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Survey Says…

Surveys are evidently a popular way to get a paper published. Put “complementary alternative medicine survey” into Pubmed and get 2,353 hits. I would have trouble coming up with a hundred groups about whom I would be interested in their use of SCAMs, but I tend to be a lumper rather than a splitter. But if you want to know about SCAM use in chronic pain patients in one Singapore hospital, the information is available.

I am a survey magnet and a remarkable number of people send me dead tree and electronic surveys which I generally ignore. So people like me, those who ignore surveys (but support public television), are underrepresented in surveys. But evidently there is no group whose attitudes about SCAM are not amenable to analysis including my medical brethren, Infectious Disease doctors.

So I was understandably curious when I was sent a link to “Infectious Diseases Physicians’ Attitudes and Practices Related to Complementary and Integrative Medicine: Results of a National Survey“. The abstract makes it sound like my colleagues are a bunch of ignorant rubes who just fell off the turnip truck:

ID physicians were most familiar with vitamin and mineral supplementation (83%), massage (80%), acupuncture (79%), chiropractic (77%), yoga (74%), and herbal medicine (72%). ID physicians most recommended vitamin and mineral supplementation (80%) and massage (62%). Yoga, meditation, and acupuncture were recommended by 52%, 45%, and 46%, respectively. Drug interactions, clinical research, and knowledge of CAM/IM modalities were factors that were considered a major influence. Almost 80% of respondents indicated an interest in IM versus 11% for CAM. Most respondents (75%) felt that IM modalities are useful, and more than 50% believed that they could directly affect the immune system or disease process. Conclusion. ID physicians expressed a markedly greater interest for IM versus CAM. They appear to be familiar and willing to recommend some CAM/IM modalities and see a role for these in the management of certain infectious diseases. Data regarding clinical efficacy and safety appear to be important factors.

Or are they? Abstracts can be misleading and the issue with many SCAM studies revolves around definitions as to what is a SCAM: it can vary from the wackaloon modalities like homeopathy and energy therapies to the potentially reasonable ones like minerals and herbs to interventions that are not alternative at all, like diet and exercise.

The first paragraph does not inspire confidence in what is to follow in the rest of paper.

In the United States of America (USA), as defined by the National Center for complementary and Alternative Medicine (NCCAM), complementary and alternative medicine (CAM) is a group of diverse medical and health care systems, practices, and products that are not presently considered part of conventional medicine and integrative medicine is medicine that combines treatments from conventional medicine and CAM for which there is some high-quality evidence of safety and effectiveness (1)

So I follow the reference to the NCCAM website where they do not give a definition for integrative medicine, instead saying:

There are various definitions for “integrative health care,

and instead give general examples and then state:

The scientific evidence is limited. In many instances, a lack of reliable data makes it difficult for people to make informed decisions about using integrative health care.

I do so love it when a reference does not reflect the claim. Of course, it may be a misplaced footnote, although it does come across as disingenuous.

Since Appeal to Popularity is perhaps the most common logical fallacy used to justify SCAM, a survey was done to see if three ID docs can make a tiger. So they surveyed 1,000 ID docs to:

…determine how ID practitioners in the USA view CAM and integrative medicine modalities by defining the following. (1) How familiar are ID practitioners with CAM and integrative medicine modalities and which ones do they recommend? (2) What are the perceived obstacles to the use of these modalities? (3) What are ID physicians’ beliefs and attitudes toward them and what role, if any, do they see for them in their patients?

311 replied. I didn’t receive the survey as it would have been one I would have filled out.

How you phrase a question determines the answer. CAM is defined as:

a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine.

and integrative medicine is defined as:

the practice of medicine that reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches, health care professionals, and disciplines to achieve optimal health and healing.

Wait. What? That is an interesting definition for the purpose of the survey, since it is an excellent definition not of integrative medicine but of medicine. It is what I aspire to do as a physician and what we teach our residents. However as a marketing ploy, it is excellent as it avoids the details as to what is being integrated.

Almost 80% of respondents indicated an interest in integrative medicine versus 11% for CAM. With those definitions it is no wonder there was interest in integrative medicine. If you are unaware that what is being integrated is fantasy (homeopathy, reiki, acupuncture etc.) with reality-based medicine… To quote me, when you integrate cow pie with apple pie, you do not make the cow pie better, you make the apple pie worse.

The abstract suggests that ID docs:

…appear to be familiar and willing to recommend some CAM/IM modalities and see a role for these in the management of certain infectious diseases.

Although the text would suggest that it depends on which SCAM. The truly wackaloon interventions are low with 8% in favor of homeopathy and 16% in favor or reiki and its ilk. Chiropractic gets a 33% “would recommend” rating and acupuncture a whopping 46%, not too surprising given the ubiquity of the former and the undeserved cachet of the latter.

I do not know whether to be proud or saddened by those numbers. I wonder how knowledgeable these physicians truly are, since it is a self-assessment. Would that embarrassing 8% offer hyperdilute duck liver as a treatment for the ‘flu? I hope not. I used to think that understanding the fantasy-based therapies would lead to their abandonment; that familiarity would breed contempt. Not so, yet again. The issues that influenced the use of SCAM were:

…drug interactions with botanicals and supplements (82%), clinical research showing clear benefit (80%), and knowledge of CAM and integrative medicine modalities (72%).

That 20% thought that clinical research was unimportant in using CAM is almost as sad as the embarrassing 8%. More information to suggest that knowledge of nonsense does not necessarily lead to wisdom with their application.

Or it could be more Dunning-Kruger than true knowledge, given that 75% felt that CAM and IM were useful for symptom relief. 50% thought the effects were due to placebo. Which is true. You are probably aware of my simple equivalency rule. SCAM effects are placebo. Placebo effects are nothing. Therefore SCAM effects are nothing.

What was really depressing was:

…more than 50% also believed that one or more CAM and integrative medicine modalities could directly affect the immune system or the disease process: mind-body modalities (n = 90), botanicals/supplements (n = 96), manipulative and body-based medicine (n = 63), energy medicine (n = 24), and whole medical systems (n = 35).

But then it is hard to say exactly what was going through the minds when filling out the survey, he says, desperately wanting to give his colleagues some benefit of the doubt. Maybe they were thinking about selenium and sepsis or treating vitamin D deficiency or, hell, please, I can’t do it. 35 thought Ayurveda or homeopathy could affect the immune system and 24 thought the same of reiki and therapeutic touch. I can’t make a silk purse out of this sow’s ear. Sorry. That is 24 to 35 too many.

And the madness continues, using SCAM for:

HIV and HIV-related complications (n = 191), recurrent bacterial infections (n = 138), autoimmune complications (n = 121), “chronic Lyme disease” (n = 116), hepatitis B, C (n = 74), acute bacterial infections (n = 35), and others (n = 43).

116 would treat the nonexistent chronic Lyme? Probably by boosting their immune system with the powerful placebo of homeopathy. Or acute bacterial infections? Or HIV? What are they thinking? Maybe I am missing some subtle thought process that would allow these modalities to be used, since the responders say that clinical research is only important 68% of the time. Or, maybe because 20% of the respondents are not Board Certified and 15% have an affiliation with a CAM center, perhaps the 311 who responded were not the best and brightest in the field.

Again, I love the flexible and inclusive way SCAM providers define their field. They call artemisinins, an extremely effective treatment for malaria, alternative. Like taxol. And aspirin. That 14% had insufficient knowledge of artemisinins and 6% thought them slightly beneficial and about half thought cranberries effective for UTI supports my thesis that the best-read in the field were not filling out the survey.

So what can you say about ID docs and SCAM? Given the broad response rates depending on the SCAM surveyed should I be happy or depressed with a statement like:

The practice of infectious diseases relies heavily on information and data; therefore it is not surprising that ID practitioners are data-driven in their clinical practice. The findings from this study support this, as 68% of respondents reported that data based on clinical research was the most important factor in determining treatment plan.

As if they expected surprise at the use of information and data. And what part of medicine does not rely on information and data? Oh, yeah. Evidently SCAM/IM practitioners.

This was a painful entry to write as it generated some cognitive dissonance. I tend towards strong loyalty to my various tribes, or perhaps my various granfalloons: SBM, ID, Trailblazers etc. And I had long considered that ID docs are without a doubt the smartest docs in the hospital and the best diagnosticians. We have to be, since ID crosses all specialties. I leave it to my readers to decide how much exaggeration I am making. But as a group we are evidently no better when it comes to thinking about SCAMs.

I went searching the Pubmeds. There are many articles on cognitive biases as they relate to diagnostic errors. There was a good reference in a recent CID. But there is very little I could find about the errors we make in deciding on a therapy. The only one that comes close is the classic “Observations on spiraling empiricism: its causes, allure, and perils, with particular reference to antibiotic therapy“.

There is nothing I can find that directly addresses the errors so routinely made in the research, evaluation, and specially application of SCAMs. The results of this survey should not come as a surprise. Most docs, even ID docs, are not given the tools to approach fantasy-based interventions.

My wife likes to sew and she has numerous tricks of the trade that she uses when putting a piece together. I am amazed when she watches Sewing with Nancy at all the shortcuts and techniques seamstresses have that allows them to make some amazing creations. She understands the subtleties that can make sewing easier. We need a similar collection of tips and tools for SCAMs.

Posted in: Acupuncture, Clinical Trials, Critical Thinking, Homeopathy, Random Thoughts Cause I Can, Science and Medicine

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34 thoughts on “Survey Says…

  1. windriven says:

    ” 68% of respondents reported that data based on clinical research was the most important factor in determining treatment plan.”

    What, I wonder, did the other 32% hold to be most important?

    So I wonder how many of the 311 respondents were really physicians? I know they were all sent to physicians. But how many were filled out by office managers, teen-aged children, or janitors who were only after the laser pen*? It would reduce my confidence in medicine greatly if I were to believe that more than half of ID physicians prescribed massage and herbal supplements for the treatment of infectious diseases.

    *I don’t think that Dr. Crislip made clear that this was a paper survey. Accompanying the cover letter and survey was a genuine Darth Vader limited edition** laser pen as a guilt pump.

    **OK, I made the Darth Vader limited edition part up. But there really was a laser pen included.

  2. Dr Crislip,

    Having done some graduate statistics and applied research eons ago, I believe I remember that when determining a number to be representative of the population I am looking at, I need to know how many total individuals are in that population. That way I have a target number to at minimum need to be able to generalize to that population. At best the research I did was only generalizable to the population I was looking at, but did indicate (in my conclusion) that more research needed to be done. As well as this I indicated the weaknesses and possible shortcomings of my research. Did they do this in their survey? How many board certified ID are there in the US? Comparing that N to the total number surveyed then only to the total surveys returned I would garner to wage the results of this survey are only representative and generalizable to those who returned the survey. Surveys and questionnaires are on the weak side on the predictive power scale in research. I know Five Hour Energy tried this with there “thousands of doctors” “recommend” commercials. Of course this was an argument from popularity tactic. I apologize I have not looked at the survey to look at the methods section. I would not be surprised if this was not a seeding survey in that those who where “chosen” to be surveyed where already identified as pro-CAM.

  3. “Integrative medicine combines treatments from conventional medicine and CAM for which there is some high-quality evidence of safety and effectiveness” – this definition was indeed found under the link they provided up to a few years ago. It is cited by a dozen or so medical articles which reference this NCCAM webpage.

  4. It’s the same with knitting, yet most who take on sewing or knitting (I suspect the same with quilting and crochet), will only achieve the most basic item or produce a holey scarf or a hat or two. I have taught sewing and knitting and know that (in general) those under 50 have difficulty threading the machine these days. They do a bit better with the knitting, but most only want the easy and instant result, not subtleties. I suspect Nancy has a fairly small following–compared to Dr. Oz, anyway.

    My husband says he is tired of hearing about this and that you all need to clean up your own backyard. How’s that for a tip/tool? :-)

  5. rork says:

    Anecdote: I know docs out there that really aren’t very smart, skeptical, or good at critical thinking. And they may be over-represented in surveys. Maybe they are somewhat better than the median, but recall that the median human is frighteningly doltish.

    1. windriven says:

      rork, if skepticism and critical thinking aren’t rewarded or selected for there is no reason to expect physicians be different from the general population of college graduates.

  6. WilliamLawrenceUtridge says:

    Just a note – anyone curious about the actual article, the weblink is to a full-text version so you don’t have to restrict yourself to the abstract.

  7. windriven says:

    “My husband says he is tired of hearing about this and that you all need to clean up your own backyard.”

    I’m with your husband on this. But then SBM is clearly part of the effort to do just that.

    Sadly, I think the die is cast or maybe the dice have been rolled or maybe it is the patient population that has been rolled. Whatever. We seem to have crossed the sCAMiferous Rubicon and rolling things back will prove Sisyphean. Even if as Mr. Jenkins suggests above the survey in question was rigged it is clear that some nontrivial fraction of MDs have gone off the reservation and embrace sCAM or Integrative Quackery.

    For decades quackery buzzed around the periphery of medicine like a cloud of irritating gnats. Now they have insinuated themselves into the very core of the medical establishment: medical schools. To quote (or misquote) Pogo, “I have met the enemy and they is us.”

    I think I’ll go say a Hail Mary just in case.

    1. I absolutely know that SBM is doing its level best to reach the public, but what are they doing about doctors who engage in this rubbish? Perhaps it’s time for real doctors to move beyond blogging and formalize some kind of pushback in the form of a lobby or professional group.

      The AMA once had enormous clout, as does a group like AARP nowadays. Shruggies need to be pulled off the fence and join the fight. Pressure needs to be brought to stop opening SCAM clinics within medical institutions and close down existing ones. Seminars on critical thinking (especially as applied to medicine and research) need to be offered–again, pressure from the medical community could contribute to this.

      I’ve learned a great deal here, but no one will listen long enough for me to pass most of it on. Talking points could be developed and distributed. Maybe (on a more fanciful note) volunteers (old ladies like me) could set up shop next door to (fill in the blank woo) shops and hand out literature (reprints of our own eBooks?).

      I dunno, and I’m just brainstorming, but we need to move Beyond The Blog (creepy organ music here).

      Note to Dr. C:

      I forgot to mention how many doctors (mostly female) I have taught to knit. Most took it up as a means of relaxation and uniformly they were very quick learners who were making lovely pairs of socks in no time at all. One anesthesiologist was particularly adept with the very small needles used for socks–she said it was a lot like giving an epidural (her specialty). Sadly, she gave it all up, took a long leave and returned as an Ayurvedic Practitioner! The Indian urologist who was engaged to the Jewish writer (to the alarm of both sets of traditional parents) was, conversely, determined to distance herself from such practices. There were nurses as well, and they were all over the map on SCAM.

      I also had a Chiro, who stormed in (literally), demanded one session instead of two as she was “a very busy doctor”. She continually answered her pager in the hip-holster and finally left halfway through claiming she had an “emergency”. I never saw her again and she didn’t knit a single stitch.

      Trust me, people tell the knitting teacher everything. I should have done a survey.

  8. Andrey Pavlov says:

    “Integrative medicine combines treatments from conventional medicine and CAM for which there is some high-quality evidence of safety and effectiveness”

    That is simply the definition of medicine. I commented at the NCCAM blog on Dr. Brigs’ most recent post essentially to that effect. I wrote very professionally and civilly, laid out my case, and asked questions. Nearly 48 hour later my comment is still not approved.

    It was my mistake not to save a copy of what I had written.

  9. mcrislip says:

    So they are just sloppy instead of disengenuous. Any idea when the change occured.

    1. WilliamLawrenceUtridge says:

      The problem is they didn’t put in the accessed date in the reference, just the year. They put “2010″, at which point the definition was:

      Defining CAM is difficult, because the field is very broad and constantly changing. NCCAM defines CAM as a group of diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine. Conventional medicine (also called Western or allopathic medicine) is medicine as practiced by holders of M.D. (medical doctor) and D.O. (doctor of osteopathic medicine) degrees and by allied health professionals, such as physical therapists, psychologists, and registered nurses. The boundaries between CAM and conventional medicine are not absolute, and specific CAM practices may, over time, become widely accepted.

      “Complementary medicine” refers to use of CAM together with conventional medicine, such as using acupuncture in addition to usual care to help lessen pain. Most use of CAM by Americans is complementary. “Alternative medicine” refers to use of CAM in place of conventional medicine. “Integrative medicine” combines treatments from conventional medicine and CAM for which there is some high-quality evidence of safety and effectiveness. It is also called integrated medicine.

      archive.org is playing silly buggers, but as far as I can tell the definition changed between April 7th, 2013 and July 27th, 2013.

  10. And I had long considered that ID docs are without a doubt the smartest docs in the hospital and the best diagnosticians.

    .. and the most modest, “without a doubt”

  11. Spurious Conventional Allopathic Medicine (SCAM/conmed) is now called as Modern Allopathic Medicine.

    Poll: Which form of medicine would you prefer to use?
    http://drnancymalik.wordpress.com/2012/06/04/polls/

    Poll: Should pharmaceutical drug treatments be publicly funded by the NHS UK?
    http://drnancymalik.wordpress.com/2012/06/05/poll-2/

    1. WilliamLawrenceUtridge says:

      Thank you for demonstrating that any monkey can put up a survey, and the results are about as credible as anything else on the internet.

      Also, hilariously, both those polls show overwhelmingly that publicly-funded scientific medicine is the preferred option. I know that’s what I chose when I voted. Twice.

  12. Craig Good says:

    “ID physicians were most familiar with vitamin and mineral supplementation (83%), massage (80%), acupuncture (79%), chiropractic (77%), yoga (74%), and herbal medicine (72%).”

    So there are 20-ish percent of ID physicians who have never even heard of these SCAMs? I would hope they’d all be familiar – and know that they’re rubbish.

    That whole survey smells funny.

    1. nybgrus says:

      You’d be surprised how many physicians haven’t heard of these modalities. Or who have, but have only heard of it in passing and tend to think the most simple, benign, and decidedly un-woo like vague things about it.

      In fact, I just finishde my first week on the ID service and my attending – who is really good and one of my favorite attendings so far – mentioned homeopathy in passing and commented rather non-chalantly about how that “all natural” stuff doesn’t really do much but could help in some cases. It was clear he didn’t think CAM was worth pursuing or advising patients to use, but he also clearly didn’t know what homeopathy actually is, and his attitude was basically “if the patient uses it who care?”

      And indeed, most physicians and most people I know think “homeopathy” simply means “holistic medicine” which to them means something more along the lines of “naturopathy” but without the really quackiest of the woos involved. Basically a benign herbalist who is nice and chatty and well meaning with essentially harmless things that you can have fun trying if you like. Sort of like astrology as entertainment to add in to your life, rather than something serious to live your life by.

      And that is the problem of the shruggie.

  13. windriven says:

    “And that is the problem of the shruggie.”

    Indeed. I am coming to believe that the shruggies are more dangerous than the batcrap-crazy woomeisters. They are much harder to identify and harder to pin down and engage. It probably won’t surprise you that many in the political class fit the shruggie profile – at least in my experience.

  14. Lynn says:

    All this raises a question for me… I am in the process of switching clinics and, therefore, MDs. In fact, I have an apt.next week. How does one find out the MD’s biases… may I just ask, outright, “What alternative medicine practices do you advocate?” Or, do I wait until I like her and then find out she pushes homeopathy or something?

    1. windriven says:

      I would suggest asking open ended questions and let the doctor answer. This is more likely to get you their actual thoughts and not just what they think you want to hear. No doctor thinks that they are advocating quackery. You need to decide what constitutes quackery in terms of your own care. Better to shop now than when you are in extremis.

  15. WilliamLawrenceUtridge says:

    @Lynn

    I wouldn’t see a problem with merely asking. A skeptical physician might say “there’s no harm in trying them” and might even go on to talk about the shoddy research base. If they say “oh, yes, I believe in using natural treatments whenever possible”, ask them what is natural about shaking a dilution of moonbeams then leave the office. That’s what I’d do :)

    As a favour – could you let us know what you decided to do, and how it worked out?

    1. Lynn says:

      Yes, I’ll share the results. Our former MD recommended (as in, “You might try”) some things from time to time, like glucosamine Chondroitin and saw palmetto, while noting that there was no good research supporting their use. Once the research became clear, he stopped such suggestions. And tht’s fine with me, as long as the MD notes what the current state of the research is. In checking the reviews on this new MD, I found one that said that she, “addressed traditional and alternative medicine treatment options in an open-minded way.” Maybe she was simply being tactful.

      1. anthro49 says:

        I am not so polite. I ask them outright if they engage in ANY unscientific practices and then I elaborate on my rigid criteria of what passes scientific muster. If they start to go shruggie on me, I tell them I will not tolerate any medical advice that does not come from rigorous scientific sources.

        They are usually surprised at my being so adamant, but all have crossed-their-hearts-and hoped-to-die so far. Most seem relieved that they don’t have to indulge the questions they get from the average patient about supplements at the least and who knows what at the most.

        My primary care doc was pregnant when I first saw her and she expressed a little concern about getting a flu shot. I told her in no uncertain terms to remember her science background and what she learned in medical school, and to consult with her peers. She got the flu shot.

        1. Oh-oh, I’m showing up as anthro49 again instead of goodnightirene. I haven’t done anything to cause the cane–I give up. Wait! I maybe fixed it???

  16. Lynn says:

    I have this bias about MD appointments…. I like to meet the MD for the first time with my clothes on. This, apparently, is not the custom at this particular clinic, but we did it my way.

    I asked her, “Are there alternative medicine practices that you recommend to your patients?” She said, “Like what?” I said, “For example, homeopathy or acupuncture.”

    She replied (at some length) that, if she had a patient with muscular/skeletal pain that was long-standing and that could not be resolved through conventional medicine, she might suggest acupuncture. I asked why, given that there is absolutely no research supporting its efficacy. She then referenced the placebo effect.

    I really don’t think that’s good enough.

    1. windriven says:

      If you live in the PNW I’d be happy to suggest a few that you might interview.

      1. egstra says:

        ” PNW”

        Pacific Northwest? In my dreams.

  17. Andrey Pavlov says:

    This actually doesn’t seem entirely unreasonable. I would probably hold the line a bit tighter and make it clear that I would support you in your decision while not recommending it outright. But the interaction in my consultation room is very different than that online or other public discourse. I aim to foster a therapeutic relationship with my patient and if I perceived your line of questioning as indicating that you would like my endorsement of acupuncture I would hedge my words carefully in order not to push you away. I’d rather keep you around and demonstrate why I am trustworthy and knowledgeable so that I have a better chance of actually getting you to drop your fanciful notions since I know that hard-lining it right off the bat is more likely to get you to dig your heels in. It is a tight balance to walk.

    Plus, most physicians aren’t as well versed in placebo effects and what they actually mean and do and even those that are (I’m looking at you, pmoran) still want to give it more leeway than it warrants. The old guard tend to view it from the “If it isn’t harming them and makes them feel better, why not?”

    So at least based from the very brief snippet you provided, I wouldn’t be so inclined to dismiss this physician. Of course, there could be a lot more you didn’t include in there and no matter what I wasn’t there so I can’t really comment definitively. All I’m saying is to be cognizant that even us otherwise hard line science based physicians will still act a little differently in closed consultation rooms purely to foster a therapeutic relationship.

    1. egstra says:

      “So at least based from the very brief snippet you provided, I wouldn’t be so inclined to dismiss this physician.”

      To tell the truth, I’d probably cut her more slack if I liked her better. But, she didn’t listen very well. OTOH, the clinic is very conveniently located. Fortunately, I like the sports medicine clinic I go to, and I spend a lot more time there (sigh).

  18. You may as well move there–about four million others have in the last 30 years. :-)

  19. That comment about moving to the PNW was supposed to be in response to Lynn. I don’t get this; you click reply and then it goes who-nows-where.

    1. Egstra says:

      LOL! I understood!

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