are so extensive that my son’s first grade class has 32 kids and the school district was contracting special education transportation to inexperience drivers of mini-vans who couldn’t install a child car seat or drop of their kindergartener with CP at the right school, perhaps one might respect that some taxpayers would like to see some sort of cost/benefit analysis or at list an hint that one should be done, before jumping on the legislate CAM band wagon

    I wish that you Doctors would expunge ineffective, dangerous therapies or dishonest practitioners from hospitals and medical schools. (The only reason I don’t say CAM is cause some people include things like pet therapy and massage in CAM. I like the puppies and have nothing against massage) But don’t you doctors have the say in what is in hospitals and schools via state medical boards and university administration? If there is not a consensus how medicine should be practiced within the medical field how is making additional laws going to help? In fact what experts would come up with standard for those laws with no consensus from medicine?

    “If you lived in a hippie commune, CAM would probably be your conventional medicine.”

    Yes, that’s exactly what I was getting at.

  40. pmoran says:

    Weing: We finally got our power back. A few thoughts after reading some of the comments. I have not seen any studies that show acupuncture to be anything but the sizzle without the steak. If you are happy with the sizzle, fine. It still won’t give you any nourishment. How is it being patronizing if you tell a grown man/woman that Santa is not real? Should we not treat them as adults? I still think we should expunge CAM from our hospitals and schools and stand for science. If you lived in a hippie commune, CAM would probably be your conventional medicine.

    You could apply a similar argument to the use of any means of symptom relief that does not address the underlying source of the illness.

    Acupuncture does seem able to relieve pain and some other symptoms, even in its sham versions, at least in susceptible populations. It is often resorted to when other methods are not proving entirely satisfactory. It thus appears to be effective as an addition to normal care for back pain, while, of course, not being shown to be efficacious in the normal, working-better-than-placebo, EBM sense of the word.

    What, then, is the problem? Do we have our patient’s best interests at heart ALL the time, or only when they behave properly, in conformance with our favoured working-better-than-placebo model of medical interactions? Explain to me again why it is for the patient’s own good that we hoist acupuncture up by the neck and shoot holes in it. Provide examples of where tolerance, and even public funding of such methods in some countries has led to a downward spiral into the depths of quackery if that is your argument.

    It is not as if blanket opposition is the only possible policy we can adopt towards unlikely treatment methods. We could apply the sound principle that quackery (and usually also the dominant risk) is not a property of the specific treatments, is it is a property of specific claims that are made for them.

    We could then accept that acupuncture and other rituals may help some people with pain and Reiki some with anxiety while still protesting against other claims made for them. We can still express the opinion that any benefits derive from non-specific responses to the sometimes elaborate medical ritual, also that we think TCM theory is sheer make-believe, while, nevertheless, being more tolerant, even more encouraging of the use of CAM for those specific purposes.

    We would then be in a very profound sense on the patient’s side in all things, just as they expect of us.

    This would not require that the methods be incorporated into normal medical practice, although that could happen if any application met normal cost/risk/benefit considerations. I would not expect that to happen very often, because the psychological processes involved are quite fragile, requiring the happy conjunction of diverse influences for optimal outcomes.

  41. nybgrus says:

    @michele:

    In that case I suppose you are looking for words like “dominant,” “mainstream,” “accepted,” “predominant,” or “established.”

    Though it also seems to be that you are searching for a very neutral term to simply describe the existance of something. “Bacteria are the predominant life form on earth.” “Curry is the mainstream diet of India.” Stuff like that.

    I think I get why you are trying to do that, and in a sense I agree. But for me it smacks of that false journalistic equipose where every opinion is equal and valid, no matter what. As weing pointed out, that sor of terminology becomes dependent on the population/geography you are describing and thus you would have to qualify every reference of it with that (as you agreed). So what use is struggling to come up with a term, when that term will have to be explained every time? I thought we were trying to come up with a term that would describe the type of medicine that I am learning to practice – science based, evidence utilizing, constantly growing, changing, improving, and indeed efficacious.

    Plus, the whole point is that as we struggle to maintain neutrality, sCAMsters are making leaps and bounds by pure marketing technique and positioning. I don’t see why marketing actual medicine in a similar manner is wrong – especially when it is actually true. Modern medicine (perhaps that terms could work?) is efficacious – why can’t we use that? It is many other things as well, but why must our hands be tied when describing ourselves but not the sCAMsters?

    Where is the evidence that acupuncture is entirely worthless? The evidence I have seen is that acupuncture works equal to placebo.

    Besides the fact that pmoran thinks placebo is a reasonable and efficacious treatment to use as isolated monotherapy, the studies have shown that acupuncture is worthless. In other words, the actual sticking of needles into people is not what is producing the effect, placebo or otherwise. That is why sham acupuncture and toothpicks work as well. So we can quibble over whether placebo is efficacious, which is something I contend it is not in isolation (and Benedetti and Hall agree), but we don’t even need to get into that. When a person sees an acupuncturist they are told that the needles entering the body are what is effecting the change. That is entirely untrue and carries with it risks. So here, there is no matter of opinion at all.

    If you want to expand it to all placebo based therapy and not just acupuncture, and claim that is opinion based you would be forced to accept homeopathy as valid treatment as well. And you would have to accept that is is beneficial and efficacious to lie to patients. Edzard Ernst recently wrote an article about why use of placebos actually cause more harm than any benefit that can be derived from them. But if we go down this route it will be another extremely long digression so I will leave it at that.

    The is why you and pmoran keep going around and around, because “worth” is not a something you can objectively measure. It’s subjective, a matter of opinion. I don’t disagree with your opinion, but I do wish that you realized that you were stating an opinion, not a scientific fact.

    Yet there can be a scientific basis for determining a cost:utility. I think it has been demonstrated that the cost:utility of placebo demonstrates it scientifically to be worthless. By your argument people can decide that continued heroin use is “worth” it to them, and if I say it isn’t, then I am only speaking an opinion with no scientific basis. You are right in sense though – I have dealt with heroin addicts before and explained to them how much they are harming their bodies (this is usually after sucking out hundreds of mLs of pus from giant abscesses they get from shooting up). Most of them rationally understand the harms, but state clearly that it is “worth it” to them for the benefits they recieve from shooting up. So is my admonition that their assertion of “worth” is false, purely opinion then?

    How do you know that skiers, climbers and horseback riders know the risks before hand and a person going to an acupuncturist doesn’t? is that “in your experience”?

    Every time I have ever skied, rock climbed, and horeback rode (yes, I’ve actually done all 3) I have had to sign a waiver stating the harms and acknowledge that I am personally responsible for outcomes.

    However, you are right – perhaps some acupuncturists do go over all the risks of it. In my experience (which I know is anecdote, but in this case an exception makes my point) and the experience of others who have had acupuncture, such risks are not described. I was not told about potential nerve damage, needles breaking off, infection, lung puncture, etc.

    So I will concede this is not my strongest point, but there does remain some validity to it. I guess the real point here is that regardless, activities like skiing are well known for what they are and there is no false marketing/advertising. Nobody is trying to sell you skiing to make you more intelligent. But acupuncturists are trying to sell you needles that will change the flow of chi in your body and cure disease.

    And lastly, I’ll touch upon this again:

    IMO you are being patronizing if you attempt to ban the sale of sizzle on the grounds that the woman may starve herself by not eating any steak.

    Nobody here is trying to ban the sale of the sizzle. We are trying to ban the state sponsored legitimizing of the sizzle. Sell all the sizzle you want – but you have no basis for calling the sizzle “steak” and yet the state legislatures are doing exactly that by granting power, authority, and licensure to people who only have sizzle. What Jan has proposed in no way affects the sale of sizzle – it just means that if the state is going to recognize you, you better prove that there is steak behind it. That is all. I think that is a very important distinction and feel it is one you have missed in your posts.

    BTW – I enjoy these conversations with you, so please don’t feel like you have offended or alienated me. I hope I have not with you either. To me this is just a conversation with someone I respect with a differing viewpoint. Of course I am trying to get you to see things my way, but that does not mean I discount your opinion.

  42. nybgrus says:

    @pmoran:

    What, then, is the problem? Do we have our patient’s best interests at heart ALL the time, or only when they behave properly, in conformance with our favoured working-better-than-placebo model of medical interactions? Explain to me again why it is for the patient’s own good that we hoist acupuncture up by the neck and shoot holes in it.

    You just don’t seem to get it. The acupuncture itself is not eliciting the effect. That is what the sham studies show. It is the patient-practitioner interaction and the expectation of benefit that effect changes, real or artifact. But lets assume they are all real. It still has nothing to do with the actual needles being actually inserted into the body.

    So acupuncture as a standalone therapy is not ethical nor effective. And Ernst gives a solid argument for why packaging it as acupuncture (well, he uses reiki as the example, but it is the same principle) is actually more harmful than beneficial. I linked it above.

    So no, it is not that something must perform better than placebo for us to utilize it. It must work better than placebo if it is to be a stand alone therapy. As I have said till I am blue in the face, a medical practitioner can use the placebo effect to his/her advantage, but only in the context of actual medical care. Referring to an acupuncturist is therefore completely out. But even medical practitioners who practice acupuncture are still in the wrong – because it isn’t the acupuncture that is giving the effect!

    That would be like giving a patient an antibiotic for an infection and telling them they have to drink water from the far side of the glass and knock three times on wood otherwise it won’t work. The point of medicine is to determine what part of that ritual worked, and eschew the drinking technique and knocking on the wood. The same applies to acupuncture. It is not the needles penetrating the skin that has any appreciable effect.

    The entire basis of your argument is that we cannot achieve the same placebo effects without calling it “reiki” or “acupuncture” or utilizing magical thinking practitioners. You have zero evidence to back that claim up. We can, and do, as medical practitioners employ the same types of placebo effects. Your advocacy for the inclusion of the magical terms and ritual for it is poorly substantiated.

  43. pmoran says:

    Nybgrus, do go and get some sleep. And stop reading this blog (or at least anything I write) until the exams are over.

  44. nybgrus says:

    such superciliousness pmoran. that’s rife and par for the course in the old gaurd of medicine though, so I suppose I should expect it.

  45. pmoran says:

    Yes, sorry, Nybgrus. I shouldn’t be stirring you up at this time, but a full response to what you have said would have had the same effect, if not worse.

    Take some good advice.

  46. Nybgrus
    “Yet there can be a scientific basis for determining a cost:utility. I think it has been demonstrated that the cost:utility of placebo demonstrates it scientifically to be worthless. By your argument people can decide that continued heroin use is “worth” it to them, and if I say it isn’t, then I am only speaking an opinion with no scientific basis. You are right in sense though – I have dealt with heroin addicts before and explained to them how much they are harming their bodies (this is usually after sucking out hundreds of mLs of pus from giant abscesses they get from shooting up). Most of them rationally understand the harms, but state clearly that it is “worth it” to them for the benefits they recieve from shooting up. So is my admonition that their assertion of “worth” is false, purely opinion then?”

    They’re addicts, the fact that they rationally understand the risks but feel compelled to continue using is…well addiction. And yes using has worth to them, more worth than living, because not using results in incredible physical and mental pain.I would think that understanding that, rather than just deciding you’re analysis of the worthlessness of heroin is correct would be helpful to someone attempting to treat an addict.

    Also, by the way, you just graphically illustrated an argument about acupuncture or placebo medicine with a story about heroin addiction. To me, the person who has almost lost her sibling to substance abuse overdose twice and has another family member, a young person, who is recently out of rehab for the second time for oxycontin and heroin addiction. Both of whom, by the way, got started on those addictions using “efficacious” medicine for back pain.

    Let’s look at the figures
    drug induced deaths in 2009- 37,485, CDC vital statistics.
    CAM induced deaths in one year – ????

    I understand you didn’t know and you are very enthusiastic about the topic and want to prove your point, but these sort of exaggerated illustrations seldom actually illustrate anything. It’s like saying drinking pee is okay because if you were stranded in a boat with no water it would be okay to drink pee.

    By the way, number of drug induced deaths in 2009- 37,485, CDC vital statistics.

    also, climbing gyms have waivers, rocks don’t. At least not the ones I’ve seen. :)

    I have no hard feeling discussing this with you. You are always polite to me, so I’m good.

  47. whoops, I didn’t mean to be redundant with the cdc stat. editing error.

    also, that’s it I’m cutting us all off.

    nybgrus, it’s rude, and my apologies, but I refuse to come back and read your response until your exams are over. So don’t bother to write a response, at least until it’s over, even then you should probably focus on having a beer for look at some clouds, that is very nice…

  48. nybgrus says:

    @michele:

    I am glad there are no hard feelings. None on this side of the ethernet either.

    Obviously I am not quite at my usual for these posts, and I admit at least a couple of my points have become muddied (or worse) as a result. I have been studying rather intensely, and as such my ability to be cogent, measured, and well thought out here has suffered. I hope not immensely so to the point of being ridiculous, but I agree in general. I tried trudging through some work today and think I will just need to take the night off and watch some Carl Sagan or Neil DeGrasse Tyson.

    I apologize if my heroin comment hit close to home. Obviously that would never be my intention. Substitute food and obesity and perhaps that is a more apt analogy.

    Your parting comment though, about the drug induced deaths, does smack of the typical tu coque argumentation offered up by CAM apologists. I’ll just leave it at that.

    And yes, actual rocks don’t have waivers, but only some very crazy and stupid people would go out climbing them without a clue of what they are doing.

    But anyways, I am happy to leave the thread and let it die. I think points have been made by all involved and I’m sure we’ll all end up picking this up again in a future article sometime down the line.

    @pmoran:

    fair enough. honestly, I think if we had a long evening and a few pots of beer to chat about all this it might make us realize we are closer in thought than we’ve let on. Well, at least it would certainly be an interesting evening.

    That notwithstanding, I’ll take your advice, as it is indeed good.

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