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Some Encouraging Backlash Against Nonsense

One of the themes of SBM is that modern health care should be based upon solid scientific ground. Interventions should be based on a risk vs benefit analysis using the best available scientific evidence (clinical and basic science).

As an extension of this, the standard of care needs to be a science-based standard. Science is (or at least should be) objective and transparent, and without such standards there is no way to have meaningful quality control. Without the filter of science there is no limit to the nonsense and magical thinking that can flow into the health care system. Increasingly we cannot afford the waste of fanciful and ineffective interventions, and even if limited resources were not an issue – individual patients deserve better.

It is for these reasons that we oppose the attempts by proponents of so-called complementary and alternative medicine (CAM) to erode or eliminate the science-based standard of care in medicine. Proponents differ mostly on how open they are about this goal, but there is no escaping the reality that at the heart of the very concept of CAM is at least a double standard – one in which the science-based bar for inclusion is lowered for some favored modalities.

Proponents will sometimes argue (against all evidence) that this is not the case but rather that there is prejudice and closed-mindedness against certain types of treatments. This is reminiscent of the claims by proponents of creationism/intelligent design that their beliefs are unfairly treated by scientists and school systems. In fact both cultural movements use the same language and tactics to promote their ideology against the defenders of a science-based standard -the “academic freedom” and “health-care freedom” strategies are two sides of the same coin.

Our primary mechanism for opposing the weakening of the science-based standard in medicine is simply to point to the rhetoric and tactics of the CAM proponents themselves. While they largely operate below the radar, when the light is shone on what they are actually doing the “shruggie” masses sometimes take notice. This occurred recently in Ontario, and provides an excellent example of all that I described above.

The conflict is about the College of Physicians and Surgeons of Ontario’s (CPSO) draft guidelines on Non-Allopathic (Non-Conventional) Therapies in Medical Practice. The first clue that these guidelines are likely to be problematic is in the title – the word “allopathic” is only used by CAM proponents. The term was coined by Samuel Hahnemann, the inventor of homeopathy, to refer to the conventional medicine of his day – prior to the incorporation of scientific methods into medicine. It does not reflect the philosophy or practice of modern medicine, and it is a pejorative term.

The guidelines also assume that “non-conventional therapies” should be incorporated into medical practice. Shouldn’t that be the real question, rather than just assuming they should be then exploring how to do so? The only justification given (the most common one given) is popularity (a fallacy deconstructed numerous times on this blog).

But that aside, here are the recommendations for how “non-conventional” therapies should be incorporated into practice:

Physicians are expected to propose both allopathic and non-allopathic therapeutic options that are clinically indicated or appropriate.

Any non-allopathic therapeutic options that physicians propose to patients must:
- have a demonstrable and reasonable connection, supported by sound clinical judgement, to the diagnosis reached;
- possess a favourable risk/benefit ratio, based on the merits of the option, the potential interactions with other treatments the patient is receiving, and other considerations the physician deems relevant;
- take into account the patient’s socio-economic status when the cost will be borne by the patient directly; and
- have a reasonable expectation of remedying or alleviating the patient’s health condition or symptoms.

Reasonable expectations of efficacy must be supported by sound evidence. The type of evidence required will depend on the nature of the therapeutic option in question, including, the risks posed to patients, and the cost of the therapy.

This superficially may sound fine, but is clearly crafted to lower the bar of scientific evidence for allowing “non-allopathic” treatments into medical practice. The guidelines stress “clinical judgment” rather than evidence-based standards. Further, the only time “sound evidence” is mentioned, it is immediately watered down by qualifying that the type of evidence will depend on the modality in question. Why is that?

The purpose of this language is to allow things like pragmatic studies (unblinded, uncontrolled studies) to serve as evidence for efficacy, something for which they are not designed. This is the sort of thing CAM proponents have been constantly calling for. Andrew Weil has advocated the inclusion of what he calls “uncontrolled clinical observation,” or what has traditional been called “anecdotal evidence.” David Katz from Yale’s Integrative Medicine program has called for “a more fluid concept of evidence.”

The evidence is absolutely clear – the CAM movement is about creating a double standard to allow in medical modalities that are not adequately science based, or to decrease the overall standard of care for medicine with healthcare freedom laws and guidelines that water-down what qualifies as evidence.

Fortunately there has been pushback against these proposed standards. The Canadian Medical Association had this to say:

“The use of complementary and alternative medicine in Canada should be founded on sound scientific evidence as to its safety, efficacy and effectiveness: the same standard by which physicians and all other elements of the health care system should be assessed. When alternative treatment modalities do demonstrate effectiveness, they are usually incorporated into the mainstream of medicine. Therefore, one could argue that complementary and alternative therapies are by definition less demonstrably effective than conventional medical treatment.”

This is exactly correct – CAM modalities by definition have not been adequately shown to be safe and effective, else they wouldn’t be CAM. In other words – we don’t need this special category of treatment. Its only practical functions are marketing and to create a double standard.

Even worse, these standards try to muzzle science-based professionals who would criticize unscientific modalities by including a provision that “non-clinical judgement” should be avoided. This too has caused push-back:

The guidelines may be “interpreted as impressing tight limits on physicians’ ability to state their honest, scientifically sound objections to pseudo-scientific medical theories and ideas,” the Committee for the Advancement of Scientific Skepticism contended. “Their non-conventional medical counterparts feel no such compunction in spreading misinformation about legitimate medical practices such as vaccination, as well as in misrepresenting the scientific standing of dubious non-conventional practices.”

This has also been a long time strategy of the CAM movement – the use of political correctness to silence legitimate criticism. This is a strategy with which I am personally very familiar – attempts at appropriately criticizing unscientific philosophies or claims are often countered with accusations of being closed-minded, bigoted, or even on the take.

Conclusion

The proposed Ontario guidelines are a transparent attempt to water down the science-based standard of modern medicine to allow for what was once called fraud and quackery into medicine, and further to shield such quackery from appropriate science-based criticism. It is no an isolated incident, but is a primary strategy of those hoping to advance CAM into modern medicine.

It is heartening, however, to see that such attempts are now meeting some backlash. Perhaps the CAM proponents have overplayed their hand a bit and those who have been uneasy with the claims of CAM proponents have felt a little more empowered to speak up. Let’s hope this trend continues.

Posted in: Science and Medicine

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48 thoughts on “Some Encouraging Backlash Against Nonsense

  1. windriven says:

    “…CAM modalities by definition have not been adequately shown to be safe and effective, else they wouldn’t be CAM.”

    And they have rarely (if ever to the satisfaction of the unbiased mind) been shown to be efficacious in properly constructed RCTs. Isn’t one of the fundamentals of SBM scientific plausibility?

    The language of CPSO is newspeak. It is heartening to see some pushback. But I wouldn’t guess it to be the vanguard of a trend. CAM is politically expedient. It will be as difficult to stamp out as MRSA.

  2. WilliamLawrenceUtridge says:

    As a resident of Ontario and recipient of a public health care system, this was one of the rare occassions that I actually read and commented on a policy. Normally I trust experts to do what experts do – parse the evidence and come to a conclusion that I am not equipped to handle. The CPSO policy was an obvious effort to please two masters but merely ended up selling the ultimate “customers” of a tax-funded health care system down the river.

    Because of the mandatory public health care system in Canada it’s a very different environment than the US (which is a shame for Americans, public health care is fantastic and I highly recommend it). The two countries have different environments and the consequences of CAM activism are different because of it – mainly because my tax dollars will end up paying for it and I don’t have an option to not pay for the parts of the bill that I don’t agree with (I have a similar issue with the Liberation Procedure for multiple sclerosis promoted by Zamboni).

    Ironically, several years ago in Ontario the partial coverage for chiropractic care was withdrawn so all expenses were out of pocket (reimbursed by some insurance companies). This policy statement seems like a large step backwards, and it annoys me.

  3. Harriet Hall says:

    “When alternative treatment modalities do demonstrate effectiveness, they are usually incorporated into the mainstream of medicine.”

    I have been saying this too, but I am frequently asked to give an example of an alternative modality that was incorporated into the mainstream of medicine. I haven’t been able to come up with a single one. Some natural medicines have been incorporated, but I don’t think that counts, since it amounts to scientific pharmacognosy. Can anyone think of a valid example?

  4. CarolM says:

    “The two countries have different environments and the consequences of CAM activism are different because of it ”

    I would be much more in favor of single payer, if I wasn’t so afraid CAM lobbyists would get the upper hand. They have already made great inroads on state insurance mandates. None of it should be covered, IMHO, not chiro not anything.

    But it seems like modern CAM represents a great giving-up on the progress of SBM and a switch to management of placebo effects, mind-over-matter and other bogus methods.

  5. DevoutCatalyst says:

    What about that neti pot you wrote about Harriet? CAM really hit one out of the ballpark with that trivial thing.

  6. Harriet Hall says:

    @DevoutCatalyst,

    I’m not so sure that qualifies. The Neti pot is only one gimmick used for nasal irrigation, and nasal irrigation itself is not exactly “alternative” but has long been recommended by mainstream medical doctors.

  7. WilliamLawrenceUtridge says:

    My standard go-to statement about CAM being integrated into mainstream care is St. John’s Wort for depression. Yes, it’s really just pharmacognosy, but it still demonstrates the willingness of practice to change in the face of evidence. Other examples would also probably be pharmacognosy (aspirin for pain relief, quinine for malaria) but acupuncture is a notable exception. It is cautiously encouraged in limited form as somewhat effective for pain relief and nausea, even if the placebo effect isn’t ruled out – I believe a safe version of acupuncture can and should be incorporated into practice by physicians. However it should be stripped of the TCM nonsense about meridians and acupuncture points, with thin, sterile needles used shallowly and well-away from any nerves, blood vessels or other anatomical danger areas. An important caveat accompanying the statement is always that most CAM is not supported upon testing, but in principle if they were found to be effective then they would be. Depends on how long the conversation continues really. If people are satisfied with “medicine changes with the evidence”, great. If they ask for examples, St. JW is a reasonable one. If they’re still curious, mention that science already has pharmacognosy as an investigational area, and the last response would pretty much have to be “and most CAM isn’t supported when tested, which is a reason to be skeptical of claims without evidence”. All that to say pharmacognosy is a pretty good example of CAM being adopted, even though it plays merry hell with your definitions of “CAM”, “medicine” and the linear nature of time :)

    Though not quite CAM, the germ theory of disease and vaccination themselves were once “alternative” medicine, though at a time when evidence was only just being considered part of the criteria for which therapies to adopt.

    Really if someone asks “can you give me an example”, it’s perfectly legitimate to say there aren’t many; if there were a lot of effective prescientific treatments, we probably wouldn’t need real medicine. I was thinking “massage” might be another one, which led me to this execrable study. Perhaps they should try this on a group that doesn’t have meridians as a cultural belief?

  8. WilliamLawrenceUtridge says:

    I would be much more in favor of single payer, if I wasn’t so afraid CAM lobbyists would get the upper hand. They have already made great inroads on state insurance mandates. None of it should be covered, IMHO, not chiro not anything.

    Certainly a concern, but I think that since even in the US, CAM is still not really that popular, so the overall cost would be low (and the benefits of a public health care option are fantastic, I can’t tell you how great it is to be able to see a doctor without wondering if you’re going to go bankrupt because of it). Private insurance is a business, so CAM can be one of the things insurers can “sell” as part of their package (“We also pay for CAM treatments!”). Public options can have a fair bit of expert input, Health Canada convenes a lot of expert panels for practice guidelines. I have both public and private health insurance (through my job) and it adopts a pretty reasonable guideline – you get a couple hundred dollars each year that can go to a variety of “optional” services. I think it’s something like $400, and it can go towards chiropractic, massage, physiotherapy, acupuncture, nautropathy and a couple others. It’s not a bad system – limited amount of money, the user makes the choice. It doesn’t come across as draconian while limiting the overall cost and you can get real, evidence-based help within that envelope. Something used to exist for the public option as well, but it was less money and got axed a couple years back. My chiropractor (yes I see a chiropractor, but he basically acts as a physiotherapist, focuses on exercise rather than weekly treatments, and I’ve asked him not to adjust my cervical vertebrae) made quite the stink about it when they cancelled the public coverage, and raised his rates considerably a couple years after.

    But it seems like modern CAM represents a great giving-up on the progress of SBM and a switch to management of placebo effects, mind-over-matter and other bogus methods.

    I will heartily agree with that. However, there should be a strong focus by mainstream doctors to capitalize on the placebo-enhancing activities of CAM practitioners. It’s the one part of the CAM turd that could be polished into something meaningful. Placebo effects can be enhanced without deception. Also helpful would be if doctors could take more time with patients for thorough histories and the lengthy consultations offerred by homeopaths and the like – but that would require massive structural changes pretty much throughout the world.

    One amusing suggestion would be having people go to naturopaths and homeopaths for consultations, then not bothering to buy any of the supplements. Essentially health-based psychotherapy!

  9. windriven says:

    “I have been saying [that modern medicine is open to adopting alternative treatment modalities] too, but I am frequently asked to give an example of an alternative modality that was incorporated into the mainstream of medicine. I haven’t been able to come up with a single one.”

    The difficulty you have citing an example outside of pharmacognosy pretty much says everything about CAM that needs to be said, don’t you think? The state of medicine has changed dramatically over, say, the last 50 years. A whole raft of new treatment modalities have been adopted. Any number of pharmaceutical agents have been isolated from plants and fungi and incorporated into the pharmacopeia. But no rattling of chicken bones, waving over of hands, twiddling of needles or schmoozing of subluxations. Why might one suppose any explanation other than that those things are idiotic fantasies of the ignorant? Supposing some failure on the part of science to embrace frank nonsense says much about the supposer and nothing about the science.

  10. Harriet Hall says:

    @WLU,
    Acupuncture may be “cautiously encouraged in limited form as somewhat effective for pain relief and nausea, even if the placebo effect isn’t ruled out –” but it would be inaccurate to say it has been incorporated into the mainstream of medicine.

    @windriven,

    “The difficulty you have citing an example outside of pharmacognosy pretty much says everything about CAM that needs to be said, don’t you think?”

    Yep!

  11. HH “but I am frequently asked to give an example of an alternative modality that was incorporated into the mainstream of medicine. I haven’t been able to come up with a single one. Some natural medicines have been incorporated, but I don’t think that counts, since it amounts to scientific pharmacognosy. Can anyone think of a valid example?”

    Firstly, From a laymen’s perspective, I don’t think you should discount natural (herbal) medicines… scientific pharmacognosy (es, ias ?) is just an example of a mechanism for adopting a useful element. It’s still valid.

    Secondly, I know these are not necessarily prescribed by doctors but they are taught in hospital workshops and by therapists as healthy lifestyle choices, so…. Yoga for exercise, strength, flexibility and chronic muscle pain. Breathing techniques* for relaxation and anxiety. Massage for muscle, tendon inflammation and pain.

    Those are just from recommendations I’ve received from doctors or therapists that seem pretty SBM. I’d check out MayoClinic’s website for other examples, I bet you’ll find some of their suggestion that might have seemed woo 20 years ago, but are mainstream medicine now.

    Funny story. 25 years ago my mom (who was an elementary school principle) was forced to pull a conflict resolution curriculum because it suggested teaching students to take a few deep breaths before responding to a classmate in a conflict. A parent group complained that the breathing technique was teaching eastern religious practices.

  12. Jan Willem Nienhuys says:

    I have been saying this too, but I am frequently asked to give an example of an alternative modality that was incorporated into the mainstream of medicine.

    Electroconvulsive therapy (Electroshock therapy) is not alternative in the classical sense, but it lacks a theoretical basis. Nobody knows why it works (I am told there are about a hundred theories why it might work, but for acupuncture and so on there are also lots of ‘theories’ that pretend to explain it). But ECT works.

    EMDR is becoming more and more mainstream. Its original theoretical foundations were rubbish. Maybe it still is a form of imaginary exposure with an extra distracting gimmick. I would be interested in a thorough evaluation.

  13. dchamney1 says:

    I took the survey concerning the ‘Guidelines’ and at every opportunity I expressed my dissatisfaction with the policy, and often with the wording of the questions and the answer choices.

    It’s the CPSO’s job to protect patients from ineffective treatments and to make sure that the Province’s limited health care budget is not wasted on ‘politically correct’ woo. They should also be advising us about nonsense treatments, even if its just as a way to protect themselves as every dollar spent on nonsense is a dollar that is no longer available fro REAL medicine

    They are clearly not doing their job as I’m amazed at how many of my friends, colleagues and coworkers have been wasting money on energy bracelets, ionic footbaths, magnetic insoles, neck manipulations and worthless supplements etc., while ganging up to ridicule me when I call them out on it.

  14. another potential recommendation adopted from the more crunchy granola crowd AKA CAM…

    Whole Grains

  15. Harriet Hall says:

    @JWN,

    I think EMDR has been evaluated sufficiently to conclude that it is merely a gimmick that helps enlist the patient’s cooperation with evidence-based psychotherapy.

  16. windriven says:

    @JWN

    I was under the impression the ECT had been discredited and is no longer in common use, but this is just a vague impression. Is ECT still commonly used? If so do you know for which indications?

  17. Jann Bellamy says:

    I gave a talk on “CAM” just this past Sunday. A pro-”CAM” M.D. in the audience said something to the effect that proponents of science-based medicine were promoting “scientism” which he likened to a “religion.” That comment is right out of the creationist/ID playbook.

  18. “Why might one suppose any explanation other than that those things are idiotic fantasies of the ignorant?”

    Someone above said that. I forgot who I pasted it from, but it doesn’t matter. I see it a lot on this blog and it’s kind of upsetting. And I’m definitely not a CAM supporter.

    In supporting SBM, you won’t win their hearts with an attitude of “Haha! Look how dumb everyone is compared to us! If you try CAM or think CAM might be effective, you’re an idiot! You’re ignorant!” This only perpetuates the stereotype that scientists and doctors are arrogant and don’t care about patients. THIS is exactly where people get that idea from.

    I don’t like CAM. But I tried CAM. People try all sorts of weird things in life for all sorts of different reasons. Being ignorant and stupid might be one of them, but when you get down to examining each individual case, you’ll find that there are usually much more descriptive adjectives that are less knee-jerk.

    My friend tells his seven year old the old addage of “you catch more flies with honey than with vinegar.” CAM uses honey. It is probably easier for them to use honey because they make a lot of grandiose promises, and medicine sometimes is the bearer of bad news. Nevertheless, even if you don’t think “everyone” who uses CAM is ignorant, you are implying that with the tone and attitude of your words.

  19. Harriet Hall says:

    @windriven,

    ECT is a standard treatment in common use. For indications, see
    http://www.omh.state.ny.us/omhweb/ect/clinical_indications.html

  20. WilliamLawrenceUtridge says:

    ECT has been well-validated as well; they may not know how it works, but they know that it does work. In addition, it meshes with the knowledge about the human nervous system in that it uses a well-established, well-understood force (electricity) on a set of cells that transmit information through that same force (membrane depolarization is essentially based on atomic-level electromagnetic forces). We may not understand it, but it’s not proposing novel forces and hitherto-unacknowledged biological structures. In addition, we don’t really understand how the brain works as a whole, thus the suggestion is a lack of understanding of how the brain works rather than something totally unanticipated.

    @Jann

    Yeah, creationism and CAM have a lot more in common than starting with the same letter of the alphabet. They essentially mimic each others’ strategies since they lack actual evidence.

  21. jerry_sprom says:

    after reading this article, one could be forgiven for thinking that the mainstream of medicine was entirely supported by solid scientific evidence.

    http://clinicalevidence.bmj.com/ceweb/about/knowledge.jsp

    And as far as the term ‘allopathy’ goes. I say if one can make up terms like ‘science based medicine’ in an attempt to usurp or ‘broaden’ EBM, then shouldnt CAM proponents be able to make up their own terms too??

  22. windriven says:

    @nobodyyouknow

    I made the statement and I hope that neither you nor anyone other than purveyors of quackery were offended.

    I make no apologies for using the word ignorant. Ignorant means uneducated and those who equate scientific facts with quackery or mystical or “spiritual” therapies are, at a minimum, ignorant*. Science is not a religion as alleged by Jann Bellamy’s conferee (see above). It is an organized, replicable system of determining objective truth.

    I make no apologies for using the word fantasies. The embrace of homeopathy, qi, or subluxations, requires a level of credulity that beggars belief.

    I do, however, apologize for the adjective idiotic. Idiocy implies stupidity – a lack of intelligence – a value judgement on my part and an uncharitable one. Clearly, many users of quackery are not stupid people so as well as uncharitable it was inaccurate.

    * We are all ignorant; none of us knows everything or, in fact, much of anything when measured against the corpus of human knowledge. My own ignorance is encyclopedic. But a basic understanding of the scientific method and why it is the cornerstone of much of that corpus of human knowledge is a fundamental requirement of being an educated person.

  23. nybgrus says:

    I agree with you windriven. Ignorance is not something to be ashamed of. I frequently make this point in conversation. Being proud to be ignorant or being willfully ignorant… well, that’s another story.

  24. ConspicuousCarl says:

    jerry_spromon 21 Sep 2011 at 7:38 pm

    after reading this article, one could be forgiven for thinking that the mainstream of medicine was entirely supported by solid scientific evidence.

    http://clinicalevidence.bmj.com/ceweb/about/knowledge.jsp

    I don’t know what point you hoped to make with that, but it clearly states that the “unknown” category contains CAM. This is not something which asserts that half of “mainstream medicine” has no evidence.

    And as far as the term ‘allopathy’ goes. I say if one can make up terms like ‘science based medicine’ in an attempt to usurp or ‘broaden’ EBM, then shouldnt CAM proponents be able to make up their own terms too??

    When my cousin first learned to talk, she used the word “cat” to refer to butterflies. And yet the oldspeak term persists.

  25. ConspicuousCarl says:

    windriven
    The embrace of homeopathy, qi, or subluxations, requires a level of credulity that beggars belief.

    It beggars belief and buggers logic.

  26. ConspicuousCarl says:

    nobodyyouknow on 21 Sep 2011 at 5:00 pm
    I don’t like CAM. But I tried CAM. People try all sorts of weird things in life for all sorts of different reasons. Being ignorant and stupid might be one of them, but when you get down to examining each individual case, you’ll find that there are usually much more descriptive adjectives that are less knee-jerk.

    “Ignorant” is a pretty good description for the many people who either don’t know what homeopathy is, or know what homeopathy is but lack 12th-grade knowledge of chemistry.

    CAM uses honey.

    That is often true, but not always. “We want to treat you like a whole person” is honey, but “doctors are narrow-minded and/or paid off by Big Pharma” is not.

  27. bobbruer says:

    Maybe I am just tired… a long day using my statistical, analytic, epidemiology and teaching skills to build support for science-based mental health care. I love my work… defending the efforts of well-trained clinicians who feel called to make a difference… providing just-in-time information towards incremental improvement … massaging tender seasoned egos away from errant belief.

    Much of my personal inspiration derives from the passionate energy and intelligence of Dr. Steve (and a shout-out to “I don’t like to be called doctor” Mark Crislip). I owe him (them) much. But as the lead investigator of a modest 2005 RCT of music therapy to treat cognition in dementia, I think I need to object to Dr. Steve’s criticism of the CPSO. I remain very grateful to the Ontario MD that signed off on the IRB forms allowing a clinical trial of a non-allo-whatever.

    Of course we all know the putative truth… short term cognitive deficits remitted through a reduction in anxiety wrought by a session of extensive music-making. But more importantly than that, the therapy simply made sense after being honed across at least 1,000 sessions: reviewed, discussed, researched, and measured… and the anecdotal stories seemed so compelling to professionals across all traditions… to test it seems an ethical essential.

    In the end, I daily work to inspire others towards collaborative, critical, reality-driven, research-informed health-care. I would argue that those great folks gain more from the clinical justification of my music therapy rct, than they gain from the psychological science.

    I’m with Dr. Steve most of the time… but I would argue that language can be elusive to even the best of us. A referral for a nerve problem for example, means something very different for a neurologist as compared to a geriatric psychiatrist… and perhaps there are more than a few moments when the latter needs something outside his basic skill-set.

  28. windriven says:

    @ConspicuousCarl

    “It beggars belief and buggers logic.”
    “CAM uses honey…”

    Perhaps they use the honey part to soothe the bugger part :-)

  29. windriven says:

    @Dr. Hall

    Thank you for the ECT link. It corrected my misimpression. It really does seem a crude tool but one can’t argue with success.

  30. jerry_sprom says:

    @conspicuousCarl

    The point is that all the categories listed in the link contain medical interventions, which means many medical procedures and medicines don’t have solid evidence to support them (at present).

  31. Jan Willem Nienhuys says:

    The link given about ECT doen’t say how often it is used. I recently read a survey claiming that in the US it is used an estimated 100,000 times a year. In the standard treatment the patient is anesthesized and given somthing to prevent violent muscle contractions. Worldwide ECT seems to be aplied about a million times a year.

  32. Earthman says:

    Harriet Hall says

    “Some natural medicines have been incorporated, but I don’t think that counts, since it amounts to scientific pharmacognosy. Can anyone think of a valid example?”

    How about the use of Leeches?

    1. Harriet Hall says:

      @Earthman,

      Leeches? Bloodletting with leeches was a pre-scientific treatment based on the idea of balancing the four humors, the conventional wisdom of the time, and was used to treat generalized illnesses like fevers. Modern use of leeches is very different, using them only as a means of removing localized accumulations of blood that have resulted from trauma or surgery. The way leeches are being used today was never proposed by CAM, so leeches are not a good example of a CAM treatment being widely adopted.

  33. nybgrus says:

    @bobbruer:

    I don’t think Dr. Novella was saying what you are implying he was. No one is saying we must stop such research or make it unavailable to people. You just demostrated how something otherwise unproven and woo-ish might be proven and adopted by medical science. We are just against the inclusion of it prior to such proof. And especially in this case, the guidelines enjoin physicians to actually promote and utilize the unproven stuff. That, in a nutshell, is what Dr. Novella’s post has been about – at least, that’s what I got from it.

  34. nybgrus says:

    @Dr. Hall – I was thinking the same thing. But I was hoping (honestly) to let CAM have at least one “win” and was thinking about whether intention counted or whether it was just use of materials.

    I do think intention should count, as you have pointed out. But that means that essentially nothing that once was CAM could be actual medicine – at least not wholesale. Because at best, we would be able to utilize the parts that are useful and eschew the rest. Of course that is exactly what SBM is supposed to do. But in the case of CAM, since the vast majority of those modalities are based in pre-scientific notions of disease and physiology, they would have to be stunningly lucky to get both the therapy and rationale right (i.e. right therapy for the right indication).

    Heck even in actual science and medicine, we often try and do something for a specific indication and end up realizing it is better for something else. Take minoxidil and sildefanil for example – both originally researched and intended as anti-hypertensives.

  35. JPZ says:

    @Harriet Hall

    It’s a valid question about CAM practices becoming medical practices. I actually had to go to the NCCAM website to get a better feel for what is and is not CAM. Here is my impression:

    Dietary supplements (my field): some of them work well and have been incorporated into mainstream treatment for AMD (lutein), depression (n-3 fatty acids) and Crohn’s disease (probiotics). Some readers dismiss this as pharmacognosy, but that is not how they are regulated, and when you can source them from spinach, fish and yogurt (albeit at extreme intakes) I feel you can make a distinction from drugs. Opinions differ.

    Meditation, tai chi and yoga: My understanding is that relaxation techniques are incorporated into numerous medical therapies.

    Massage therapy: Overlaps with physical therapy and relaxation in some cases? There is a significant amount of training for accredited massage therapists.

    Pilates: perhaps not medical treatment per se but a popular physical fitness routine (preventative medicine)

    I realize some readers see “CAM” and default to homeopathy and acupuncture, and I would agree that there are some bizarrely unscientific practices that fall under CAM. Maybe I am just uncomfortable with absolute statements about “all” CAM since it is an invitation to overgeneralization. I know Harriet takes pains not to overgeneralize (at least in what I have read), so I am just sharing a general impression of many other replies and posts that focus on homeopathy and accupuncture and then generalize.

    1. Harriet Hall says:

      @JPZ,

      I don’t find any of those very convincing. Dietary supplements fall under pharmacognosy even though they are not regulated as drugs. Most of the others relate to things that were already part of conventional medicine like relaxation and exercise and/or that have not been incorporated into standard medical practice. A lot of prescientific practices evolved into scientific medical practices. “CAM” really only dates from about 1970. I’m still looking for an example of something that was advertised as CAM that was later scientifically proven and adopted into mainstream medicine as a standard treatment.

  36. davidp says:

    “an alternative modality that was incorporated into the mainstream of medicine”

    Spinal manipulation has migrated from the Chiropractors to be part of Physiotherapy without the magic subluxation baggage. This isn’t all thee way to mainstream medicine, but it has then been tested and used in a mainstream setting.

    1. Harriet Hall says:

      Spinal manipulation as a practical treatment for back pain is not an invention of CAM: it dates back to Hippocrates. Yes, it is used by some mainstream medical providers, but I don’t think you could say it has been incorporated into standard treatment recommendations for back pain. Spinal manipulation to correct subluxations or to treat conditions other than back pain is a chiropractic invention and is not used in mainstream medicine.

  37. bobbruer says:

    @nybgrus

    No, I don’t believe (with great respect) I misunderstood the inferences made by Dr. Novella. The RCT I led would never have seen the light of day had not physicians (most certainly having some science-based theory to support plausibility) supported for years, within a government-funded facility, the use of music therapy to treat cognitive deficits in dementia and persons with dementia-like illness.

    One mitigating factor would have to be the limitations of current approaches… cholinesterase inhibitors are it, as far as I know (or at least, as far as I knew at the time or the RCT)… ugly drugs for the elderly, sloppily prescribed and screaming for replacement through comparative-efficacy study.

    As to denying “inclusion prior to proof “, I disagree with that position. I am most thankful to the Ontario system – where in theory, any resident over 60, with:
    1. intact hearing,
    2. a cognitive challenge sufficient to require hospitalization, and
    3. living within 50 miles of the government facility;
    had an equal probability to be randomized to the tx or control in my little study.
    The findings would appear (rightly or wrongly) more suspect outside a socialized blanket of care. Ergo, one fact that attracted co-sponsorship by a leading US medical school (where I was studying at the time).

  38. Enkidu says:

    RE: CAM

    I follow about 3 Hollywood types on Twitter. The other day this comes through my feed: “Had cupping yesterday for my back. Drained so much bad blood. Hurt like hell. Feel great today!”

    http://yfrog.com/klnnamoj

    “Your spine needs oxygen to heal. when ur injured ur blood clots around the injury. To release the “bad blood” they poke holes & suck it out.”

    I had no idea what cupping was, but I could figure it out after that picture OUCH. Several docs and skeptics sent her links about cupping and it’s utter ridiculousness, but they were pushed aside: “Feeling good today…judge if u want. Done everything I was told for 3 months in rehab & have gotten worse “I’m thinking out’a the box now.”"

    I wonder how many people are now on the cupping bandwagon from this series of tweets? *sigh*

  39. HH, I think you are thinking too narrowly about the meaning of “adopted by conventions medicine”. The phrase does not necessarily imply adopted whole cloth or exactly as it was proposed or explained in CAM.

    I dare say* that many treatments in medicine that are used today were originally conceived differently. The point is that SBM is willing to examine treatments outside it’s discipline and adopt whatever aspect of that treatment it ultimately finds evidence of being useful.

    *It just made my day that I was able to work “I dare say” into a post.

  40. JPZ says:

    @Harriet Hall

    I follow your logic, and I can see your point of view as well as the internal consistency of that viewpoint. It is one of those slippery things that happens on SBM when one is in a discussion about CAM – what is or is not included in CAM? I consulted a list of CAM practices provided by NCCAM (http://nccam.nih.gov/health/whatiscam/). Is there a more authoritative list? The practices I listed were listed as CAM on the NCCAM website. If you want to call some of them “pharmacognosy” or “relaxation,” I suppose I understand your point of view, but how does that make them no longer CAM? For example, probiotics were developed to make yogurt, but there are plenty of good clinical trials showing their efficacy in Crohn’s disease. If you want to call them a “drug” now, that does not unmake their presence in food and regulation as a dietary supplement. Maybe I don’t get the full meaning of “yoga is just relaxation.” Isn’t that like saying “martial arts is just fighting?”

  41. Harriet Hall says:

    Let me clarify:
    Michele said it best: “The point is that SBM is willing to examine treatments outside it’s discipline and adopt whatever aspect of that treatment it ultimately finds evidence of being useful.”

    When I say that any CAM method that is proved to be effective is adopted into mainstream medicine and no longer considered alternative, people ask me to give an example. Often they are thinking that SBM is too prejudiced to accept anything from CAM. I would like to find one really good, clear-cut example that would demonstrate SBM’s open-mindedness. Obviously, the fact that it is hard to come up with one is evidence that CAM is not a fertile field for medical discoveries.

  42. JPZ says:

    @Harriet Hall

    It is a very fair question that you pose. If you can gift me a bit of latitude on whether dietary supplements are CAM, I may be able to provide an example.

    With regard to that latitude, much of pharmacognosy (not all) is taking plant extracts, fractionating them, and testing their activity in an in vitro screening assay. Live microorganisms have not traditionally been subjected to this line of drug inquiry.

    But, yogurt and other fermented milks were proclaimed to have all kinds of health benefits well before science examined them. Remember the 1970′s Dannon yogurt ad (http://www.youtube.com/watch?v=5xI6vH5w7bQ)? The beliefs around yogurt, et al. were very CAM in terms of believing a food was nearly a cure-all for no scientific reason. The actual science started going long ago around how a company could make fermented milk products without batches of it going bad from the wild yeast and bacteria they relied upon. Once companies had moved to pure cultures of the fermenting bacteria, scientists curious about the topic could reproducibly begin testing why people thought fermented milk products were so healthy. Early findings led to companies who made highly concentrated, pure cultures of those bacteria and claimed all kinds of crazy stuff about health benefits. Mostly, the stuff they were selling was dead bacteria. Still very CAM.

    Highly concentrated, pure bacteria products (from industry or made at the university – L. acidophilus NCFM is a great example of public sector probiotic research) provided testable material for better preclinical studies and clinical trials. Funding from the profitable yogurt companies helped as well. Now you start to turn the corner into more, high-quality science and applications in medicine and funding to do GCP/ICH compliant clinical trials. There are many gastrointestinal diseases that have been studied, and there is a body of literature supporting efficacy, e.g. the rather conservative and under-referenced opinion at the American College of Gastroenterology (http://www.acg.gi.org/patients/gihealth/Probiotics.asp).

    So, we aren’t in CAM-ville anymore. This isn’t classical pharmacognosy, but it grew up from ancient food to dietary supplement (with tons of CAM-like claims in between) to accepted therapy for the patient to acquire from non-pharmaceutical sources. Is that what you were seeking?

  43. DevoutCatalyst says:

    Harriet Hall wrote:

    “CAM is not a fertile field for medical discoveries.”

    That’s so beautiful.

    And sad. If it WAS a fertile field, maybe you and Mehmet could have your own TV show, Ozzie and Harriet.

  44. tmac57 says:

    DevoutCatalyst- That was brilliant! Hats off to you :)

  45. elburto says:

    NobodyYouKnow – your resorting to the Tone Argument notwithstanding, I think you’ll find there’s something which catches more flies than either honey or vinegar.

    Magical thinking is the result of ignorance. Nobody has a duty to coddle and encourage the ignorant until they see the light.

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