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The Marino Center for Integrative Health: Hooey Galore

Two weeks ago I promised that I would discuss the Marino Center for Integrative Health, identified in the recent Bravewell report as having a “hospital affiliation” with the Newton-Wellesley Hospital (NWH) in Newton, Massachusetts, which is where I work. I also promised in that post that I’d provide examples of ‘integrative medicine’ practitioners offering false information about the methods that they endorse. I’d previously made that assertion here, and Jann Bellamy subsequently discussed its legal and ethical implications here. The Marino Center is a wellspring of such examples.

A Misleading ‘Affiliation’

Let’s quickly dispel the “hospital affiliation” claim. According to the Marino Center website:

Hospital Affiliations

In support of our services and to ensure that our patients have access to exceptional tertiary care, the Marino Center maintains deeply established relationships and affiliations for referrals and admitting privileges with major medical facilities in the Boston area.

The Marino Center:

  • Is a proud member of the Partners Healthcare family
  • Is affiliated with Newton Wellesley Hospital
  • Makes referrals to Mass General Hospital, Dana Farber, Children’s Hospital and more

Well, it wouldn’t surprise me if the Marino Center is a ‘member’ of the Partners Healthcare family, which includes not only the Newton-Wellesley Hospital, but lesser known entities such as the Massachusetts General Hospital and the Brigham and Women’s Hospital. After all, there are already unfortunate pseudomedical schemes involving Partners entities, such as the Osher Center for Complementary and Integrative Medical Therapies and, even under my own roof (I shudder as I write this), a Reiki Workshop. Nevertheless, it’s telling, I hope, that not only does the Marino Center fail to appear under any list of Partners affiliates, Community Health Partnerships, Wellness, Prevention, or any other conceivable category, but it fails to yield a single ‘hit’ when entered as a search term on the Partners website (the term ‘integrative’ yields seven hits, but none appears to be about ‘CAM,’ except possibly for an RSS feed that I’ve no patience to peruse. Is it possible that Partners is embarrassed by the Osher Center? I hope that, too).

I’ve previously asserted that the NWH is not affiliated with the Marino Center, other than that some Marino Center physicians have been—against my judgment, not that I was consulted—granted hospital staff privileges. I made this assertion in my original Bravewell post a couple of weeks ago, after having questioned the NWH Chief Medical Officer, Dr. Les Selbovitz, who verified it; nothing on the NWH website suggests otherwise.

I’ve no reason to doubt the Marino Center’s third bullet above, “makes referrals to Mass General Hospital,” etc., but this is something that any physician can do, regardless of affiliation. I suspect that if there were an ‘integrative hospital‘ in Boston, reason forbid, the Marino Center would make referrals to it.

False and Misleading Information about ‘Services’

Let’s get to the meat of the problem.

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Posted in: Acupuncture, Homeopathy, Medical Ethics, Science and Medicine, Science and the Media

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Bravewell Bimbo Eruptions

This is yet another response to the recent “Integrative Medicine in America” report published by the Bravewell Collaborative. Drs. Novella and Gorski have already given that report its due, so I won’t repeat the background information. Inevitably, I’ll cover some of the same points, but I’ll also try to emphasize a few that stand out to me. Most of these have been discussed on SBM over the years, but bear repeating from time to time. Let’s begin with:

If it Ducks like a Quack…

Misleading language is the sine qua non of ‘integrative medicine’ (IM) and its various synonyms. The term itself is a euphemism, intended to distract the reader from first noticing the quackery that is its distinguishing characteristic. As previously explained, Bravewell darlings Andrew Weil and Ralph Snyderman, quack pitchmen extraordinaires, recognized nearly 10 years ago that if you really want to sell the product, you should dress it up in ways that appeal to a broad market.

Let’s see how this is done in the latest report. Here is the very first sentence:

The impetus for developing and implementing integrative medicine strategies is rooted in the desire to improve patient care.

Who would disagree with improving patient care? (Try not to notice the begged question). Here’s the next paragraph (emphasis added): (more…)

Posted in: History, Medical Academia, Medical Ethics, Politics and Regulation, Science and Medicine, Science and the Media

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What is Science?

Consider these statements:

…there is an evidence base for biofield therapies. (citing the Cochrane Review of Touch Therapies)

The larger issue is what constitutes “pseudoscience” and what information is worthy of dissemination to the public. Should the data from our well conducted, rigorous, randomized controlled trial [of 'biofield healing'] be dismissed because the mechanisms are unknown or because some scientists do not believe in the specific therapy?…Premature rejection of findings from rigorous randomized controlled trials are as big a threat to science as the continuation of falsehoods based on belief. Thus, as clinicians and scientists, our highest duty to patients should be to investigate promising solutions with high benefit/risk ratios, not to act as gatekeepers of information based on personal opinion.

–Jain et al, quoted here

Touch therapies may have a modest effect in pain relief. More studies on HT and Reiki in relieving pain are needed. More studies including children are also required to evaluate the effect of touch on children.

Touch Therapies are so-called as it is believed that the practitioners have touched the clients’ energy field.

It is believed this effect occurs by exerting energy to restore, energize, and balance the energy field disturbances using hands-on or hands-off techniques (Eden 1993). The underlying concept is that sickness and disease arise from imbalances in the vital energy field. However, the existence of the energy field of the human body has not been proven scientifically and thus the effect of such therapies, which are believed to exert an effect on one’s energy field, is controversial and lies in doubt.

—Cochrane Review of Touch Therapies, quoted here

 …

Science is advanced by an open mind that seeks knowledge, while acknowledging its current limits. Science does not make assertions about what cannot be true, simply because evidence that it is true has not yet been generated. Science does not mistake absence of evidence for evidence of absence. Science itself is fluid.

—David Katz

When people became interested in alternative medicines, they asked me to help out at Harvard Medical School. I realized that in order to survive there, one had to become a scientist. So I became a scientist.

—Ted Kaptchuk, quoted here.

 …It seems that the decision concerning acceptance of evidence (either in medicine or religion) ultimately reflects the beliefs of the person that exist before all arguments and observation.

 —Ted Kaptchuk, quoted here.

Together they betray a misunderstanding of science that is common not only to “CAM” apologists, but to many academic medical researchers. Let me explain. (more…)

Posted in: Basic Science, Book & movie reviews, Clinical Trials, Energy Medicine, Faith Healing & Spirituality, Homeopathy, Medical Academia, Science and Medicine

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Homeopathy and Its Kindred Delusions

Note: The James Randi Educational Foundation (JREF) is publishing a new series of e-books.  The first two offerings are an excellent new book on critical thinking by Bob Carroll, Unnatural Acts, and the first in a planned series of republications of classic skeptical works, Homeopathy and Its Kindred Delusions, by Oliver Wendell Holmes. I was asked to write the introduction for the latter, and the JREF has kindly given their permission for me to reproduce it here.

————–

The German philosopher Hegel said, “We learn from history that we don’t learn from history.” “Homeopathy and Its Kindred Delusions” is a remarkable little book based on two lectures Oliver Wendell Holmes gave in 1842. It is a masterful debunking of homeopathy. If his lessons had been taken to heart, homeopathy would not have survived and we could have avoided a great number of other medical delusions that continue to plague us today, both from charlatans and from well-meaning advocates who lack Holmes’ critical thinking skills.

To realize just how remarkable this book is, imagine the world of 1842.  Samuel Hahnemann, the inventor of homeopathy, was still alive. Roentgen wouldn’t discover x-rays until 1895. The germ theory was not yet established. Semmelweis wouldn’t make his observations on puerperal fever until 3 years later. It wasn’t until 1854 that John Snow removed the Broad Street pump handle and stopped a cholera epidemic. Koch’s postulates for determining infectious causes of disease weren’t published until 1890. Doctors didn’t wash their hands or use sterile precautions for surgery. Bloodletting to “balance the humors“ was still a common practice. The randomized placebo-controlled trial wouldn’t appear for another century. Contemporary medicine often did more harm than good. In fact, Holmes himself famously quipped “I firmly believe that if the whole materia medica could be sunk to the bottom of the sea, it would be all the better for mankind and all the worse for the fishes.” (more…)

Posted in: History, Homeopathy

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Night of the living naturopaths

Colorado’s “degreed” naturopaths (NDs) are nothing if not persistent. Starting in 1994 they have tried seven times to convince legislators that the Colorado’s public needs protection from what “traditional” naturopaths (traditionals) do, and that the best way of providing that protection, they claim, is to bestow licensure on the guys with the college degrees. The irony in this is that the NDs could well be the more dangerous practitioners.

Legislators have been largely sympathetic to the concerns of the more numerous traditionals who fear the loss of their right to work as naturopaths. The NDs have tried neutralize these opponents by reassuring them they could continue to practice naturopathy, but the traditionals don’t buy that. And they won’t easily forfeit the title of “naturopath” to which they believe to have more claim.

So what we have here in Colorado is near 20-year turf war between two types of naturopaths: the NDs who seek legislation to transform naturopathy into a protected guild, and the traditionals who are happy with the status quo. There is no love lost between these groups. Legislators repeatedly advise them to resolve their differences before asking for licensure again, but they haven’t gotten close to détente.

Colorado NDs have made no secret of their economic motivations. Before the 2011 legislative session, the Colorado Association of Naturopathic Doctors (CAND) was reinvigorated by the passage of the Patient Protection and Affordable Care Act which has this “non-discrimination” provision:

(a) Providers- A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider’s license or certification under applicable State law. This section shall not require that a group health plan or health insurance issuer contract with any health care provider willing to abide by the terms and conditions for participation established by the plan or issuer. Nothing in this section shall be construed as preventing a group health plan, a health insurance issuer, or the Secretary from establishing varying reimbursement rates based on quality or performance measures. [Sec. 2706]

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Posted in: Naturopathy, Politics and Regulation, Public Health

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Defining what a “physician” is

The very concepts of “complementary and alternative medicine” (CAM) and “integrative medicine” (IM), the former of which “complements” science-based medicine with quackery and the latter of which “integrates” pseudoscience-based with science-based medicine are all about slapping a veneer of scientific legitimacy onto something that has failed to achieve such legitimacy through actual basic, translational, and clinical science. The reason I start out by saying this is to emphasize that CAM/IM is all about using language to persuade that pseudoscience is actually science-based. It’s far more about marketing than accurately communicating concepts. In CAM, everything is “holistic,” and doctors “care for the whole patient,” while “Western medicine” is “reductionistic” and “allopathic.” At the very heart of this language is a false dichotomy: That you must either embrace pseudoscience or that you somehow can’t provide care as compassionate and caring as what the quacks supposedly provide, nor are you able to provide for the emotional needs of your patients. There are two false dichotomies, actually, in that there is also the not-so-subtle implication in CAM that you can’t be truly “holistic” without—you guessed it—embracing the pseudoscience that is at the heart of many CAM/IM modalities.

This use and abuse of language for propagandistic purposes in CAM/IM is not limited to just these examples. In fact, the misuse of language infuses the whole enterprise of CAM/IM to the point that its adherents, not content with being mere “practitioners,” are trying to claim the very title of “physician” for themselves. I learned this from John Weeks, the main force behind the Integrator Blog, a blog dedicated to issues of CAM and IM. He’s the one who first let me know about Andrew Weil’s attempt to put together a board certification in IM. In particular, his reporting on the reaction of CAM/IM practitioners, both physicians and non-physicians, to this initiative by Andrew Weil was most illuminating to me. What was most telling was how further propagandistic use of the language focused on “dominance” by MDs, which in this case struck me as actually being closer to the truth than the usual CAM-speak is. In any case, Dr. Weil’s initiative does indeed appear to be more about taking control of CAM for physicians, his high-minded language about “establishing standards” notwithstanding.

This time around, Weeks has provided me with an education about how alternative/CAM/integrative practitioners now covet the title of “physician”. In the process, he also uses and abuses language in the same way that Andrew Weil and CAM/IM advocates do. This time around, it’s all about co-opting the title of “physician” for non-physician CAM practitioners. It’s bad enough to me when actual physicians are seduced by the pseudoscience of CAM, but this effort appears to be an intentional strategy designed to confuse the public by proclaiming as physicians practitioners who lack the essential skills to be a physician, such as acupuncturists, chiropractors, homeopaths, and naturopaths.
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Posted in: Chiropractic, Homeopathy, Naturopathy, Politics and Regulation

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Dummy Medicine, Dummy Doctors, and a Dummy Degree, Part 2.2: Harvard Medical School and the Curious Case of Ted Kaptchuk, OMD (cont. again)

“Strong Medicine”: Ted Kaptchuk and the Powerful Placebo

At the beginning of the first edition of The Web that has no Weaver, published in 1983, author Ted Kaptchuk portended his eventual academic interest in the placebo:

A story is told in China about a peasant who had worked as a maintenance man in a newly established Western missionary hospital. When he retired to his remote home village, he took with him some hypodermic needles and lots of antibiotics. He put up a shingle, and whenever someone came to him with a fever, he injected the patient with the wonder drugs. A remarkable percentage of these people got well, despite the fact that this practitioner of Western medicine knew next to nothing about what he was doing. In the West today, much of what passes for Chinese medicine is not very different from the so-called Western medicine practiced by this Chinese peasant. Out of a complex medical system, only the bare essentials of acupuncture technique have reached the West. Patients often get well from such treatment because acupuncture, like Western antibiotics, is strong medicine.

Other than to wonder if Kaptchuk had watched too many cowboy ‘n’ Native American movies as a kid, when I first read that passage I barely blinked. Although the Chinese peasant may have occasionally treated someone infected with a bacterium susceptible to his antibiotic, most people will get well no matter what you do, because most illnesses are self-limited. Most people feel better even sooner if they think that someone with special expertise is taking care of them. If you want to call those phenomena the “placebo effect,” in the colloquial sense of the term, fine. That, I supposed, was what Kaptchuk meant by “strong medicine.”

Turns out I was mistaken. Let’s briefly follow Kaptchuk’s career path after 1983. In the 2000 edition of The Web, he wrote:

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Posted in: Acupuncture, Basic Science, Book & movie reviews, Chiropractic, Clinical Trials, Homeopathy, Medical Academia, Science and Medicine

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Homeopathy and Plausibility

The fundamental concept of science-based medicine (SBM) is that medical practice should be based upon the best available science. This may seem obvious, but there are many important details to its application, such as the relationship between clinical and basic science. Clinical claims require clinical evidence, but clinical evidence can be tricky and is often preliminary. It is therefore helpful (I would say essential) to view the clinical evidence in light of all of the rest of science.

A thorough basic and clinical science analysis of a medical claim can be summarized by the term “plausibility,” or “prior probability” if you want to put it into statistical terms. When we say a certain belief is plausible we mean it is consistent with what we know from the rest of science. In other words, because of the many weaknesses of clinical evidence, in order for a therapy to be generally accepted as part of SBM it should have a certain minimal supporting clinical evidence and overall scientific plausibility.

These can exist in different proportions – for example one therapy may be highly plausible (it would be shocking if it were not true) and have modest supporting clinical evidence, while another may have unknown plausibility but with solid clinical evidence of efficacy. But no therapy should have clinical evidence that suggests lack of efficacy, nor extreme implausibility (not just an unknown mechanism, but no possible mechanism).

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Posted in: Homeopathy

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The College of Physicians and Surgeons of Ontario’s muddled draft policy on “non-allopathic” medicine

Detroit is my hometown, and three and a half years ago, after nearly twenty years away wandering between residency, graduate school, fellowship, and my first academic job, I found myself back in Detroit minted as surgical faculty at Wayne State University and practicing and doing research at the Barbara Ann Karmanos Cancer Institute. One thing that I had forgotten about while I was away for so many years is just how intimately southeast Michigan interacts with Canada. This closeness is not surprising, given that Detroit and Windsor are separated by only about a half mile of Detroit River. Indeed, a there are a lot of Canadians who cross the border on a daily basis to work in the Detroit area, many of them in the medical center within which my cancer center is located. The reason I point this out is not to wax nostalgic for trips to Windsor or for the occasional trip to Stratford to see plays but to point out that Ontario is right next to us. What happens there is of concern to me because I know quite a few people who live there and because it can on occasion influence what goes on over here on the U.S. side of the border.

I recently learned that the College of Physicians and Surgeons of Ontario (CPSO) has been working on updating its policy on the use of nonconventional medical therapies. The wag in me can’t help but wonder why such a policy would need to say anything other than that, if it isn’t science- and evidence-based, the CPSO doesn’t support using it, but in a less sarcastic moment I realized that such a policy is probably not that bad an idea, as long as it doesn’t legitimize pseudoscience, which is, of course, the biggest pitfall to be avoided when writing such a policy. Not too long ago, the CPSO released its draft policy and has asked for public comments, with the deadline being September 1. I was happy to learn that I had not missed the deadline, because there is much to comment about regarding this policy, but it’s definitely true that time’s short. Unfortunately, I wasn’t so happy when I read the title of the draft policy, namely Non-Allopathic (Non-Conventional) Therapies in Medical Practice, with a subtitle of “Formerly named Complementary Medicine.” The full policy in PDF form can be found at this link.
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Posted in: Homeopathy, Politics and Regulation, Public Health

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Dummy Medicines, Dummy Doctors, and a Dummy Degree, Part 1: a Curious Editorial Choice for the New England Journal of Medicine

Background

This post concerns the recent article in the New England Journal of Medicine (NEJM) titled “Active Albuterol or Placebo, Sham Acupuncture, or No Intervention in Asthma.” It was ably reviewed by Dr. Gorski on Monday, so I will merely summarize its findings: of the three interventions used—inhaled albuterol (a bronchodilator), a placebo inhaler designed to mimic albuterol, or ‘sham acupuncture’—only albuterol resulted in a clinically important improvement of bronchial airflow; for that outcome the two sham treatments were equivalent to “no intervention.” For all three interventions, however, self-reported improvements were substantial and were much greater than self-reported improvements after “no intervention.” In other words, dummy treatments made the subjects (report that they) feel better, whereas real medicine not only made them feel better but actually made them better.

Before proceeding, let me offer a couple of caveats. First, the word ”doctors” in the flippant title of this post refers mainly to two individuals: Daniel Moerman, PhD, the anthropologist who wrote the accompanying editorial, and Ted Kaptchuk, the Senior Author of the trial report. It does not refer to any of the other authors of the report. Second, I have no quarrel with the trial itself, which was quite good, or with the NEJM having published it, or even with most of the language in the article, save for the “spin” that Dr. Gorski has already discussed.

My quarrels are the same as those expressed by Drs. Gorski and Novella, and by all of us on the Placebo Panel at TAM. This post and the next will develop some of those points by considering the roles and opinions of Moerman and Kaptchuk, respectively.

A True Story

Late one night during the 1960s a friend and I, already in a cannabis-induced fog, wandered into a house that had been rented by one of his friends. There were about 8-10 ‘freaks’ there (the term was laudatory at the time); I didn’t know any of them. The air was thick with smoke of at least two varieties. After an uncertain interval I became aware of a guy who was having trouble breathing. He was sitting bolt upright in a chair, his hands on his knees, his mouth open, making wheezing sounds. He took short noisy breaths in, followed by what seemed to be very long breaths out, as though he was breathing through a straw. You could hear the wheezing in both directions. Others had also noticed that he was in distress; they tried to be helpful (“hey, man, ya want some water or somethin’?”), but he just shook his head. He couldn’t talk. My friend, who had asthma himself, announced that this guy was having an asthma attack and asked if he or anyone else had any asthma medicine. No one did.

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Posted in: Acupuncture, Cancer, Clinical Trials, Energy Medicine, Faith Healing & Spirituality, Health Fraud, Homeopathy, Medical Academia, Medical Ethics, Naturopathy, Pharmaceuticals, Public Health, Science and Medicine, Science and the Media

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