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Resistance is futile

Dr. Sampson’s droll post on Thursday written from the point of view of an advocate of unscientific “alternative” medicine modalites (these days known as “complementary and alternative medicine”–abbreviated “CAM”–or “integrative” medicine), coupled with Dr. Atwood’s most recent contribution to his ongoing series on how the mish-mash of a little valid herbal medicine mixed with a whole lot of woo otherwise known as the “profession” of naturopathy is pushing for greater legal legitimacy, depressed me mightily. The posts depressed me because they are but more evidence of just how effective advocates of non-science-based medicine have been over the last several years at twisting the linguistic landscape to their advantage and winning. Indeed, I’ve written about this before on this very blog, including my (in)famous list of medical schools that have embraced CAM and my lament about a medical school that has even gone so far as to “integrate” so-called “integrative” medicine into every aspect of its curriculum from day one of the first year. These disheartening trends accompany and draw succor from the $120 million a year budget of that center of woo in the heart of the National Institutes of Health, the National Center for Complementary and Alternative Medicine, the equal amount of money coming yearly from, alas, the National Cancer Institute, and, of course, the financial clout of the Bravewell Collaborative.

Things are not looking good for science-based medicine in academia right now. I say this in particular because I just learned of a press release issued three weeks ago by Andrew Weil and his University of Arizona Program in Integrative Medicine that, as Emeril Lagasse would say, “Kicks it up a notch,” but not for the better.

The press release begins:

TUCSON, Ariz., June 12 AZ-UofA-CoMPIM-Award TUCSON, Ariz., June 12 /PRNewswire/ – The Arizona Board of Regents recently conferred Center of Excellence status on The University of Arizona College of Medicine Program in Integrative Medicine — a move that reaffirms the positive impact integrative medicine has had on health-care system transformation.

Now known as the Arizona Center for Integrative Medicine (AzCIM), the program underwent an intensive evaluation process and earned unanimous endorsements from UA health sciences program directors and college deans. The new designation formally recognizes the center’s achievements in the field over the past 14 years, and its status as the world leader in integrative medical education.

Founded in 1994 by internationally renowned author and integrative medicine pioneer Andrew Weil, MD, the Arizona Center for Integrative Medicine joins nine other Centers of Excellence at the UA College of Medicine.

“Having our work recognized in this way is among our greatest accomplishments to date,” Dr. Weil said. “The Center of Excellence designation formally recognizes us as an innovator in educating the next generation of physicians and health-care professionals. Our challenge now is to remain at the forefront of innovation so as to make integrative medicine available to everyone, regardless of economic or geographic limitation.”

Indeed it is one of Andrew Weil’s greatest accomplishments in pushing his not-so-unique blend of some science-based nutrition advice mixed with a whole lot of woo. Steven Novella once rightly referred to him as wanting to change the rules of scientific evidence supporting the efficacy (or lack of efficacy) of various medical interventions, and indeed he clearly does, favoring “uncontrolled clinical observations” over well-controlled, double-blind randomized trials:

But for all the other stuff, we don’t have time to do that, so we have to have other methods of estimating how things work. Now one of the attitudes that I run into in the research community that just drives me up the wall is people who dismiss what they call anecdotal evidence. And I have challenged some of these people in public to strike the word “anecdote” from the medical vocabulary.

I think it is a trivializing word. If you want to call this uncontrolled clinical observation, that’s fine with me. The fact is that the scientific method begins with raw observation. You notice something out there that catches your attention, that doesn’t fit your conceptions. You see it again. That gives you an idea that generates a hypothesis which you can then test. It is this kind of uncontrolled observation which is the raw material from which you get hypotheses to test in a formal manner. If you dismiss all that stuff, if you drop it into a mental wastebasket labeled “anecdote,” you cut yourself off from the raw material of science.

Of course, Dr. Weil is being disingenuous. In science- and evidence-based medicine, anecdotes are indeed the raw material from which we as medical scientists derive hypotheses, and “anecdotes” are published all the time in the medical literature. They’re called “case reports.” We do not dismiss them out of hand just because they are “anecdotes.” When appropriate, we dismiss “anecdotes” because frequently they are “testimonials” and not controlled observations or because anecdotes themselves, even when the observations are controlled, are often deceiving, which is why further study in the form of more controlled trials is always necessary before science-based medicine will accept a claim. Anecdotes are not enough, but doctors like Dr. Weil want to give them far more weight in medical science, often (as Dr. Weil does) reducing their arguments to a tu quoque fallacy, as Dr. Weil does in characterizing research on St. John’s Wort and depression as “useless information.”

But I digress. However it is a relevant digression, because the real effect of the CAM movement is to downplay the importance of science in medicine and to elevate anecdotal evidence far above what its role should be. In this, CAM is moving medicine back to the days of Hahnemann and homeopathy. Indeed, physicians like Dr. Weil are more dangerous than quacks like Hulda Clark, because he mixes his brand of unscientific medicine with enough scientific medicine to make it sound plausible and to blur the line between the two to the point that it is not always apparent even to skeptics where science ends and woo begins.

He’s succeeding, too, in transforming medicine in a way bigger than one “integrative” medicine program being recognized by its university as a so-called “center of excellence” (which makes me wonder just how low the University of Arizona’s standards are in that respect) indicates. The real significance of this press release is that it also announces another huge step made by Dr. Weil and his fellow ideologues in “integrating” non-scientific and non-evidence-based medicine into science- and evidence-based medicine. It is the next logical step after the “integration” of woo “seamlessly” into the medical school curriculum:

The Center of Excellence designation will enhance the center’s ability to court top-tier faculty and inspire a new era of program growth — led by the center’s most ambitious program to date: the Integrative Medicine in Residency (IMR). The center’s integrative medicine curriculum soon will be incorporated into standard three-year family medicine residency programs across the nation. Residents will learn to incorporate integrative medicine concepts into their practices, including patient-centered care techniques that facilitate lifestyle change.

Through funding raised from both public and private sources, an IMR pilot program will be launched in July at eight family medicine residency programs nationwide, including the UA; Beth Israel Medical Center, New York City; Carolinas Medical Center, Charlotte, N.C.; Maine Medical Center, Portland, Maine; Maine-Dartmouth, Augusta, Maine; University of Connecticut, Storrs, Conn.; Hennepin County Medical Center, Minneapolis, Minn.; and the University of Texas Medical Branch, Galveston.

“This will be the first program in the nation to create a required curriculum in integrative medicine for physicians during residency,” said Victoria Maizes, MD, executive director of the Arizona Center for Integrative Medicine. “Over the next 10 years, development of IMR into the national model for residency education is a major goal for the center. We will gradually move beyond primary care into subspecialty training.”

I can’t help but mention that clearly I need to add every one of the above medical schools and academic medical centers into my hall of shame, clearly a project for the impending Fourth of July weekend. That aside, this accomplishment represents a quantum leap in the infiltration of CAM into academia. In one fell swoop, Dr. Weil has transformed CAM from a mere elective to a fully co-equal and mandatory element of the family medicine residency. True, it’s only eight residencies now in a pilot program. However, given the current attitude in this country and in medicine, it’s highly likely that this pilot program will be “successful” (successful for woo, a disaster for science-based medicine), in which case it will spread, and it is no longer unthinkable to visualize something like IMR insinuating itself into the national standards of the American Board of Family Medicine in a decade–or even less. Certainly it doesn’t help that Medicare and third party reimbursements have become so paltry for primary care doctors that woo suddenly becomes attractive as an “alternative” (or should I say “integrative”) additional source of income; that only makes resisting it more difficult.

If Dr. Weil succeeds, every new family practice physician will graduate from his or her residency program with a knowledge of CAM. This would not be a bad thing if it were truly a science- and evidence-based approach to CAM and a knowledge of what herbal remedies might interact with “conventional” pharmaceuticals. The optimist in me would like to believe that that’s what would happen, but the realist in me knows that it’s not. Given the history of CAM programs in medical schools and academic medical centers thus far, where credulous promotion of quackery–yes, I say quackery–such as reiki, therapeutic touch, and even that quackery of quackeries, homeopathy, somehow manage to be “integrated” into science-based offerings with nary a word of skepticism about the extreme (and I do mean extreme) lack of scientific plausibility and the preponderance of scientific studies demonstrating no greater efficacy for these modalities than placebo, I fear that when I visualize myself in the hospital 20 or 30 years being subjected to therapies parodied in this video, I may look back at it as prophetic, not funny. Steve Novella was right to wonder whether a golden age of quackery and antiscience is upon us. My fear, though, is that 20 or 30 years from now, we will look back upon these days as beginning of the end and yearn for the level of science in medicine that we have today.

The Brave(well) New World is upon us. Resistance is futile. Your life as it has been is over. From this time forward, medical culture will adapt to service CAM. Science is irrelevant.

Think I’m exaggerating? I guess we’ll see in 20 or 30 years.

LocutusOfBorg

Posted in: Clinical Trials, Medical Academia, Science and Medicine

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28 thoughts on “Resistance is futile

  1. vinny says:

    CAM instruction is alive and well within accredited medical schools. Cranial bone manipulation techniques are being taught at osteopathic schools and hordes of medical students are indoctrinated into this philosophy. What is needed at these institutions is a course on evidence based medicine, and a class on debunking common quack fallacies.

  2. Michelle B says:

    Indeed, physicians like Dr. Weil are more dangerous than quacks like Hulda Clark, because he mixes his brand of unscientific medicine with enough scientific medicine to make it sound plausible and to blur the line between the two to the point that it is not always apparent even to skeptics where science ends and woo begins.
    ______

    Well said. Though I agree with your emphasizing the seriousness of the problem and its connotations for a dismal future for efficacious medicine, the savvy young of today’s interconnected world and the advances in Metabolomics, etc., may still win the day and convince people that there is an already existing medical modality that works and will continue to work, science-based medicine, and it needs not to be chained to the garbage of the wishy-washy nonsense of unproven modalities.

    Weil always gave me the creeps. Why do people see him as comforting and wise? Ugh.

  3. Joe says:

    I think I have asked this before- where are the medical associations in this? A colleague of mine used an undergad text in a grad course and the American Chemical Society made her adopt a more rigorous book. Surely, the wholesale adoption of nonsense (in med schools) is a more serious problem than one professor using a watered-down text.

  4. vinny says:

    I would wholeheartedly join the campaign to arm our medical students with tools they will need in confronting these charlatans. I recall only one class at my school about medical quackery, and it was a presentation on the Laetril scam. When patients asked me about herbals and alternative medicines, I typically informed them that it was not my area and they should seek such advice from herbalists or naturopaths. Only recently, I learned what these “alternative to medicine” folks actually do and now will be much more cautious about my advice regarding herbals,…

  5. Harriet Hall says:

    Joe asks where are the medical associations.

    Two thoughts come to mind.

    (1) Political correctness. The medical associations want to please their members and too many of their members are part of the problem.

    (2) The legal system. When the AMA has tried to take action against quackery, the courts have interfered. They used to have an active anti-quackery division, but the courts interpreted their actions as a self-serving ploy to protect their own profession and create a monopoly.

  6. daijiyobu says:

    I’ve something positive to say, along the lines of ‘a stubborn optimism,’

    as regards all this ‘integrative crappola,’ Dr. Gorski.

    I have resisted the ‘CAM nanoprobes!’ [I know my Star Trek].

    I went into an ND program because of their supposed ‘science not belief’ context,

    and finding it NOT, I stopped. I resisted, and I will continue to, too.

    To quote from Neil Jordan’s film Michael Collins:

    “we have a weapon more powerful than any [...] and that weapon is our refusal.” [There's my stubbornness].

    Along the lines of science, critical thinking, and skepticism, two other quotes come to mind:

    a) my eighth grade General Science teacher, Mr. Rotandaro, whose mantra was:

    “science is organized, systematized, self-testing and self-correcting. We must establish a fiduciary point!!!” [I enjoy those words -- and memories of his animated / dramatic fervor -- to this day. The dross and the dregs will in time be disposed of].

    b) and Franz Fanon:

    “make of me always a man who questions.” [I think that is the most radical of ethos].

    So how specifically do I think people can gain immunity?

    Simple, really: never stop thinking, never stop learning.

    If people with doctorates cannot be discerning, if they are simply lemmings…

    Well, I think that reflects more so a DEEPER problem with what our colleges churn out from Baccalaureate programs.

  7. overshoot says:

    The legal system. When the AMA has tried to take action against quackery, the courts have interfered. They used to have an active anti-quackery division, but the courts interpreted their actions as a self-serving ploy to protect their own profession and create a monopoly.

    With that as a precedent, maybe it’s time for “Complementary and Alternative Law?”

  8. David Gorski says:

    When the AMA has tried to take action against quackery, the courts have interfered. They used to have an active anti-quackery division, but the courts interpreted their actions as a self-serving ploy to protect their own profession and create a monopoly.

    Harriet is, of course, referring to the most recent and famous example, Wilk v. American Medical Association.

    In fairness, though, the AMA was clearly self-serving during the first half of the 20th century when it came to its war with osteopathic medicine. Basically, the AMA overreached, and that overreach came back to haunt it in Wilk v. AMA, in which a chiropractor sued the AMA for restraint of trade.

    In any case, having been badly burned once since then the AMA has been largely silent on the matter of quackery. It’s a shame. Any time the AMA decides to try to do anything to fight quackery now, the specter of that ruling tends to give it pause. For example, just this month I came across an attack on the AMA’s Scope of Practice Partnership that unjustifiably cries “suppression.”

  9. Oh, please, Weil is a salesman, a fantastic salesman. Look through his webpage:
    http://www.drweil.com/drw/u/id/PAG00346
    Here are some excerpts:
    Now you can purchase and use Dr. Andrew Weil’s products simply and quickly, through our new Dr. Weil Marketplace. Choose from a carefully selected group of Dr. Weil’s new line of cookware, best-selling books, high-quality supplements, and CDs and DVDs for your body, mind and spirit. And, you can buy Dr. Weil’s products, through our trusted affiliate partners, knowing that a portion of your purchase goes to the Weil Foundation, Dr. Weil’s not-for-profit, independent 501(c)(3) organization dedicated to supporting integrative medicine through training, education, and research.

    Yours in health,

    The DrWeil.com Team

    Supplements

    “When it comes to obtaining the vitamins and minerals your body needs, your best possible source is food. But circumstances may prevent you from eating optimally every day. The main reason I take supplements is for insurance against gaps in my diet. Also, researchers are finding that some important vitamins and minerals are protective against disease in amounts that may be difficult to obtain through diet alone, no matter how conscientious you are. This is another reason I take supplements faithfully and encourage my patients to do so as well.” – Andrew Weil, M.D.

    Dr. Weil’s exclusive vitamin, supplement and herb formulas are developed for maximum effectiveness, use only the highest-quality ingredients, and are based on years of research.
    END QUOTE

    He started selling “information”. Then if I remember correctly and I may not, one of the supplement chains paid him a great deal to let them sponsor his webpage which was full of ads for their products. Now he is expanding into cookware and organic foods and anything else he can somehow connect to “wellness”.

    Weil is very clever. Maybe that’s how he got into Harvard med? He points out that the best source of nutrition is food, but….?

    Weil has come out very strongly against the use of silver supplements stating they are useless and can cause argyria. One of the supplement trade groups did the same thing, but I don’t think it was out of the goodness of their hearts. I think that some of the people high up in the supp industry met me in person, saw my face, heard me testify and saw the material I submitted to the FDA & FTC about the silver fraud and thought, “This is a marketing disaster waiting to happen. We better cover our butts now before the new cases of argyria start appearing.”

    I suspect that the biggest in roads into medical schools will come in the form of botanical drugs. People like Varro Tyler, Norman Farnsworth, the American Botanical Council with their publication HerbalGram have tried very hard to convince doctors, nurses and doctor and scientist wannabes that there is hard science supporting the claims of safety and efficacy made for most of their products when there is not. It is far easier to dress up and pass off herbalism as science than it is with something like TT or prayer. All you have to do is churn out bad studies and cut and paste your citations to fool a lot of people.

  10. vinny says:

    rjstan@together.net,
    Are you Rosemarie Jacobs? If you are, I wish to thank you for your enlightening story and your effort to warn the public of dangers of silver.

  11. Yes, Vinny. I am Rosemary Jacobs, and thank you for the story of the lady with untreated breast cancer. Stories like that are powerful and very educational for the general public many of whom have so little experience with serious diseases that they don’t appreciate scientific medicine.

    The site you linked to is just one of many with erroneous, dangerous claims. It goes on about dumb people who take “too much CS”, but there are no toxicology studies telling you what “too much” is. They tell you there are benefits derived from ingesting silver but don’t offer any substantiation. Silver was used before the advent of antibiotics. It didn’t work but it did discolor lots of people. I know scientists who have tested many brands including the homemade variety in vitro against many common bacteria and found that none of them had any effect against any of the bacteria they tested them against. My favorite claim is about “boosting the immune system”. Whenever anyone tells me that, I say that if it really did that it would be truly dangerous since there are many horrible diseases caused by overactive immune systems.

    When I first posted my webpage over 10 years ago, the salesmen said I didn’t know what I was talking about. When I predicted that their products would cause argyria, they said that I was comparing apples to oranges, but when I asked for their evidence of safety and efficacy, they didn’t have any.

    When the new cases of argyria started to appear, they blamed the victims. They told them they had taken “too much” or taken or made the “improper” kind even when they took or followed the recipe the very same saleman recommended. They said Stan Jones’s mistake was using tap water! It was the minerals in the tap water that discolored him! I agree with them about Jones making his brew incorrectly, but I am quite certain that the only mistake he made was adding silver to it.

    I’ve heard from people who tell me, “I feel so stupid. I believed the salesmen who told me it was nontoxic and I could take as much as I wanted. I believed them till I turned gray.”

  12. Andrew Weil is a brand like Martha Stewart. She sells style. He sells wellness. I’m surprised he hasn’t changed his name to Dr. Well or maybe Dr. B Well. I’m waiting anxiously to see when he will introduce a supplement to cure for baldness. Boy would that be a money maker, well at least if he could patent it. But then of course who will do the research required to discover the cure if you can’t patent it?

  13. Zetetic says:

    Argyria? Valid medical uses for silver? I recall back in my days as an army medic during the Vietnam war that we treated burns with 0.5% silver nitrate solution. The patient’s skin typically did turn black but we didn’t consider that a dangerous side effect.

  14. There are approved topical silver drugs with a long history of use in treating burns. In very rare instances they have caused argyria, gray skin, but I think that most would agree that the benefit is worth the risk. I would also have to check the literature since I believe that the argyria caused by the topical use was at the site where it was applied, and as I’ve said already, the instances of this happening are exceedingly rare.

    Silver drugs taken internally were used widely before the advent of antibiotics. They didn’t work but caused many cases of argyria. Silver and argyria were studied extensivley in the early part of the 20th century. The definitive work ARGYRIA was written in 1939. I have material on all of this with extensive references on my webpage.
    http://www.webanstrich.de/rosemary/

    In the 1990s alt. med practitioners took silver, which they usually called colloidal silver or CS, back then out of the garbage pail of disgarded drugs and introduced it to commerce again as a “natural remedy” or “natural antibiotic”. When DSHEA went into effect, it became a “dietary supplement”. Ingesting silver is all risk and no benefit and as I predicted starting in 1995 when I learned that silver was sold as a supp, it has caused many cases of argyria. Google Paul Karason and Stan Jones. Also look at these:

    http://nccam.nih.gov/health/alerts/silver/index.htm
    http://www.fda.gov/oc/nutritioninitiative/report.html
    http://www.fda.gov/cvm/CVM_Updates/silver.html
    http://homepages.together.net/~rjstan/finalrule.html
    http://www.tga.health.gov.au/docs/html/csilver.htm
    http://www.drweil.com/u/QA/QA3690/
    http://www.drweil.com/drw/u/id/QAA363388
    If you cannot access Weil’s articles and want me to send them as attachments, let me know.
    http://www.pdrhealth.com/drug_info/nmdrugprofiles/nutsupdrugs/col_0289.shtml
    http://www.waikato.ac.nz/news/index.shtml?article=178
    http://dermnetnz.org/reactions/argyria.html
    http://canadianpress.google.com/article/ALeqM5j_CggIcaOqRvkXM777XZWV_dClyA
    Using the term “argyria”, you will find cases here:
    http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed
    This is the site of a lawyer who has gotten one out of court settlement and is now suing on behalf of other victims of argyria:
    http://www.goldenberglaw.com/CM/PracticeAreaDescriptions/Colloidal_Silver-Argyria.asp
    This is a great article except when you get to the end and they say that you probably won’t get argyria from CS if you use it for a short time in the “amounts recommended”. They obviously don’t know of all the “amounts” promoters recommend and the cases caused by people who took the “recommended” amounts. They also don’t realize that lab analysis has shown that the amount of silver listed on the label often is not the amount in the bottle. It can be higher or lower or even nonexistent.
    http://health.msn.com/general/articlepage.aspx?cp-documentid=100169473&GT1=10412
    http://canadianpress.google.com/article/ALeqM5j_CggIcaOqRvkXM777XZWV_dClyA

  15. wertys says:

    I am currently involved in the development of a curriculum for a new medical school in our part of Australia, and I’m pushing hard to get some content into the course on critical thinking and teaching the prospective new drs how to recognise and combat sCAM. At the moment it’s looking like I’m going to have to add the content as an ‘optional extra’ via online resources for students who are interested, but what the hell, it’s a start !

  16. pmoran says:

    “Approximations of the magnitude of the problem of overdiagnosis range from 10% to 30% of newly diagnosed Breast Cancer cases, depending on utilization and intensity of screening.[23,24]”

    Pec, why did you not quote this bit from the source you quoted? ( http://breast-cancer.kb120.com/Breast-Cancer-Screening—Harms-of-Screening_3.html )
    It would seem to supply the kind of information you state is not available.

    Of course, the rate of non-progressives cancers would have to be much lower in normal surgical practice, where many of the cancers are found by women as a newly developed lump (even by those already involved in screening programs).

    The rate will also presumably be lower in younger populations, so that autopsy rates for undiagnosed cancers will also exaggerate estimates as to the influence of non-progressive cancers on cure rates over a twenty year time frame. Also many of the cancers found at autopsy will be obvious cancers that were simply miseed during life in a rarely screened aged population. They would be deadly in longer-living patients.

    I hope you grasp the fact that much of this is of relevance to how we screen patients and what we do when we find tiny abnormalities on screening (many tiny lesions are simply reassessed at six monthly intervals looking for changes suggesting a progressive lesion). It can obviously have no influence on what we advise to a person with a biopsy diagnosis of invasive breast cancer. Do you agree? You should know that even some < 1cm cancers can metastasise to lymph nodes and beyond.

  17. Andrew Weil claims that he has received “insights” for his treatments while stoned. The “nutriceutical” and vitamin industry is nothing but that… an industry. This trove of useless “alternative” pills has not been shown to help people’s health, in fact it may cause harm. And it is in collusion with food manufacturers, e.g. snowing people into thinking that they need to eat vitamin fortified cereals in order to survive, while Denmark banned Kellogg’s cereals because they were concerned about the risk of osteopororis from excessive levels of Vitamin A.

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