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Science, Reason, Ethics, and Modern Medicine, Part 5: Penultimate Words

My Discussion with Dr. P

After last week’s post, Dr. Peter Moran answered with more salient points. I’ll spend this week discussing those, because I share Dr. Moran’s “interest in examining the kind of messages we are putting out.” Acknowledging the inequality inherent in his not being the blog author, I’ll offer the last word to Dr. Moran by ending this series* and letting whatever comments he may have in response to today’s post be the last, at least for now.

Here is Dr. Moran’s response to my response:

The standard healthfraud position is that even if CAM may sometimes be helpful to people, it is a bad thing regarding which there can be no compromise.

It is a bad thing because, to quote KA, “implausible claims being promoted, tacitly or otherwise” leads to  “unnecessary expense, a patient later feeling betrayed by her physician when the treatment doesn’t work or the ‘placebo effect’ wears off and she realizes that it was only a ‘pretend medicine’ all along, other patients or physicians concluding that the treatments have validity (and possibly being convinced to forgo rational treatment), people in general losing confidence in modern medicine when it appears that many physicians can’t distinguish between the rational and the bogus, wasted research funds, human subjects unnecessarily duped and endangered, a befuddled media, a befuddled public, befuddled leglislators endorsing quacks to a befuddled public,” [and more].

Superficially this is a powerful line of argument, because we can fairly easily find instances where such predictions are fulfilled. Yet I have suggested that healthfrauders routinely exaggerate the risks of CAM, that some potential dangers are not realized much in practice, and it again needs to be said that the medical risks depend very much upon the specific “quack” claim. Also, some of these outcomes, if as truly awful as implied, may be thought of as mainly exposing a puzzling lack of reach for more rational voices. This is the very reason why I have an interest in examining the kind of messages we are putting out.

And there is considerable evidence against some of the above. Surveys routinely show that the majority of CAM-using patients express great satisfaction with them. Despite this, nearly all also use conventional methods, and are satisfied with that. Even in this heyday of CAM, very few of the public use CAM exclusively.

The Scots are an interesting case study. They don’t seem to be vastly worse off health-wise or science-wise, or even exceptionally befuddled, yet 50% of their doctors prescribe homeopathic remedies and a further 10% use herbs.

What this adds up to is that the public may not be (generally) as indiscriminate in their use of alternative methods and as in need of protection from unscientific concepts as we healthfrauders like to think. Maybe we skeptics encounter a disproportionate amount of the dangerous and nutty extremes of “alternative” medicine because we go looking for it and we hang about on forums that gather it. We are also fairly obviously more deeply offended by it than most, which can lead to confirmation bias.

Which brings me to this: in science-based medicine we are quite accustomed to evaluating medical options in terms of benefits vs. risks. We normally try to quantify them so that we can reach a reasonable balance. An example is studies designed to determine the optimum dose of a noxious chemotherapeutic agent, so that cancer remissions are produced at acceptable risk. These days such studies even often include quality-adjusted life year (QALY) measurements so that all aspects of patient life can bear upon a precise, measurement-based, final judgment.

That’s how we normally operate. Not so, apparently, when it comes to CAM. In relation to that we adopt the meanest, least flexible possible position, even while lacking any clear evidence-based handle on the medical or psychosocial benefits or the social functions of unconventional and folk medical activity, or their risks. All we know, having completely dismissed all the anecdotal evidence, is that they usually don’t work obviously better than placebo when put to the test in the banal environment of the typical controlled trial. We don’t care that they may be being used mainly when there is no entirely satisfactory evidence-based treatments for the complaint, nor that some of the methods may simply have not yet been subjected to sufficient study to be quite sure whether they have intrinsic medical activity or not. It’s all one, if it is seen to be “alternative”.

Is the resort to ethical argument about the use of placebo medicines a lazy way of justifying such a globally rigid approach? The ethical card has some force, even when set against other primary ethical obligations of doctors towards their patients, but in reality it can only apply to that select few who have a clear enough grasp of the scientific evidence to be as certain as can be that any given CAM treatment IS a placebo. But Healthfraud has to also deal with what a lot of other practitioners think and what our patients are often trying out on their own initiative. It is a waste of time talking ethics to those who don’t share quite the same scientific convictions, and that applies to almost everyone.

KA seems to help my argument with personal medical experiences that are reminiscent of some of stories of “alternative” testimonial. I was quite struck by them, for I have had very similar personal experiences and observed them in many patients. They illustrate how there can be a complete disconnection between the benefits of medical interactions and their scientific content, and, indeed, any treatment content.

We have no basis on which to assume that similar benefits are not regularly occurring within CAM, especially when a lot of people are telling us so. In fact, KA elsewhere is arguing the reverse, that while CAM may be offering placebo and other non-specific medical benefits these can equally well occur within the 5-15 minute hurly-burly of the typical present day medical practice, I am sure they can, with good doctors, but I would love to be quite sure about the “equally”. Depending on the condition, and with as much reluctance and regret as anyone here, my money would be on the practitioner who is not hamstrung by what science says, and in consequence has a confident explanation for everything and never runs out of remedies. Sure, some of his clients may eventually realize that he is actually a nutcase, but even most of those will probably find ways in which they think he has helped them.

The reason I am being a bit stubborn about these matters is that I have what is as yet merely a vague inkling that they are important — that they may, despite initial appearances, help rather than damage our purposes.

Those who we might wish to influence in various ways may not have sufficient familiarity with science and medicine to be able to articulate the line of argument I am developing (it is difficult enough for me and I know I have a long haul ahead of me even if I am entirely right), but one of the reasons for our distressing inability to have the influence we desire may well be that people of ordinary intelligence and experience can nevertheless almost instinctively sense the weaknesses and exaggerations in some of our habitual arguments. They switch off. We may be able to do better with a change of tack that might actually be more in touch with medical realities.

Be reassured that looking at CAM methods in strict cost/risk/benefit terms will definitely not change most of our judgments concerning CAM. The main difference would be in the emphasis of argument and some of the rhetoric. We would still be able to describe Hulda Clark as a dangerous and severely deluded cancer quack, or, if you prefer, an unspeakable criminal fraud.

My Response to His Response to My Response

Let me say, again, that I am not trying to prohibit free citizens from pursuing whatever “CAM” they feel like pursuing. What I’m against is physicians violating their own ethical mandates, and governments and medical schools tacitly or explicitly promoting pseudomedicine. If 50% of Scots use homeopathy, so be it, even if it illustrates a deficit of science education in Scotland (I agree that “some of these outcomes…may be thought of as mainly exposing a puzzling lack of reach for more rational voices.” We’ve discussed that before: it argues for a better reach for rational voices, not for rational voices condoning the irrational). If “50% of [Scottish] doctors prescribe homeopathic remedies,” that is a different and real problem, both for medical ethics and for the regulation of physicians in Scotland. If Scots are not ”vastly worse off health-wise,” that is a triumph of modern public health and scientific medicine in spite of homeopathy, not because of it. Scots are obviously worse off “science-wise” for homeopathy, whether or not this has been measured, just as Americans would be worse off science-wise if “intelligent design” advocates had their way.

Yes, “we can fairly easily find instances where such [dire] predictions are fulfilled.” We on SBM have written about many of them. How many such instances does it take to counteract the (possibly) many more instances of patients expressing “great satisfaction” with “CAM”? Very few, it seems to me. I think that the public is in need of protection from unscientific concepts, both because some people are not as capable of discriminating as others, and for the larger societal reasons listed above. Even if that were not the case, my point in these posts is that physicians ought not to be dishonest. The border between what a physician can and cannot ethically recommend must be the point at which honesty and integrity are compromised, not the point at which some arbitrary distinction is made between “safe” and unsafe implausible treatments—even if pseudoscience might make some patients feel better.

A Digression

A regular column in the New York Times Magazine is “The Ethicist,” by Randy Cohen. Readers send real examples of ethical dilemmas for commentary by Mr. Cohen, who is very good at providing it. The July 27th issue included a non-medical illustration that “little white lies” are not the best policy:

The Ethicist

Hidden Opinions

By RANDY COHEN

Published: July 27, 2008

A friend, a nonwriter, retired after a distinguished career, asked me to read his screenplay because I am a published author. It was terrible: poorly written with no plot. Worse, it was clearly autobiographical, abounding in self-aggrandizement and intimate sexual details. To be kind, I told him merely that it was too personal. Recently he met a literary agent. I fear he will share this document with the agent and be humiliated. Must I now tell him my full opinion? — NAME WITHHELD, ARIZONA

If we rejected every work of fiction marred by vanity or cringe-worthy self-exposure, miles of shelf space would be left vacant at Barnes & Noble. And as a commercial matter, it is curious to discourage your friend from writing about himself in an era when memoirs proliferate like kudzu, which had sex with some other kudzu, to which it was not married. But it is in neither your literary judgment nor your commercial savvy that you most failed your friend — and fail him you did — but in your lack of candor. If he requested your honest opinion (and not just praise, another possibility), you should have provided it, as gently as possible. To be misleading is not to be kind.

It’s no picnic telling a friend that you don’t think much of his work, but you agreed to give him your professional assessment, and that’s what you should have done…

To be fair, I make the following disclosure. I asked Mr. Cohen’s permission to include that quotation in this blog, briefly suggesting to him how I would use it. He kindly gave his permission, but with this caveat:

I’m not sure I agree that the editor-writer relationship is analogous to the doctor-patient relationship, and I should also mention that many people—many writers—disagree with me here. Several said they’d absolutely lie to a non-writer friend who sought their opinion; they’d cosset the non-writer with praise.

I think that Mr. Cohen should give himself more credit. If anything, the doctor-patient relationship requires more ethical rigor, as it were, than does an informal interaction in the “outside world.” What many writers say they would do, moreover, is only barely relevant to the ethics of the situation. I agree that “to be misleading is not to be kind,” and also that there is a gentle, constructive way to be honest in such situations. That applies to writers talking to non-writers and to physicians talking to patients.

Digression Complete

Back to Dr. Moran. I’m not sure I understand his point about “quality-adjusted life year (QALY) measurements.” How can chemotherapy, a rational treatment whose effects, both good and bad, are well documented, be compared to “balancing qi”? We know a lot about implausible treatments. We know that they are implausible. We need to know about their “social functions” as much or as little as we need to know about the social functions of our patients’ religious beliefs. Sometimes that may be considerable (as in Dr. Moran’s previous example of the witch doctor), other times not at all, but never does it mean that we ought to promote such social functions—any more than we would promote religious beliefs.

“CAM” is not necessarily “all one, if it is seen to be ‘alternative’.” The occasional “CAM” treatments that are plausible—some molecules, mainly—deserve the same consideration from physicians as do plausible new drugs that have not yet been approved for general use: we should favor appropriate investigations but not premature recommendations, except in extraordinary circumstances. Other treatments that are typically labeled “CAM” but are not, such as relaxation, exercise, some diets, and some manual therapies, are perfectly rational and are not at issue here.

Was Dr. Moran referring to physicians when he wrote of the “select few who have a clear enough grasp of the scientific evidence…”? If so, that is a sad commentary on recent medical training. It also may reflect a little-appreciated deficiency of Evidence-Based Medicine, i.e., its failure to acknowledge the necessity of scientific plausibility. Regarding the charge that to “resort to ethical argument about the use of placebo medicines” is “lazy,” I think that in the current cultural environment, the easier and therefore lazier stance for physicians is to acquiesce to the “CAM” fad (just as to “cosset the non-writer with praise” is the lazier stance for writers). This is evidenced by the widespread encroachment of “CAM” onto medical school campuses and the almost complete lack of formal opposition.

Regarding the “placebo effects” that I reported having experienced (my “personal medical experiences”), I don’t see how those help Dr. Moran’s argument. The whole point of those experiences was that they occurred in the context of rational medicine. I don’t see any “disconnection between the benefits of medical interactions and their scientific content” in those experiences. On the contrary, it was the rational content of the information that I got from those interactions that made me feel better. Even if other people might get similar comfort from irrational content, so what? I have not denied that in any of these discussions; I have argued that physicians ought not to steer patients in that direction by subterfuge or ignorance, and that rational medicine has a similar, if sometimes unrealized capacity for comforting patients.

Dr. Moran’s next paragraph is the most troublesome. He surely knows that impugning the “5-15 minute hurly-burly of the typical present day medical practice” can only be an argument for changing the way present day medicine is practiced, not an argument for “CAM.” Regarding non-specific medical benefits that might accrue from “the practitioner who is not hamstrung by what science says, and in consequence has a confident explanation for everything and never runs out of remedies,” what is new or worthy about that? It’s a perfect description of the classical quack. It is remiscent of a passage quoted previously on SBM, whose very authors appeared to have missed the point:

Chiropractic finds its voice exactly where biomedicine becomes inarticulate. Too often, biomedicine fails to affirm a patient’s chronic pain. Patients think their experience is brushed aside by a physician who treats it as unjustified, unfounded, or annoying, attitudes that heighten a patient’s anguish and intensify suffering. Chiropractors never have to put a patient’s pain in the category of the “mind.” They never fail to find a problem. By rooting pain in a clear physical cause, chiropractic validates the patient’s experience.

Should MDs aspire to similar, deceptive practices, merely because they “validate the patient’s experience”? I’m sure Dr. Moran will agree that the passage does not constitute an argument for that. All it does is portray chiropractors as sleazy salesmen.

Conclusion

If rational medical practitioners need “a change of tack that might actually be more in touch with medical realities,” such a change might include offering patients more time, better explanations, more honesty, more sympathy, and a more creative range of rational treatments. All of Dr. Moran’s points argue for those. None argues for “CAM.”

KA will be on vacation next week.

………………

* The Science, Reason, Ethics, and Modern Medicine series:

Science, Reason, Ethics, and Modern Medicine Part 1: Tu Quoque and History

Science, Reason, Ethics, and Modern Medicine, Part 2: the Tortured Logic of David Katz

Science, Reason, Ethics, and Modern Medicine, Part 3: Implausible Claims and Formal Ethics Statements

Science, Reason, Ethics, and Modern Medicine, Part 4: is “CAM” the only Alternative? And: the Physician as Expert Consultant

Science, Reason, Ethics, and Modern Medicine, Part 5: Penultimate Words

Posted in: Medical Ethics, Politics and Regulation, Science and Medicine

Leave a Comment (29) ↓

29 thoughts on “Science, Reason, Ethics, and Modern Medicine, Part 5: Penultimate Words

  1. pec says:

    ” some of the methods may simply have not yet been subjected to sufficient study to be quite sure whether they have intrinsic medical activity or not.”

    Very true. You label them as “implausible” and never wonder if they might actually work.

  2. ama says:

    Let me point to one disadvantage of most of the discussions I see: they are too long. Using many words leaves too many “if”, too many “perhaps”, too many holes for the esottery to creep through.

    To give you an idea of what I mean:

    The naturopaths (and the whole esottery scene) claim: “It is not us who heal, the body heals itself.”

    They are right. The body heals itself, because the naturopaths HAVE NO MEDICINE. The body heals itself DESPITE the nonsense the naturopaths do. The disadvantage is that the body heals itself only in a part of the cases. The others die.

    If we are consequent, we leave out the whole esottery and leave it all to the body. If the body heals itself, it is fine. If not, the geene pool is cleaned.

    So, if were are consequent, we do not need any medicine at all.

    If we do medicine, we do medicine. And all esotery and snake-oil must be kept out. It is as simple as that.

  3. Jules says:

    A few things:

    1) Why do you seem so surprised that doctors aren’t being trained in how to critically evaluate studies? Medical school had one statistics course, over one semester, which most people (myself included) half-assed because pathology and microbiology were much more pressing. And this was a scant 5 years ago. Maybe things might have changed, but I doubt it. Medicine can be incredibly conservative in some respects–do you remember the huge fuss kicked up when some groups advocated reducing resident hours?

    2) As much as we may ridicule a patient’s belief that herb such-and-such works great, taking on a “Doctor knows best” attitude is a REAL turn-off. I once had a case of impetigo diagnosed as “just another flare-up” of my eczema–I knew it was different, but you couldn’t have told the dermatologist that. Validating your opposition’s (the patient’s) point of view, as any marriage counselor will tell you, goes a long way towards persuading them to at least try things your way. And no, I didn’t take the steroid cream he prescribed, because it made it worse.

    3) Do you suppose there is such a thing as “individualized medicine”? In the US, if a drug shows a chance of being a hERG channel blocker, it is required to be labeled as such, and in some cases it ends up being pulled from the market. The evidence is now pointing towards the culprit being the patient’s SNP mutations in certain binding domains of the hERG channel. Suppose that, in a patient, a “bad” drug works wonderfully well and he wants to continue taking it. But there’s a 10% chance, according to the latest journal, that he’ll die. He’s seen the article, he knows the math. But he doesn’t think he’ll be one of the dead ones, and he asks you to keep giving him the drug.

    The question is not “What would you do” or even “Is this ethical”. It’s that, given our increasing body of knowledge about the workings of receptors, the effects of mutations, and the rate at which molecular databases are growing, will a clinical trial still be as meaningful in the future as it is now?

  4. ama says:

    What is the purpose of a clinical study?

    1. A clinical study in nearly all cases will NOT help those who are ill NOW.

    2. There are cases where ill persons take part in a study – and hope that they might profit from the study. But in so many cases the risks for the participants are high.

    Result 1: Most studies will bring good IN THE FUTURE.

    3. A study must do something good. Would it make sense to make a study on what would happen if we do NOT do appendix surgery? Not likely.

    Now, what would you think about people who DO WANT that appendix surgery MUST BE STOPPED? Would you believe that such people even make petitions in the senate?

    Does this sound insane?

    Would you believe that we FOR YEARS now are contronted with exactly THAT situation?

    Yes, ware really are. except that it is not that these people want appendix surgery be banned, they want vaccination be banned.

    Result 2: If you guess about the ethics of a study, you also should guess about WHO wants it, WHY he wants it, and about the ethics of NOT doing that study.

  5. Jules says:

    @ ama: I think you misunderstood the question, so I’ll try it again differently.

    Medicine is moving in a direction where therapies are targeted towards individuals. This could mean that a risky drug (the 10% death rate is at the higher end of the drugs that are hERG channel blockers) is actually okay for some people and not for others. So your large-scale clinical trial, in which 10% of people die, wouldn’t necessarily be applicable to a particular patient. Does this render clinical trials useless?

    And for future reference: appendectomies are usually emergency procedures. It’s not a question of wanting, but a question of how quickly can an inflamed appendix be taken out before the patient dies. In these cases, most would agree: cut first, ask questions later.

  6. ama: “Let me point to one disadvantage of most of the discussions I see: they are too long.”

    In principle I agree with your entire point. The problem is that it was exactly this response, ie, that the issue was not even worthy of discussion, that provided the opening for esotery (now that’s a word I haven’t heard in a long time…) to ooze into medical schools and everywhere else (see Jules’ point number 2). Hence, better late than never, we now attempt to explain why that oozing wasn’t a good idea.

    Jules: “1) Why do you seem so surprised that doctors aren’t being trained in how to critically evaluate studies?”

    If you are referring to the sentence, “If so, that is a sad commentary on recent medical training,” I was not expressing surprise that doctors aren’t being trained in how to critically evaluate studies. I was expressing surprise that doctors don’t “have a clear enough grasp of the scientific evidence” (Dr. Moran’s language) to distinguish fantasy—homeopathy, craniosacral rhythms, meridians, chakras, homunculi on the iris, ear, and foot, coffee enemas, and all the rest—from reality. Those are scientific issues that have little or nothing to do with studies, as explained in a series of posts several mos. ago, more or less beginning here: http://www.sciencebasedmedicine.org/?p=42

    Jules: “2) As much as we may ridicule a patient’s belief that herb such-and-such works great, taking on a “Doctor knows best” attitude is a REAL turn-off.”

    If that comment was directed at my posts, you have misinterpreted them. Read the conclusion and my response to ama above.

    Jules: “3) Do you suppose there is such a thing as ‘individualized medicine’?…The question is not ‘What would you do’ or even ‘Is this ethical’.”

    Yes, there is individualized medicine, and it’s already practiced. There are plenty of drugs (maybe even most of them) that have intolerable side effects (including death) for some people, but are nevertheless useful for others. It sounds as though the only difference between that and your example is the incidence of death. In the U.S., a 10% death rate could result in the FDA refusing or withdrawing approval, depending on the indication for the drug (for high blood pressure it would certainly be refused; for cancer chemotherapy, not necessarily so). Thus the choice may be out of the hands of both doctor and patient. If it is in their hands, one of the questions is always “is this ethical?”.

    Regarding studying appendectomy: believe it or not, it has been done more than once recently. The results strongly favor surgery, in my opinion, but not in the opinion of the authors: http://www.ncbi.nlm.nih.gov/pubmed/16736333?ordinalpos=4&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

    ama is also correct, literally, that “we FOR YEARS now are confronted with exactly THAT situation.” Here is the naturopathic view of appendectomy, quoted from the Alliance Legislative Workbook (the site has since been blocked):

    Appendectomy is a costly technology with the standard risks associated with surgery. The relative benefits and risks of treating appendicitis through surgery or other treatment have not been fully evaluated. For example, there is strong evidence suggesting that appendicitis may be treated with substantially fewer appendectomies without increased loss of life. Thus a controlled clinical trial of the nonsurgical or delayed surgical approach to treatment…might be warranted.

  7. Jules says:

    I was expressing surprise that doctors don’t “have a clear enough grasp of the scientific evidence” (Dr. Moran’s language) to distinguish fantasy—homeopathy, craniosacral rhythms, meridians, chakras, homunculi on the iris, ear, and foot, coffee enemas, and all the rest—from reality.

    Even so, I don’t see why you’re surprised by that. I don’t think it’s so much that doctors don’t have a clear enough grasp of the scientific evidence as it is that they have a crystal clear grasp of how little we actually know (and, of that, how miniscule the portion is that’s actually clinically useful). Either that, or they’ve forgotten all of the science that they’ve ever learned–which is not at all hard to do, and when some of the bunk actually coincides with some of the science–chakras are more or less aligned with the major plexi–it’s not entirely illogical to say, “Well, why not let that person have it his way?”

    I did read your conclusion. I’m just not convinced that attempting to explain away someone’s beliefs that they grew up with is going to get you anywhere when it comes to actual treatment, and would probably worsen compliance. Once you leave the model of a white, reasonably-well-educated patient (who would be receptive to the ideas of science), and go into not-educated-at-all-and-slightly-paranoid places, rational explanations against what are very powerful emotions and beliefs seem pretty weak. I think you underestimate the conservativeness of human nature–when what someone experiences on a daily basis confirms what he’s been taught to believe, who are you to say, “No, that’s wrong?” It’s akin to explaining to a devout Christian that God doesn’t exist.

    Of course main question is “Is it ethical?” but I was referring to the utility of clinical studies in an age where every patient is an N of 1.

    As far as the appendicitis study: I would agree with you that the evidence says that surgery is probably the best choice. And I would say that the authors think so, too. The goal of the study was simply to determine whether appendicitis could be resolved without surgery with an acceptable rate of success, and it could (though, again, I agree, surgery is better). That was all that they said in the conclusions. Please don’t read too much into abstracts–they’re abstracts for a reason. Without the paper, you can’t really tell what they actually opined.

  8. “I don’t think it’s so much that doctors don’t have a clear enough grasp of the scientific evidence as it is that they have a crystal clear grasp of how little we actually know (and, of that, how miniscule the portion is that’s actually clinically useful).”

    How little we actually know is not an excuse to give credence to nonsense. Much of what we know is clinically useful. We know that Avagadro’s number and the 2nd law of thermodynamics refute Hahnemann’s “law of infinitesimals.” We know that there are no homunculi on the iris, ear, or foot. We know that if only a few people believe that they can detect “craniosacral rhythms” but they can’t agree among themselves about what those are, and that if a highly sensitive instrument cannot detect them, the most reasonable conclusion is that “craniosacral rhythms” don’t exist. We know that inflating a balloon in the nasopharynx is vanishingly unlikely to “allow the connective tissues (including the meningeal system) to release their residual tensions and move the bony structures incrementally back towards the body’s original design.” We know that chakras do not correspond to “the major plexi” in any physiologically important way. We know that coffee enemas are a dangerous and irrational way to “remove toxins” that, in the “CAM” sense, are ill-defined to the point of uselessness. We know that even if that weren’t the case it would already be too late for a patient with cancer, because we know that cancer is a genetically stable change in crucial cell characteristics. We know much more: enough to reasonably judge many claims, including almost all “CAM” claims that don’t involve the ingestion of biologically active molecules (and many that do), implausible.

    “I’m just not convinced that attempting to explain away someone’s beliefs that they grew up with is going to get you anywhere when it comes to actual treatment, and would probably worsen compliance. Once you leave the model of a white, reasonably-well-educated patient (who would be receptive to the ideas of science)…”

    Who in our culture “grew up with ‘CAM’?” Ironically, it is the “white, reasonably-well-educated patient” who is most drawn to “CAM,” according to every study that has looked at that. We discussed that issue last week when contrasting the “primitive tribesman” with the typical American or European “CAM”-seeker. “CAM” is not religion, except in a very limited sense that is hardly what we are talking about here.

    Even if it were, physicians must still be honest to be ethical. If Christian Science parents asked my opinion about how to treat their toddler with meningococcal meningitis, I’d give it in a gentle but unequivocally honest way. If they demurred, I’d change that to a brutally honest way. Wouldn’t you?

    “Please don’t read too much into abstracts–they’re abstracts for a reason. Without the paper, you can’t really tell what they actually opined.”

    Are you new here? :-) I’ve read the whole paper: its conclusion is exactly what the abstract suggests, but there is even more evidence that this conclusion is unjustified. I disagree that “appendicitis could be resolved without surgery with an acceptable rate of success,” because the standard for an “acceptable rate” is that associated with surgery, and it remains clearly superior to that without surgery. I’ll admit, however, that the success rate without surgery was surprisingly high, and I suspect that this explains why both the authors and you have overstated it.

  9. pmoran says:

    Brief points.

    1. KA, we are still talking across each other, with your arguments explicitly referring to the activities of ” — physicians violating their own ethical mandates. and governments and medical schools tacitly or explicitly promoting pseudmedicine ” and me mainly thinking of everyone else that healthfrauders have to talk to, those who are usually not bound by these mandates.

    And, for Pete’s sake, you only need to be a tad uncertain as to whether a treatment works or not, sometimes no easy judgment on any basis (how many studies have been needed on SJW and glucosamine again?) for a trial of its use to become ethical under certain conditions. The presumption of clear-cut demarcations is one of the weaknesses of healtfhraud rhetoric.

    2. Finding certain healthfraud arguments unconvincing is by no means the same thing as “promoting pseudomedicine.” yet this implication concerning my views seems to again to be creeping into your writing. I assume you don’t mean it. What could be more hostile to the pseudoscientific content of CAM, than my contention that CAM is based wholly upon a terrible misinterpretation of what patients observe and report (i.e. the placebo, other non-specific “effects” of medical nurture, spontaneous events etc)? The only difference between us is that I am taking a matter that we are both agreed upon, i.e. that alternative methods and practitioners probably can sometimes help their patients, through to certain logical conclusions.

    3. Yes, one result is a slightly less rigid attitude towards the USE of methods that are deemed unscientific (even if they can “work” :-) ), but what is fairer and more science-based than wanting to apply a strict cost/risk/benefit standard to them?

    I have yet to reveal how, even if we are prepared to credit CAM with the limited, baseline. generic beneficial influences that pervade ALL medical activity, this approach may have a serious sting in the tail for some of the promoters of CAM. It may force everyone, critics and supporters alike to concentrate on the main game, not letting the waters to become muddied (sorry, those bloody metaphors again! :-)) by peripheral matters and pseudo-argument .

    For example, it may help force holistic protagonists and other “alternative” theorists out of their habit of talking of illness and medicine as vague abstractions wherein doing nice-sounding things might be nice. They may be forced at last to state exactly what kind of illnesses their methods are good for and what their methods actually do and don’t do. They will have to justify their cost to those having to foot the bill, and also explain why this treatment that seems to have a similar range and potency of activity to placebo should be chosen over dozens of methods having similar qualities. Accepting that they do some good immediately defuses many of the diversionary arguments and puts the onus onto the claimant to show how much.

    Such an approach may also help relegate interminable, pointless arguments about whether HEFs exist and dilute solutions can have memory to the fun, hobbyist, side of healthfraud activity and get “what’s in it for the patient” to the forefront when important public decisions have to be made or the public needs to be informed as to what to expect of them.

    But I am still thinking about all this.

    It is up to you whether you want to respond further. I would prefer it if others including yourself attacked me wherever you want, as I am as yet merely working on a hypothesis as to how best to approach CAM so that it does least harm.

  10. durvit says:

    KA wrote:

    Who in our culture “grew up with ‘CAM’?” Ironically, it is the “white, reasonably-well-educated patient” who is most drawn to “CAM,” according to every study that has looked at that.

    It might depend on what you call CAM. I’ve met people in the 30-50s whose parents fed them wholefoods and the occasional supplement at a time when that was definitely ‘alternative’ or food faddism in the UK. The parents may also have practised yoga. Interestingly, of course, some of them may have been referred for homoeopathy treatment on the NHS. Before streptomycin, it’s unlikely that the success rate for homoeopathy and other treatments for TB was very different.

    So, not crystals, reiki or similar, but in the UK, and elsewhere in Europe, it is entirely possible that a number of people in earlier generations “grew up with ‘CAM’” and possibly carried that with them, even to the US, and that is still influencing various beliefs and practices. I’ve no idea whether it is a gateway to believing in other CAM or whether people remain attached to beliefs with which they are familiar.

  11. Jules says:

    Who in our culture “grew up with ‘CAM’?” Ironically, it is the “white, reasonably-well-educated patient” who is most drawn to “CAM,” according to every study that has looked at that.

    I’d have to guess a fair number of people, actually. There are people who eat clay (not from pica), swear by the healing powers of urine and saliva, and, depending on how much “alternative” you want to get, grow up on/teach their kids the value of macrobiotic diets, the importance of “balance” in their lives. Any runner you’ll talk to will swear by the now-known endorphin rush, but it’s not clear whether that’s got anything to do with the increased creativity and concentration that people attribute to running, yet people will swear by it. In the inner cities, esp. immigrant populations, there are a diverse array of beliefs about spirits and toxins and bad things and good omens that a doctor would be stupid to ignore (“Well, you don’t seem to have a fever, so I guess it can’t be the flu”–when the patient’s just downed a cup of willow-bark tea before coming in–and of course such things wouldn’t count as “medicine”, because that’s what the doctor gives you). Neither of us would seriously take sangria as “medicine”, but I would hope that we would both realize the importance of the belief in a patient’s life.

    Ironically, the fact that it is “white, reasonably well-educated” patients seeking CAM actually lends credence to my point that they’d be the ones most amenable to additions to their body of knowledge. If they didn’t grow up in it then they most likely adopted it because they heard one thing and drew the wrong conclusions, whereas adding some more information would lead them to the right ones.

    I didn’t know you’d read the paper–I can’t access it, seeing as I don’t have $55 to spare for the sake of argument :-D But I question the impact factor of that journal, the types of articles it publishes–is it an otherwise good journal that just let an anomaly slip, or is it a small journal that will publish anything that will stick?

    And yes, I would tell the parents that they’d better treat meningococcal meningitis or else their kid dies–I’m not one to pussyfoot about with explanations. But that’s undoubtedly an area where allopathic medicine will succeed. What about a patient with neuropathic pain which is, at best, partially relieved with the strongest legal dosage of opioids (which are slated for failure in six months) wanting to try accupuncture? Or someone who swears that fasting is good* for them?

    *Having “accidentally” fasted before (grant proposal due in a week, started it on Monday, one of those weeks), I can assure you, you feel VERY good after a few days, so much that you almost don’t want to eat again. Of course, getting to that point is an awful ordeal–and no, I do NOT and would NEVER recommend fasting, but having done it a few times (under similar pressure deadlines) I can definitely see why people swear by it.

  12. Fifi says:

    Most people – it seems as an outside observer (since both my parents are doctors I started out in a different boat than most people) – grow up surrounded by unscientific medicine. There are folk remedies particular to certain cultures but there are also family folk remedies and family health myths that get passed down through the generations (some useful, some not). The other source of confusion – particularly in the US since direct to the public drug advertising has been allowed – are the myths about health and illness of all kinds that are essentially created by the marketing divisions of the pharmaceutical and “wellness” industry. Advertising is about creating need and the way this has been done is to create the illusion that feeling “good/happy/safe” all the time is natural, reasonable or even attainable or desirable (anyone who questions the utility of pain should see what happens to children born without the ability to experience pain – they routinely gouge their eyes out and inflict severe harm on themselves because they can’t feel the damage they’re doing to themselves). Of course, nobody does feel good/happy/safe all the time (even the Dalai Lama feels anger, sadness and emotional and physical pain). However, advertising (and some spiritual/religious orders) create the impression/illusion/delusion that this happily-ever-after state is entirely attainable and realistic as a constant state (Disney really does hold some responsibility here!)….if only you buy their product, of course. I’d say the huge popularity of CAM in the US has a lot to do with how industry has created and nurtured this dissatisfaction and false expectations in the general public, and sold them the holy grail of a magic bullet that will create inner peace, health and unbounded joy. Advertising outside of the US also does this but not to quite the same extent (and the American Dream TM – two cars, a house and the latest appliances – is itself a contrived idea sold to the American public by advertisers that has been internalized as a national identity).

  13. As far as I can tell, the arguments offered above for Westerners “growing up with ‘CAM’” in a sense comparable to growing up as “a devout Christian” amount to these:

    1. Some recent immigrants and some “natives,” e.g., Christian Scientists, actually have grown up with deeply held, irrational beliefs about health and disease. I agree, although I’d argue that this is not, for the most part, what we are talking about when we speak of “CAM.” I have also previously discussed my view of how physicians ought to respond to people with those backgrounds (remember the “primitive tribesman” and the “social functions of unconventional and folk medical activity”?), and I suspect that it agrees with that of Dr. Moran, Jules, etc.

    2. Runners who swear by the “endorphin rush” and people who “teach their kids the value of macrobiotic diets” did not adopt those views for reasons that are remotely comparable to having grown up as a devout Christian. Nor, I will continue to argue, did the large majority of Western “CAM” seekers, who are “white [and] reasonably-well-educated.”

    I suspect that Dr. Moran (and perhaps others) and I are inching closer to agreement. Using Jules’ example of “a patient with neuropathic pain which is, at best, partially relieved with the strongest legal dosage of opioids (which are slated for failure in six months) wanting to try accupuncture,” we come to the crux of the issue. If it is the patient who brings up acupuncture, what the physician must do is be honest: “there is no reason to predict that the treatment has any effect beyond counter-irritation and ‘placebo.’ Nevertheless, some people swear by it (although for most it is slated for failure in six months) and it is likely to be harmless, in the purely physical sense. There is no such thing as ‘expertise’ other than in avoiding dirty needles and vulnerable anatomical structures, even if there are ‘degrees’ and experience. If you choose to do it, please be wary of the practitioner venturing medical opinions beyond the issue at hand (which will almost certainly occur); if this happens and you are tempted by it, please call me ASAP.” I probably wouldn’t even get into “theory” unless the patient asked, and in that case I’d tell him or her the unequivocal truth, not necessarily in this language: it is as rational as the 4 humors and lacks internal consistency.

    It should be clear by now that what I consider unethical is for the physician to recommend acupuncture (or homeopathy, etc.) to the patient who has not brought it up, or for the physician whose patient does bring it up to respond “what a good idea!” That is what I’ve been railing against, and that is what is happening all too frequently in the US (and Scotland ;-) ) right now. I get the feeling that Dr. Moran, for Pete’s sake, agrees.

    Note to Jules: modern medicine is not “allopathic.”

  14. I almost forgot: Fifi, you hit the nail on its proverbial head.

  15. Fifi says:

    Thanks Dr Atwood. It’s one thing to identify the problem though and entirely another to come up with a solution! I do agree that the physician needs to be clear with a patient about the science around CAM treatments and not actually promote them (other than something simple and entirely non-magical, from what I’ve observed a lot of the “benefits” of many CAM treatments aren’t particularly magical and are quite easily explained). I do think there are some areas where some GPs (and specialists) could do a better job but that’s true of any profession – and particularly true of one where communication is an important part of the interaction. It’s also highly unfortunate that more and more often people who train as doctors don’t want to be GPs and family doctors – unfortunate for both medicine and patients because GPs actually do most of the on-the-ground communicating and explaining of complex issues (and everyday questions) that patients have to deal with. It’s also unfortunate because it’s the longterm relationship between a physician and a patient that builds trust and also allows the doctor to know the patient well enough over a substantial period of time. This means s/he is better equipped not only to spot potential problems and bring preventative measures up with the patient, and potentially knows family history of disease and the family character (so the patient’s medical and emotional/psychological context), but also knows the patients medical history well. All these things make a huge difference to the kind of treatment the doctor can provide and the communication between doctor and patient.

  16. KA, “It should be clear by now that what I consider unethical is for the physician to recommend acupuncture (or homeopathy, etc.) to the patient who has not brought it up, or for the physician whose patient does bring it up to respond “what a good idea!” That is what I’ve been railing against”

    Perhaps I am the only one confused. I knew very well that you were “railing against” that, but I also felt that you were railing against what i consider very rational approaches of speaking with patients about CAM that were mentioned by Drs. Moran and Hall, approaches that took into account the complexity of medicine, human beings and the interaction of the two in the real life practice of medicine. I thought you were saying, Sorry, evidence based medicine has nothing that can help you, Mrs. Jones. You say you are interested in CAM? Well CAM offers several things for which they make implausible claims but they are all based on irrational beliefs. Only a fool would try them. Goodbye. However, from what you write above about what you would tell a patient interested in trying acupuncuncture, either I was incorrect or you have changed your position.

    I too agree that Fifi hit the nail on the head, but I think she has said similar things before and I have tried to say that too several times but for the most part was ignored. So let me try again.

    Marketers do their damndest to create a need in the mind of their target markets, a need that they pitch and sell goods and services to fill, and they are very good, very scientific about their jobs. As i’ve said so often before, the reason quackery is now an epidemic is because the MBAs and marketing geniuses saw how ripe society was for their “wellness” businesses. They brought it from those with fringe beliefs in the backwoods to the general public in the mainstream market. It came from the bottom up not the top down, from the backwoods to Harvard.

    As i’ve also repeatedly said, supplements are the fuel, the $$$$, that fuels the billion $$$ alt industry. You (plural) can take the high intellectural and moral ground and say that you don’t know much about supplements. Some may have a rational base for use, but what really annoys you and what you are out to expose and stop at least in hospitals and med schools is CAM or therapies based on implausible claims and irrational beliefs. As soon as you do that, I believe that you disconnect from the general public and the MD in the trenches. I don’t think very many of them take “energy fields” and other wacky things not supported by solid evidence seriously the way you seem to assume that they do. Most are just looking for something that makes them “feel better” or offers them hope even if they only feel better for a short time and even if the hope is false. They are looking for comfort that used to be offered by chaplains and doctors with a good “bedside manner”.

    Pharmacology is a wonderful science. It tells us which drugs generally work for which diseases and conditions, but it doesn’t address the needs of each and every individual, and as others have stated, there are many serious diseases and conditions, including psychological ones, for which pharmacology and scientific medicine have no remedies. These too are dealt with by practicing MDs and their patients everyday. At that level it is not an intellectual or moral debate.

    As i’ve said, not all quackery is created igual. You can’t paint it all with a broad brush or give it all igual weight. Peter M. has put it better explaining the need to warn patients outright about dangerous and fraudulent remedies and therapies but being less forceful in talking about harmless things like homeopathy. (Of course, that is based on the premise that not all implausible claims are igually dangerous, a position I too hold.)

    The other thing I think you have to realize is that MDs are part of our society subject to the same pressures as everyone else. Most have a great desire to help people. Most don’t want to see people suffer. If they know a patient’s problems are psychological and that psychotherapy will not or has not helped him but think that maybe a hands-on useless therapy by someone who appears very caring will make him feel better for awhile or that maybe a useless pill will do it, I don’t think that is something to get railed up about. I think our energy and talent is better spent going after the cause of the epidemic, the fraud perpetrated by marketers to make money, lots and lots of money. Fraud is much easier to fight than “irrational beliefs” and “implausible claims”. Actually, I think that everyone who cares deeply about people understands that need, the need to protect people from danger and crooks.

  17. diogenes says:

    The claim that the Scots are being poorly served by a bunch of quacks – “50% of their doctors of their doctors prescribe homeopathic remedies and a further 10% use herbs”, is an appalling distortion of the facts. Alas, it is all too typical of the self-serving hyperbole and manipulation of real data in this kind of debate.
    Have a look at what I presume to be the supposed source of this calumny – http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1885188

    I can do no better than to quote the first sentence of the paper’s Discussion – “Almost half of Scottish general practices prescribe homoeopathic and a third herbal remedies, indicating that at least 12% of Scottish GPs prescribe homoeopathy and 1.8% oral herbal remedies”. A far cry from the notion that half of all doctors are engaged in the practice.
    Note also that the survey was a snapshot of prescribing habits in 2003-2004.

  18. It is my impression that those extremely concerned with irrational beliefs sound like philosophers and theologians not scientists. This comes across when they speak of things like the serious dangers of things like the belief in psychics, dowsing, homeopathy, etc.

    It seems especially strange to me when true believers in evidence based medicine do this. I don’t understand why they don’t look for the evidence and weigh risks against benefits like they would in evaluating a drug or therapy.

    IMO, a few good articles explaining what homeopathy is or the danger of a stroke from chiropractic neck manipulation are sufficient. To continue on and on is like beating a dead horse. No one will ever convince everyone of anything. Trying to is a waste of resources. What we can and should do if able is to state the facts and our sources, give the reference or link when the subject comes up again and leave people to draw their own conclusions.

  19. RJ: “…from what you write above about what you would tell a patient interested in trying acupuncture, either I was incorrect or you have changed your position.”

    I have not changed my position. I do believe, however, that the greater societal problems of “CAM,” eg, unethical human trials, wasted public money, governments portraying quacks as “primary care physicians,” medical students being taught nonsense, science and evidence being perverted, etc., are more important than whether or not some patients are comforted by its more benign forms. That’s why I write about those things, mainly, and that’s how this series began.

    Regarding how I speak to patients about “CAM,” which in my anesthesiology practice I rarely do, I probably should have been a bit more adamant. After the “nevertheless, some people swear by it” part I might, depending on the patient, discuss the post hoc fallacy, although not necessarily using that term. I would probably say that I do not recommend “CAM,” and I might say that if anyone in my family were to ask my opinion of it, I’d strongly advise against it. If the patient wants to discuss it at length or read about it from honest sources, I would (and have) provide those.

    On the other hand, I would never say: “Sorry, evidence based medicine has nothing that can help you, Mrs. Jones. You say you are interested in CAM?…Only a fool would try [it]. Goodbye.” I don’t believe that rational medicine ever “has nothing that can help,” as I thought I made clear last week, and being honest doesn’t mean being an asshole.

    Now, about your contention that the “supplements” industry drives most of “CAM.” Maybe yes, maybe no: it had nothing to do with James Reston’s acupuncture story in 1971 (or whenever) and it wasn’t particularly involved in the creation of the OAM, for example. It’s also a slightly different, albeit related, issue from what Fifi wrote about: a Madison Avenue-driven myth that everyone oughtta be “happy,” and that anything less implies a diagnosis and/or the lack of some product.

    Nevertheless, it’s possible that much current sCAMmery, particularly at the level of the US federal government, is prop’d up by “Big Supple” (BS). This should be discoverable to an extent. Are the major Congressional bad actors, eg, Burton and Harkin, on the BS payroll? I imagine Orrin Hatch is, but he’s from Utah, where most BS resides.

    What to do about it? The most obvious strategy would be to work for the repeal of DSHEA, which as previously argued may not be an impossible task. Are any groups (eg, Consumers Union, CSPI) working for this? Are any congressmen (Henry Waxman, for example, who chairs Burton’s old committee and who seems interested in reversing the Burton damage)?

  20. Fifi says:

    rjstan – One thing that makes discussing these issues complex is that there are many different issues that tend to get tied in together (they cross over but are actually separate issues in many senses). I suspect we agree about many things but my perspective on the influence and effect of advertising (as Dr Atwood pointed out) was from a larger sociological/cultural level. Advertising (and other propaganda) has been shaping our culture and influencing how we think and feel – and distorting our perceptions of ourselves and the world around us – for over half a century (advertising has been around much longer but it took TV to really make the medium the message). So, what I was really pointing out how ALL advertising and social propaganda – almost all of which sell “lifestyle” and social image at this point with the actual product tagging along merely as a signifier of lifestyle – has set up people to be dissatisfied and lacking and to believe in magic bullets. The issue of Big Sup lobbying is connected but is more of a symptom than the issue when looked at from a cultural perspective.

    There seem to be many issues and ways to look at them…
    1- The infiltration of CAM into academic and institutional environments that superficially at least profess to be evidence and science based (this is due to a variety of factors that range from economic to political, as well as genuinely curious or misled academics). This is about academic and institutional integrity.

    2-The influence of Big Sup on politicians and direct marketing to the public based upon false claims (I understand this is an area where you’re very knowledgeable). I’d thrown the direct to consumer advertising by pharmaceutical companies in here too since they’re just as bad in terms of creating a false need and false expectations – though they skate around legalities a bit more carefully. This is about political influence and legislation. This is a different issue in different countries for a variety of reasons (universal vs private healthcare being a big factor).

    3-Well meaning people who become CAM practitioners (most of the CAM practitioners I know fall into this category) and the people who go to see them – so what your average person gets out of CAM. This is about cultural context, sociology and psychology. These are the people who think CAM works because their education/training was hard/expensive/long and they’re invested in it on many levels, and patients who believe it works because it helps them feel “better”. This would be the bulk of people from my perspective.

    4. Total quacks and charlatans – these come in a variety of flavors (including royalty, dictators in hiding and pig farmers ;-) ). Though, even here, I wouldn’t underestimate the capacity of the human mind to justify anything they profit from as a “good thing” in some way (even the most heinous people tend to see themselves as “good” or righteously carrying out god’s plan or radical heroes that will be vindicated by time, etc). If Big Oil can pretend they’re environmentalists and “green” there’s no limits to the fantasies apparently.

    5. The relationship between a doctor and patient, and the doctor’s ethical responsibilities and how to communicate about CAM in a way that’s ethical and science based – that first does no harm – but that also recognizes that CAM can encapsulate religious/spiritual ideologies for some people.

    No doubt there are more issues that overlap but are somewhat different in nature and require different approaches and solutions. Good marketing or political strategy always requires tailoring your approach to your audience

  21. Fifi says:

    I’d like to add that the effects of the advertising age (whether it’s cars or government policies being sold) and denigration of reality-based thinking impact us and our societies in a practical way in more areas than healthcare.

  22. overshoot says:

    What to do about it? The most obvious strategy would be to work for the repeal of DSHEA, which as previously argued may not be an impossible task. Are any groups (eg, Consumers Union, CSPI) working for this?

    Funny you should ask that question.

    It would seem that Consumers Union recently did a report on homeopathy, and at least one woo merchant (http://www.liddell.net) has gone on the counteroffensive.

    I’m very interested in how the “Pharma Shill Gambit” works against CU.

  23. Fifi says:

    This seems relevant to the conversation…an article about a study that shows how private insurance policies are changing the face of psychiatric care in the US (and not for the better or in the patient’s best interest – this is despite evidence for talk therapy with or without pharmaceutical intervention).

    http://www.sciencedaily.com/releases/2008/08/080804165316.htm

  24. pmoran says:

    KA, if the patient with uncontrolled pain asks you “what do you think of acupuncture?” and you are sure you are interpreting the meaning of the question fully, then it would be reasonable to tell the patient everything that you do think about it in such negative terms.

    If, OTOH, the patient’s request is a disguised or open “I would like to try acupunture for my unresolved medical problem”, I think it is presumptuous on many grounds to see this as a opportunity for advancing what you see as the interests of science or “truth”, as you interpret them. That has almost nothing to do with this particular patient-doctor interaction and it is, frankly, ridiculous to suggest that the future of science or medicine is to any degree at stake for what you may or may not say to this person about acupuncture.

    As you yourself imply, there are many ways in which we can offer the patient our support and best wishes for success without having to lie to them. You can have no certainty as to how any particular patient will respond to acupuncture or how the additional medical attentions may help them cope with their problem.

    Science and scientific medicine are irrestible forces because they work and and are based upon an obvious logic for most people. I don’t understand why some are so insecure about its future.

  25. This obviously isn’t the place for a detailed account so I will only make a few comments and suggest that anyone interested who has the time and resources talk to professional marketers and with their help do a study of the way unscientific medicine is presently marketed. Brand Weil would be a good place to start. He sells “wellness” like Martha Stewart sells style. One of his many prducts is “information”. Check his webpage.

    I don’t have a reference at hand but I believe that marketing or advertising as we know it originated with the patent medicine business in the early part of the last century. Read The Great American Fraud.

    Orrin Hatch represents Utah the Dietary Supplement Capital of the World. It has a long history of snake oil manufacture. The FBI has called it The Fraud Capital of the US, but they didn’t have supplements in mind when they said it.

    Fifi, “This is about political influence and legislation. This is a different issue in different countries for a variety of reasons (universal vs private healthcare being a big factor)” Fifi, I disagree based on my experience which of course is not scientific. However, until I see good studies I will believe that the conclusions I draw based on my experience are accurate. That is because my experience is a bit broader than most. I lived in Quebec from 1989 to 1999 and now live in Vermont, just across the boarder. I have spoken with consumers, scientists and even regulators from many different countries and I’ve been sent promotional material from many countries. The stuff is all the same. I’m sure it is all coming from the same source.

  26. pmoran says:

    Diogenes, thankyou very much for pointing out my mistake, as I have made the same one elsewhere. I assure you it is merely due the interpreting of “medical practice” in its more usual sense of one practice = one doctor and not any intention to use “hyperbole and manipulation of data”.

    I could easily have used other examples of heavy use of “alternative” methods by doctors without, so far, any obvious adverse effects. This paper outlines some, with references —

    http://www.mja.com.au/public/issues/aug17/easthope/easthope.html

  27. diogenes says:

    Dr P. thanks for your response. I’m sure my harsh comments don’t apply to you. I’m afraid I’m so accustomed to seeing quite appalling disregard for the truth from the CAM industry.

  28. PM: “If, OTOH, the patient’s request is a disguised or open “I would like to try acupuncture for my unresolved medical problem”, I think it is presumptuous on many grounds to see this as a opportunity for advancing what you see as the interests of science or “truth”, as you interpret them. That has almost nothing to do with this particular patient-doctor interaction…”

    I agree. Frequently, moreover, the request is initiated as such: “my friend swears by acupuncture…” Obviously, the appropriate response of the physician depends on how the patient presents the issue and on how well the physician already knows the patient. If that request is followed by “what do you think?”, it may or may not be an opportunity to advance truth. It is not “the interests of science,” by the way, that I’m advocating in such an interaction. It is honesty. Please don’t confuse my statements about what I think are the greater problems of “CAM” with how I think physicians ought to speak to individual patients.

    PM: “…and it is, frankly, ridiculous to suggest that the future of science or medicine is to any degree at stake for what you may or may not say to this person about acupuncture.”

    See above.

    PM: “Science and scientific medicine are irresistible forces because they work and and are based upon an obvious logic for most people. I don’t understand why some are so insecure about its future.”

    I am not insecure about the future of science and scientific medicine, at least not so because of “CAM.” I am appalled by current examples of science and scientific medicine being perverted for profit or political or quasi-religious purposes, often at the expense of innocents, because of “CAM.” I have already provided several examples on SBM (here, here, here, and here, among others), as have other SBM bloggers (here, here, here, and here, among others).

  29. durvit says:

    Dr Ben’s Goldacre has a 2-part radio exploration of the placebo. The BBC is currently offering Listen Again for Part 1 and Part 2 shall be broadcast next week and they have a programme information page (Goldacre links to it).

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