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The 2nd Yale Research Symposium on Complementary and Integrative Medicine. Part II

The Main Event: Novella vs. Katz

The remainder of the Symposium comprised two panels. The first was what I had come to see: a Moderated Discussion on Evidence and Plausibility in the Context of CAM Research and Clinical Practice, featuring our Founder, Steve Novella, who is also Assistant Professor of Neurology at Yale; and David Katz, the speaker who had borne the brunt of the criticism after the 2008 conference (as I wrote in Part I). According to the Symposium syllabus, he is:

David L. Katz, MD, MPH, FACPM, FACP, an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. Katz is the Director and founder (1998) of Yale University’s Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, CT; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. He currently serves as Chair of the Connecticut Chapter of the Partnership to Fight Chronic Disease and represents Yale University on the Steering Committee of the Consortium of Academic Health Centers for Integrative Medicine.

The syllabus had excerpted that statement from a much larger, remarkable document, which I urge you to review.

I will attempt to report the Moderated Discussion as neutrally as possible, as though I were a disinterested journalist (don’t worry: later I’ll rail).

The session began with 10-minute remarks by each of the two panelists. Each was then asked to respond to a few scripted questions posed by the moderator, Dr. Barry Boyd (whose earlier talk I discussed in Part I). The panelists were aware of the questions beforehand.

Dr. Novella went first. He began by suggesting that everyone in the room shares a common ground: wanting to do what’s best for patients, and in particular wanting to offer them things that work. He proceeded to summarize what he means by “science-based medicine.” My notes are scant and illegible, but I’ll try to re-create the points. Steve can fill in any glaring omissions later.

Science-based medicine, said Dr. Novella, is not a list of treatments, procedures, specialties, drugs, diseases, or whatever; rather, it is a methodology. It seeks the best diagnostic and therapeutic options wherever it may find them; it is, like science in general, always open to new directions and willing to scrap existing ones, if the evidence so leads. It is based in the natural sciences, especially biology, but it also applies scientific methods to practical aspects of clinical medicine, such as testing diagnostic and therapeutic hypotheses. It assumes “consilience”: like science itself, it is not “Eastern” or “Western,” but universal.

Science-based medicine doesn’t “cherry-pick”: it starts with a problem and follows the evidence toward or away from potential solutions; it does not first pick a solution and then assemble whatever evidence there may be to support it. It acknowledges numerous sources of bias and error, from our flawed brains to small studies and studies sponsored by advocates (Steve cited drug companies). It recognizes the necessity to consider the “meta-evidence” (I think that was Steve’s term), meaning evidence gleaned from the entire range of potential sources: basic science to clinical trials to clinical realities.

Dr. Katz followed. He began by observing that it isn’t very often that he begins a debate by agreeing with the other debater. This yielded a smattering of appreciative chuckles. He continued with a series of “bullets,” and once again I’m afraid I don’t have them all in my notes, but here’s my attempt, followed by most of the points that Dr. Katz made in his opening remarks:

  • “Plausibility and Pandora”
  • “Tail wags Dog”
  • (illegible), Serendipity
  • Absolute Relationship
  • Scylla and Charybdis

Dr. Katz mentioned that according to astrophysicists (or perhaps one in particular that he had read or heard speak), there is more empty space between the elementary particles in each of our bodies than exists in the entire universe. He doesn’t understand it himself, but assuming it is true he wonders, for example, how others can so easily dismiss Therapeutic Touch merely because it isn’t really touch, since what we think of as touch isn’t really touch, either.

He listed a few innovations in the recent history of medicine that were “heresy” when first proposed, suggesting that if plausibility had ruled the day they would never have emerged:

  1. H. pylori shown to be the cause of peptic ulcers;
  2. Beta-blockers beneficial even for patients prone to congestive heart failure;
  3. Rocky Mountain spotted fever established as caused by a bacterium.
  4. (Later he mentioned the right heart catheter as an example of something that everyone thought was safe and effective, until a study showed that it wasn’t; but even then it took a long time for MDs to finally stop using it)

He mentioned that the monoamine oxidase inhibitor (MAOI) class of antidepressants had been discovered serendipitously when TB patients taking isoniazid (INH), a related drug, didn’t seem so depressed.

He said, “relative absence of evidence is not absolute evidence of absence.”

Evoking Scylla and Charybdis, he invited the audience to consider this choice: that something “works whether or not it’s plausible”; or that something is “implausible whether or not it works.”

He offered the metaphor of a solid floor and a moving ceiling to represent proven and unproven treatments, and noted that if we insist on using only proven treatments, we will soon get squeezed (he didn’t say it exactly that way, but I think you get the point).

The two participants then sat down and the moderator asked the questions. I can remember only one, but I remember most of the discussion. A large part of it involved how to deal with patients who are suffering, but for whom scientific medicine has no clear solution. Dr. Novella argued that he would never abandon such a patient, and that there are ways to be compassionate and caring without offering implausible treatments. He has also discussed similar points here on SBM. When asked what he would do if a patient asked his opinion about a particular method, he replied that he would be honest. He said that according to surveys, only a small fraction of those who seek “CAM” do so because of having exhausted all “conventional” options. Most do it for other reasons, having more to do with their beliefs.

I must admit that I can’t remember exactly how Dr. Katz responded to that point and to Dr. Novella’s opinions, but it presumably had to do with his floor/ceiling metaphor; his views on the same general topic are available elsewhere.

The scripted question that I distinctly remember went something like this: “what would you do if your hospital decided, in response to a perceived demand in its community, to establish a Therapeutic Touch program?”

Dr. Novella replied that he would oppose it on the grounds that hospitals have made an implicit commitment to offer science-based treatments, and Therapeutic Touch does not meet that standard.

Dr. Katz disagreed, suggesting that we don’t really know that TT doesn’t work; there have been intriguing studies, he said, showing effects on cells in tissue culture that couldn’t possibly be explained by a placebo effect. He suggested that extreme skeptics believe that TT doesn’t work and can’t work, while extreme advocates are certain that it does, and thus the reasonable, moderate position—represented by himself, presumably—would seem to be somewhere in the middle. He made similar comments about homeopathy.

Dr. Katz said that if he were advising the hospital in question and certain physicians were adamantly opposed, he would suggest that the hospital offer Therapeutic Touch to patients but provide them with a disclaimer stating that those (named) physicians were opposed to it.

Dr. Novella, referring to Dr. Katz’s earlier point about the space between elementary particles justifying a tentative plausibility for TT, asserted that counter-intuitive concepts in quantum mechanics and cosmology do not apply to the macroscopic, everyday world of clinical medicine.

There was a brief exchange about plausibility and mechanism. After Dr. Katz asserted that we needn’t know the mechanism to conclude that something works, Dr. Novella replied that “knowing the mechanism” and plausibility are not equivalent.

Dr. Novella asked if “CAM” advocates would ever be willing to say that something doesn’t work; he noted that even among Cochrane Reviews one doesn’t find such conclusions for “CAM” methods. Dr. Katz said that he had concluded that one particular substance (I don’t remember what it was) doesn’t work, but he was not willing to say the same for many others, including homeopathy, TT, and Meyers’ Cocktail, although his own studies of homeopathy and Meyers’ cocktail had not shown benefit. He argued that his studies had been hampered by stipulations from the IRB that made them not applicable to typical use.

………

I’ve witnessed these sorts of debates before. The usual scenario is that the audience is heavily biased in favor of the pro-“CAM” stance, and the skeptic finds himself backpeddling from the outset. The pro-“CAM” participant need merely raise his eyebrows or utter a word such as “reductionistic” to get supportive laughter or applause, whereas the skeptic can barely open his mouth without being hissed and booed. That this did not happen at the Yale Symposium is a tribute to Steve Novella, who is better at being sympathetic to others’ heartfelt beliefs while maintaining his intellectual integrity than anyone I’ve seen in such a spot. It also reflects the civil tone of the meeting as a whole and of the tone presented by the moderator, Barry Boyd. I congratulate them all, even Dr. Katz—although I must admit to a secret suspicion that he was frustrated by not having succeeded in making Steve Novella look like a curmudgeon. I could be wrong.

………

The final panel of the day consisted of Drs. Novella, Katz, and a few other Symposium faculty fielding questions from the audience. Most of the questions were directed to the two debaters, who reiterated several of the previous points. Other panelists spoke to an extent; Auguste Fortin, Associate Professor of Medicine and Director of Communication Skills Training for the Yale Primary Care Internal Medicine Residency Program, repeatedly referred to himself and his colleagues as “allopaths.”

Comment

A quick aside to Dr. Fortin: please, for the sake of your residents and of accurate communication skills in medicine, learn the basis for the term “allopath” and cease using it to refer to physicians. (Hint: look here). Modern medicine is “modern medicine.” We are “medical doctors.”

Regarding Dr. Katz’s assertions, particularly amusing to me was the one about H. pylori and plausibility. I usually find wanton self-promotion distasteful, but He Who Debunked the Marshall-and-Warren-as-Galileo Myth was sitting right there in the audience! The short story, for the benefit of John Millet and medical students in general, is that even if clinicians scoffed at the hypothesis when they first heard it, there was no discernible effect on its progress from bench to practice.

Practicing physicians and even academics tend to be conservative (with a small ‘c’) and risk-averse; this is a different issue from that of how scientific medicine as a whole deals with novel hypotheses. (Josephine Briggs also failed to appreciate the distinction when she offered her list of “quirky ideas from outside the mainstream,” reported in Part I). The notion that bacteria might cause an inflammatory lesion was entirely plausible, of course, and even if some physicians were surprised to hear that bacteria can adapt to an acidic environment, bacteriologists were not.

The H. pylori hypothesis became intriguing at the moment that Marshall and Warren reported having successfully cultured the organism. It was rapidly investigated all over the world, and within a few years the old etiologic “paradigm”—ironically, a rather implausible mind-body hypothesis involving stress—was no more. The story of H. pylori is a great triumph of science-based medicine, not a reason to dismiss plausibility arguments.

After the conference I approached Dr. Katz and suggested that the time it took for H. pylori to be accepted as the cause of peptic ulcer disease was entirely reasonable. He replied, “reasonable for whom? What about patients?” I’d meant, of course, “reasonable according to how long it takes to do the work,” which I told him, adding, “so what do you mean about patients? That we should have started treating them with antibiotics before…?” I didn’t finish the obvious question, but what would we have been treating? Marshall and Warren had no idea what the organism was when they first saw it.

In talking with Katz I quickly realized that he is surprisingly naïve for someone who holds himself out as an expert in “integrative medicine.” It hadn’t occurred to him that Therapeutic Touch (like all versions of “energy medicine”) is a form of psychokinesis (PK), nor did he know that PK has been studied for well over 100 years without having yielded any reproducible evidence for its existence. (The notion that it is a recent hypothesis deserving the attention of medical academia is a ruse). In an attempt to offer another example of strange powers that are beyond our understanding, he stumbled when he reported that during his recent vacation, a “mentalist” in a restaurant had come right up to him and effortlessly bent the tines of his fork with merely two fingers of one hand, a task that Katz himself could barely accomplish with both hands. He exclaimed, “I don’t know how he did it, but I know he did it!” I replied, “but you know that it was a trick, don’t you?”

There is no shame in being fooled by a good conjurer—most people are—unless the very field in which you claim expertise requires that you know about such things. Spoon bending (or, in this case, fork bending), is claimed by some of its more illustrious practitioners to be a form of PK. There is a pattern here: Dr. Katz’s counterpart at Harvard, Dr. David Eisenberg, is also innocent of such matters. He is also the co-author of language quoted in Part I of this report, praising chiropractors for “never failing to find a problem.”

Dr. Katz betrayed a naïveté about clinical trials, in spite of his professed expertise in that realm. When Dr. Novella and I asked what he thought the aggregate results of several trials of an ineffective but passionately advocated method are likely to be, he replied that they would certainly hover around the null. We would all like this to be true, but it isn’t. Clinical trials are not physics experiments. Even RCTs are fraught with opportunities for error and bias.

Experience shows that the typical history of clinical research for a “CAM” method is this: early trials, usually small, poorly designed, and performed by advocates, tend to be “positive”; later ones that are larger and better trend toward the null, but it can take years and many trials before it becomes clear that this is their fate—if it happens at all. There will inevitably be sporadic “positive” studies that are trumpeted by advocates, even if they can’t be replicated. The study that Dr. Katz mentioned at the Symposium, purporting to demonstrate Therapeutic Touch exerting an effect on cells in culture, is a perfect example.

It may be formally true that one can’t “prove a negative,” but this is no reason to take seriously every crackpot notion that comes along. To position oneself as “middle of the road” or “balanced” regarding a claim such as homeopathy or Therapeutic Touch is misleading and unscientific. It is the equivalent of asserting the same for long-settled questions such as whether the earth is planar or spheroid, whether or not perpetual motion machines can work, and so on. It is akin to a call to “teach the controversy” of evolution vs. “creation science.”

In the meantime, implausible “CAM” methods continue to be held out as “promising” or at the least not disproven, and more trials are invariably called for—no matter that in many cases existing knowledge is sufficient to refute the hypothesis. This has been the trajectory of research in homeopathy, acupuncture, ‘distant healing,’ the ‘supplements’ discussed by Dr. Briggs at the Symposium, and other “CAM” proposals. (Natural products are not highly implausible, of course, but for a number of reasons are usually moderately implausible). In acupuncture and homeopathy research, such futility has continued for decades. The same is true for the entire field of parapsychology (the investigation of paranormal claims such as PK, ESP, etc.), in spite of highly sophisticated experimental designs over the past 30-40 years—more sophisticated than would be possible for most “CAM” trials.

As several have argued, parapsychology research is an example of pathological science. I suspect that this is the inevitable result of performing trials of any highly implausible claim that has passionate adherents, and that much of “CAM” research is doomed to repeat this history. Just as paranormal claims are an important subset of “CAM,” parapsychology research is an important historical precursor of “CAM” research—even if most medical academics, including those who identify with “integrative medicine,” are unaware of it.

I’ve sparred with Dr. Katz in the past, in print, addressing some of the other points that he made at this Symposium:

  • Dr. Katz here; my reply (to his and a ton of other indignant letters) here (included are responses to his right heart catheter argument, a discussion of “mechanism” as it applies to plausibility, a rebuttal to post-modern language devices, and more).
  • Dr. Katz’s response to his critics following the 1st Yale Symposium here; my take on his response: here and here (including comments on the false dichotomy of proven methods vs. “CAM”; his hyping of homeopathy, TT, craniosacral therapy, Myers’ Cocktail, and other bogus treatments; his and others’ casual flouting of well-established medical ethics)

Conclusion

Most of the content of the 2nd Yale Research Symposium on Complementary and Integrative Medicine, Dr. Katz’s comments being a notable exception, was not “complementary” or “integrative,” but simply medicine. What proponents mean by the term “integrative medicine” seems to vary according to political expediency. To onlookers it is not substantially different from the “holistic medicine” of 30 years ago, described by philosophers Clark Glymour and Douglas Stalker:

Is there another, holistic, conception of medicine distinct from [modern medicine]? Certainly, many people seem to think so…Popular bookstores are filled with works on “holistic medicine,” many edited by medical doctors…[or]…authored by professors at distinguished medal schools… The therapies described and recommended in a typical book of the genre include biofeedback, hypnosis, psychic healing, chiropractic, tai chi, iridology, homeopathy, acupuncture, clairvoyant diagnosis, human auras, and Rolfing…

What ties together [these] diverse practices…? In part, a banal rhetoric about the physician as consoler… In part, familiar and rather useless admonitions about not overlooking the abundance of circumstances that may contribute to one condition or another. Such banalities are often true and no doubt sometimes ignored, with disastrous consequences, but they scarcely amount to a distinctive conception of medicine. Holist therapies can be divided into those that are adaptations of traditional medical practices in other societies—Chinese, Navajo, and so forth—and those that were invented, so to speak, the week before last by some relatively successful crank…

The recent success of the “Integrative Medicine” (IM) movement at medical schools is a curious turn of history. Enthusiasts portray it as “patient-centered,” “healing-oriented,” “preventive health” and more, but what can honestly be held out as distinct from modern medicine is no more than a collection of practices that don’t withstand either scientific or ethical scrutiny. To claim otherwise distorts the history of medicine and of what the practice of modern medicine involves. It misrepresents the relation between science and medicine and the extent to which the tools of Evidence-Based Medicine can be brought to bear on highly questionable claims. It distracts from the usefulness of physicians learning a wide range of critical thinking skills. Such skills might be applicable, for example, to evaluating strange powers such as PK and fork-bending, or to the ethics of studying “Lyme-Literate” practitioners. Perhaps most importantly, it constitutes a radical departure from firmly established medical ethics.

Fundamental to the movement is euphemism: accurate terms are replaced by those that seek to reassure and soothe. This obscures, rather than elucidates the phenomenon. It facilitates bait-and-switch ruses both for individual practices and for “CAM” or IM as a whole. One of our fellow bloggers, a Stanford oncologist who has been a student of such matters since the peak years of the Laetrile fraud, wrote a depressingly accurate satire explaining how medical schools have been duped by what amounts to a clever PR campaign. Language distortions have literally changed the standards of care in medicine, and not for the better. The term “integrative medicine” is now central to that change.

Medical students have not been told these things by “integrative medicine” mentors, who themselves are largely innocent of them—just as they tend to be naïve about many of the practices that they find so intriguing, as documented in the two parts of this report.

I hope that this report provides some small impetus for John Millet and other IM enthusiasts at Yale and elsewhere to re-evaluate their thoughts. They are, almost without exception I’m sure, smart, committed, enthusiastic, caring young people who are trying to become the best that they can be in medicine. I certainly developed that opinion of John in the short time that I spoke with him and observed him. He reminded me, in fact, of our very own Tim Kreider. I hope that this report will suggest to John and others that there is more to an honest, comprehensive, and ethical evaluation of IM than its proponents acknowledge.

In addition to this report and the links from it, here is a short template for how medical schools might begin to teach “CAM” in an honest, rigorous way (scroll down to “ ‘CAM’ for Medical Students”). I’m slightly embarrassed to say that we at SBM have been talking for a couple of years about creating a more comprehensive set of materials just for that purpose, perhaps to occupy its own website, but we’ve not yet done it.

For John and other Yalies, of course, there is a much better resource: Dr. Steve Novella himself, who is without a doubt the most knowledgeable skeptic under the age of 80 that I’ve ever met. I’m not kidding, Yale medical students: this guy is the real deal, and you don’t want to miss your brief opportunity to learn from him.

Finally, I’m imagining that some who read this report will wonder whether it really matters: if medical students are learning real medicine anyway, so what? Who cares if a little woo sneaks through the doors of the White Coat Academy? Isn’t it better that IM is calling attention to some things (walnuts, nutrition, exercise, relaxation methods) that tend to be short-changed by medicine even if they shouldn’t be?

Uh, nupe. Those who are interested in walnuts and exercise and relaxation are to be encouraged, but should also be encouraged to repudiate “CAM” or IM precisely because of its pseudoscientific, unethical content. There are all sorts of hazards awaiting those who fail to understand this—we saw a small example in Part I, regarding “Lyme-Literate” practitioners prescribing colloidal silver. (If the Yale IRB is still watching, please scroll down Part I to the comment from ‘rosemary’). There are, of course, larger, almost unbelievable hazards emanating from the very pinnacles of “CAM” research: for starters, look here and here.

Afterword

The philosophers Glymour and Stalker were uncanny in their predictions, made more than 25 years ago:

If holistic-health advocates were content with encouraging sensible preventive medicine or with criticizing the economic organization of American medicine, we might be enthusiastic, but they are not. If the movement were without influence on American life, we would be indifferent, but it is not. Holistic medicine is a pablum of common sense and nonsense offered by cranks and quacks and failed pedants who share an attachment to magic and an animosity toward reason. Too many people seem willing to swallow the rhetoric—even too many medical doctors—and the results will not be benign. At times, physicians may find themselves in sympathy with the holistic movement, because some fragment of the rhetoric rings true, because of certain practices and attitudes they encounter in their daily work with colleagues and patients, or because of dissatisfaction with the economic and social organization of medicine. One hopes they will speak bluntly, but it does no good to join forces with cranks and quacks, magicians and madmen.

A not-benign result that even Glymour and Stalker may not have predicted is the epidemic of commercialism and self-promotion that would have been unthinkable only a few years ago. It is abundantly evident on Dr. Katz’s website and on “integrative medicine” websites elsewhere. If the mood of society has changed so much that this does not strike today’s medical students as profoundly unprofessional (as it would have struck us in the 1970s), I hope that they will at least consider the conflicting interests of practitioners whose patients expect untainted advice. It is self-evident that we should strive to immunize ourselves, our patients, and our institutions against sales pressures from Big Pharm, no? Why should this, which by virtue of its infatuation with magical thinking is even more likely to lead us astray, be any different?

Link to Part I

…………….

The Prior Probability, Bayesian vs. Frequentist Inference, and EBM Series:

1. Homeopathy and Evidence-Based Medicine: Back to the Future Part V

2. Prior Probability: The Dirty Little Secret of “Evidence-Based Alternative Medicine”

3. Prior Probability: the Dirty Little Secret of “Evidence-Based Alternative Medicine”—Continued

4. Prior Probability: the Dirty Little Secret of “Evidence-Based Alternative Medicine”—Continued Again

5. Yes, Jacqueline: EBM ought to be Synonymous with SBM

6. The 2nd Yale Research Symposium on Complementary and Integrative Medicine. Part II

7. H. Pylori, Plausibility, and Greek Tragedy: the Quirky Case of Dr. John Lykoudis

8. Evidence-Based Medicine, Human Studies Ethics, and the ‘Gonzalez Regimen’: a Disappointing Editorial in the Journal of Clinical Oncology Part 1

9. Evidence-Based Medicine, Human Studies Ethics, and the ‘Gonzalez Regimen’: a Disappointing Editorial in the Journal of Clinical Oncology Part 2

10. Of SBM and EBM Redux. Part I: Does EBM Undervalue Basic Science and Overvalue RCTs?

11. Of SBM and EBM Redux. Part II: Is it a Good Idea to test Highly Implausible Health Claims?

12. Of SBM and EBM Redux. Part III: Parapsychology is the Role Model for “CAM” Research

13. Of SBM and EBM Redux. Part IV: More Cochrane and a little Bayes

14. Of SBM and EBM Redux. Part IV, Continued: More Cochrane and a little Bayes

15. Cochrane is Starting to ‘Get’ SBM!

16. What is Science? 

Posted in: Energy Medicine, Medical Academia, Medical Ethics, Science and Medicine, Science and the Media

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37 thoughts on “The 2nd Yale Research Symposium on Complementary and Integrative Medicine. Part II

  1. Telum says:

    “Dr. Katz mentioned that according to astrophysicists (or perhaps one in particular that he had read or heard speak), there is more empty space between the elementary particles in each of our bodies than exists in the entire universe. He doesn’t understand it himself, but assuming it is true he wonders, for example, how others can so easily dismiss Therapeutic Touch merely because it isn’t really touch, since what we think of as touch isn’t really touch, either.”

    Dr. Katz is very much wrong here. Incredibly so. Every large volume is the sum of smaller volumes. Since the universe contains us, it must therefore be larger than us.

  2. moderation says:

    I am normally not prone to statements of intolerance, but I am completely and utterly depressed to share the title of MD, with individuals who lack the critical thinking skills of my labrador. Even my dog can rub her canine brain cells together and determine, through the evidence of its odor, which hand the doggie treat is in.

    The infiltration of CAM into medical schools of such high reputation as Yale and into medical associations, such as the AAP, has left me feeling like the dutch boy with his thumb in the dike. It is time for physicians to speak out en masse and not stand on the sideline thinking that this somehow does not affect them.

    Thank you to Dr.’s Novella, Atwood, et al. for trying to stem the flood of woo.

  3. windriven says:

    I believe that the astrophysical remark was distorted by Katz or misinterpreted by Dr. Atwood. I suspect that the astrophysicist was suggesting that the ‘space’ between atomic nuclei in the human body (and elsewhere) is proportionately greater than the space separating stars. I’m not holding this to be true or false as astrophysics isn’t my area of specialty; just a conjecture.

    Another observation is that if Dr. Katz is representative of the quality of scholarship at Yale Med and the state of medical science in America, I think I’ll go to Botswana the next time I’m ill. Having one’s head in an ivory tower is one thing, having it in one’s rectum is quite another.

  4. lizkat says:

    The CSICOP article on parapsychology is intentionally deceptive. This statement about Bierman is not accurate:

    “Bierman fitted a regression line to the data in each area. In all cases, the regression line revealed a consistent trend for the effect sizes to decrease with time and to eventually reach zero.”

    He never said the effect sizes eventually reach zero, or that they could be expected to eventually reach zero.

    No one has succeeded in explaining away the massive quantity of positive results in parapsychology. It can’t all be dismissed just because it isn’t all perfect. No research is perfect.

    The only mention of evidence in that article is Bierman’s meta-analysis, which did NOT conclude that parapsychology overall has negative results. No one has been able to claim that, since it is not true.

    But CSICOP has managed to slant things in a way that pleases anti-CAM “skeptics.”

  5. Nescio says:

    Thanks for this report.

    We clearly need to teach our children critical thinking skills, logic, and how to assess evidence rationally. Urgently.

    “Science is a way of trying not to fool yourself. The first principle is that you must not fool yourself, and you are the easiest person to fool.” Richard Feynman

  6. Dacks says:

    Fascinating report. Reading between the lines, it seems to me that the main lack in Katz et al is any genuine attempt by them to examine the evidence for and against TT, homeopathy, etc. They insulate themselves against drawing conclusions about the ethics of recommending these practices by simply NOT knowing what the facts are.

    Thinking is hard, it’s work. We’d all rather glide along on the comfortable pillow of our preconceptions, and sometimes there’s no harm in that. Bravo to you all who push a little harder to figure things out.

  7. DREads says:

    I get really annoyed by CAM types when they make reference to Western vs. Eastern medicine. Living in Santa Cruz, California, this happens a lot. Conventional medicine cannot be divided ethnically like one does with restaurants (Italian v. Thai v. Indian v. American cheeseburgers n’ hot dogs). Dr. Novella hit the nail on the head about conventional medicine: science-based medicine is about using science as a methodology to find what works and what doesn’t. Science is a highly structured methodology for evaluating ideas that’s ignorant of culture. It’s universal. A researcher in any part of the world (China, India, Africa) can contribute to SBM simply by rigorously applying the methodology to form plausible hypotheses, design experiments in a manner that minimizes confounds, records measurable observations in a repeatable fashion, test hypotheses empirically through controlled experiments, perform rigorous statistical analysis of results, and publish results and methodologies completely so they are repeatable and understandable by other researchers.

    Mathematics, although different from science, is also universal. Lay people seem to understand its universality better than with medicine, which is unfortunate. The Egyptians, Chinese, and Americans all agreed on the first couple hundred digits of pi before they exchanged knowledge of it. Air China doesn’t change the aerodynamical formulas in the autopilot computers in their 747s to make them culturally-consistent. Why? Because the notion of cultural consistency does not exist in aerodynamics! Why should we apply a different standard to medicine? Shouldn’t medicine be about what works and what doesn’t rather than preserving cultural medical rituals that predate the scientific revolution?

    Statistics is fundamental in science because it enables us to systematically make sense of data in the presence of variation. I often proselytize the following to undergraduates, “statistics is the bridge between mathematics and science.” We make reasonable assumptions about the data (e.g. observations from two groups are distributed IID from heteroscadistic multivariate Gaussians) then you apply estimation algorithms that make mathematically provable guarantees (e.g. QDA will give you a Bayes-optimal discriminant to classify your data.) There’s nothing culturally-defined about statistics. The MLE estimate of the mean assuming RVs drawn IID from a multinomial is the same in China as it is in the US! Statistics, the tool used to analyze empirical data to validate scientific results, is strictly mathematical. You make assumptions, you prove theorems based on those assumptions, and then the theorem statement makes it’s way into a textbook as a formula. In med school, doctors read the stats textbook and hopefully appropriately form reasonable assumptions about their data and apply a methodology consistent with those assumptions. Why forego statistical rigor for CAM therapies?

    In my local area, it is common to encounter docs who got their MDs from reputable med schools and advertise their practice as conventional medicine but peddle CAM. You make an appointment based on their credentials then your next appointment a year later, you get offered a CAM remedy. Argghhh! I really hope the doctors pushing SBM are able to establish better controls to make it harder for doctors to practice medicine that’s not validated by science.

  8. Lawrence C. says:

    Thank you for both parts of an interesting and very informative report. It is good to know things aren’t as bad as they could be at Yale (yes, perhaps faint praise) and especially that civility ruled the day. Although I find it unfortunate that such unfounded methods should be so enticingly presented at a respected university it does sound like CAM at Yale is losing momentum. (Perhaps instead of “God and Man at Yale” someone should write “CAM and Science-Based Medicine at Yale”?)

    As a long-retired physicist, my only quibble is that the remarks at the symposium and here speculating on the nature of cosmic and quantum spatial realities are (a) not germane and (b) lack a grasp of the subject.

    But what the heck, might as well stop by the party, since I’m past care and won’t be around anyway. I shall make a prediction. Dr. Atwood reported:

    “Dr. Novella…asserted that counter-intuitive concepts in quantum mechanics and cosmology do not apply to the macroscopic, everyday world of clinical medicine.”

    My prediction is this: within one hundred years, probably less, this assertion will seem quaint. The medical doctors of the future will look back on the early 21st century and, in a dignified yet astonished way, cringe when they read the history and see that their predecessors had to deal with patients on a primitive “molecular” level. The real “integrative medicine” of the near future will integrate these alleged “counter-intuitive concepts” into practical medical applications. And the changes will be as profound as those from the ancient healer who threw rocks at his charge to drive away the miasmas to today’s laparoscopic outpatient surgeries.

  9. JMB says:

    I think that SBM would do well to add some formalism of rules that distinguish it from EBM.

    It is easy to accept the rules for judgment of empirical evidence coming from EBM (RCT vs observational trials vs basic medical science concepts vs clinical experience).

    To those rules for judging the quality of evidence, would be rules for judging the quality of scientific concepts of mode of action (the plausibility). Is the mode of action based on concepts of medical science (such as pathology, neurology, immunology, nephrology, etc.), or biologic sciences (bacteriology, virology, parasitology, cell biology, physiology, genetics, immunobiology, etc), or chemistry (biochemistry, organic chemistry, inorganic chemistry, etc), or physics (biophysics, astrophysics, quantum physics, etc). Each step down the order of the scientific endeavors takes you one more step away from observed responses in a human subject (with the possible exception of bacteriology, virology, and parasitology). So the strength of the scientific concept of the mode of action gets progressively weaker (and more prone to woo) depending on the origin of the scientific concept. The scientific concept would also be subject to scrutiny by the scientists from which the concept arises (unleash the dogs of physics on the quantum physics basis of energy healing).

    SBM would also do well to formalize what factors increase or decrease placebo effect (the advocacy of the study director, the obscurity of the explanation making it sound more intelligent, fancy choreography of moves, mood lighting, presence of student observers, etc). Furthermore, more formal methods of controlling placebo effect should be specified (having the test subjects of energy healing experiments being trained quantum physicists, having thespians duplicate the moves of therapeutic touch without the training to perform therapeutic touch, blindfolding the subjects and muffling the subjects’ hearing so that the test subject does not know that the practitioner is standing over them, etc). The most effective control of the placebo effect is to have the subject unaware of the presence or absence of the practitioner of the therapy. It is important to state that placebo effect will vary based on the outcome measure and design of the intervention being tested. It is hard to insure that any placebo effect is equal in the experimental and control groups.

    So SBM could add reasonable formal rules to assess plausibility and greater controls for placebo effects to the rules of strength of evidence currently formalized in EBM. In addition, SBM could formally state the pitfalls of even RCTs in arriving at valid conclusions (frequentists want to be wrong 5% of the time). I like the rule of 3 RCTs previously discussed in one of the articles on the site. A formal statement of the rules similar to the formalism of EBM would be a good starting point for arguments. SBM could even develop a woo scale, based on historical evidence of what eventually was discredited as quackery, and what was proved to be effective. For instance, using scientific concepts from poorly understood branches of science (electromagnetism, quantum physics, at least poorly understood by the general public) would ring the bell of the woo meter.

    The formalisms would at least make a nice slide for presentations.

  10. JMB says:

    I forgot to add another thing to the formal specification of SBM. A statement can be made about the probability of identifying an effective treatment based on plausibility and the woo meter. The likelyhood of a plausible mechanism of action and a low woo meter resulting in an effective intervention is about 1 in 20. The likelyhood of an implausible mechanism high on the woo meter scale resulting in an effective intervention is about 1 in 1000 (unless you consider magnifying the placebo effect as an effective intervention).

    I think medicine can tolerate woo so long as the patient asks for it without the provider suggesting it, there is no cost in money or health risks, the provider does it on their personal time (a nurse on duty should provide standard nursing care), the patient is properly informed about the lack of evidence, a provider cannot be criticized for not participating, and it does not replace scientifically proven effective therapy. Patients can get pretty bored sitting around the hospital, and it’s probably better for them than watching TV. It is also a way of respecting the patient’s beliefs.

  11. JMB says:

    @Lawrence C
    “My prediction is this: within one hundred years, probably less, this assertion will seem quaint. The medical doctors of the future will look back on the early 21st century and, in a dignified yet astonished way, cringe when they read the history and see that their predecessors had to deal with patients on a primitive “molecular” level. The real “integrative medicine” of the near future will integrate these alleged “counter-intuitive concepts” into practical medical applications. And the changes will be as profound as those from the ancient healer who threw rocks at his charge to drive away the miasmas to today’s laparoscopic outpatient surgeries.”

    I may be revealing my ignorance of quantum physics and pharmaceutical chemistry, but I think the pharmaceutical industry has been using computer calculations based on quantum physics/statistical mechanics to come up with candidate macromolecules for blocking/triggering known receptors for about 30 years. I do think those methods will become much more prominent when genetic sequencing becomes cheaper and more widely available for application to disease understanding and treatment. It is a revolution in medicine that is just starting to take off, as you indicated.

  12. StatlerWaldorf says:

    Very interesting!

  13. BillyJoe says:

    Lawrence,

    “Dr. Novella…asserted that counter-intuitive concepts in quantum mechanics and cosmology do not apply to the macroscopic, everyday world of clinical medicine.”

    “My prediction is this: within one hundred years, probably less, this assertion will seem quaint. The medical doctors of the future will look back on the early 21st century and, in a dignified yet astonished way, cringe when they read the history and see that their predecessors had to deal with patients on a primitive “molecular” level. The real “integrative medicine” of the near future will integrate these alleged “counter-intuitive concepts” into practical medical applications. And the changes will be as profound as those from the ancient healer who threw rocks at his charge to drive away the miasmas to today’s laparoscopic outpatient surgeries.”

    What sort of an argument is that?
    I could say the complete opposite and sound as silly.

    ;)

    regrds,
    BillyJoe

  14. Lawrence C. says:

    BillyJoe, devotee and ceaseless seeker of argument, asks me:

    “What sort of an argument is that?”

    It may interest you to know that not all forms of verbal or written expression are put in the form of an argument. For instance, a prediction of future events can be called a speculation, even one based on things already happening as JMB notes.

    He then states: “I could say the complete opposite and sound as silly.”

    No, you’d sound ridiculous and appear invertible as you’d be stealing someone else’s prediction and standing it wrong-side up. Everyone knows that a prediction must be viewed right-side up and taken with either a grain of salt or a tumbler of scotch. Unless you’re the son of the late, great Criswell, which you could very well be.

  15. JEAN M says:

    Re CAM TT –Having taught, university physics for many years, I would recommend Dr. Katz sing up for an elementary refresher course. His remarks indicate a lack of knowledge of how the world works. Maxwell’s equations and the laws of thermodynamics do not fail at molecular levels. These determine the impossibility of creating healing at the chemical level from the waving of hands.

  16. TsuDhoNimh says:

    Katz says that “Rocky Mountain spotted fever established as caused by a bacterium” was heresy? The hell it was! (note – I did several college papers about RMSF and suffered many ‘tick shots’ as a child … I have a personal grudge against that disease)

    Way before Ricketts, it was well known that something in the Rocky Mountain woods could make you sick or kill you, except during freezing weather. Certain canyons were OK, others were very dangerous. The Nez Perce believed that evil spirits infested those canyons, and the spirits hibernated like the bears. You waited until the bears and spirits were sleeping before entering those areas to hunt. Wildly unscientific, but it kept them out of the worst of the infected areas. Today, some of those canyons show up as “hot spots” with either high % of infected ticks or highly virulent strains.

    Ricketts scientifically, systematically, and deliberately established that it was transmissible via ticks, had a tick-animal-tick cycle (as well as trans-ovarial transmission) and that wild ticks could be predicted as infectors based on the presence or absence of the intracellular organisms. There was no heresy, just patient lab work and a lot of dead guinea pigs. I knew people who, as children, had raised and sold guinea pigs to Ricketts. It was a profitable gig for a while.

    The only thing different about it was that the Rickettsia are intracellular parasites and he had to work with animals and not culture media.

  17. BillyJoe says:

    Lawrence,

    “It may interest you to know that not all forms of verbal or written expression are put in the form of an argument.”

    I would have believed that it you hadn’t put it against Dr. Novella’s quote.

    “For instance, a prediction of future events can be called a speculation, even one based on things already happening as JMB notes.”

    Oh, so it is an argument.

    “No, you’d sound ridiculous and appear invertible as you’d be stealing someone else’s prediction and standing it wrong-side up. Everyone knows that a prediction must be viewed right-side up and taken with either a grain of salt or a tumbler of scotch. Unless you’re the son of the late, great Criswell, which you could very well be.”

    (Well, I know you’re just being silly here, but anyway…)

    Yeah, sorry, I meant to say: “YOU could have said the exact opposite and sounded just as silly”.
    Anyway, it seems you do have an argument even though you deny it. Certainly you haven’t stated it as yet, though you have referenced and supported JMB.

    But you don’t need to smear JMB. He was just responding to your speculation and providing you with an argument. He was not pretending it was an argument against what Dr. Novella said which, of course, it isn’t. But then, I might be revealing my ignorance of quantum physics as well!

    regards,
    BillyJoe

  18. BillyJoe says:

    Lawrence,

    Here is what Dr. Novella meant:

    Jean: ” Maxwell’s equations and the laws of thermodynamics do not fail at molecular levels. These determine the impossibility of creating healing at the chemical level from the waving of hands.”

    Well, sort of complementary to it anyway, if I may use a pun.

  19. EricG says:

    @ dreads

    “Mathematics, although different from science, is also universal. Lay people seem to understand its universality better than with medicine, which is unfortunate. The Egyptians, Chinese, and Americans all agreed on the first couple hundred digits of pi before they exchanged knowledge of it. Air China doesn’t change the aerodynamical formulas in the autopilot computers in their 747s to make them culturally-consistent. Why? Because the notion of cultural consistency does not exist in aerodynamics! Why should we apply a different standard to medicine? Shouldn’t medicine be about what works and what doesn’t rather than preserving cultural medical rituals that predate the scientific revolution?”

    YES!

  20. Lawrence C. says:

    BillyJoe,

    Perhaps you need to read more carefully and also read less into things. Your reply at 3:18, including a madcap remark about a “smear,” is abstruse. I would be happy to exchange pertinent comments with you but they have to make sense first to enable a reply.

  21. Versus says:

    [Dr. Katz said] “relative absence of evidence is not absolute evidence of absence.”

    That is straight from the chiropractors’ playbook. It seems to be their most popular explanation for why there is no evidence that the chiropractic “subluxation” exists. Of course, they can’t say “relative absence” because there is a total absence of evidence, so their version is: “Absence of evidence is not evidence of absence.”

    Very nice posts, Dr. A. Since CAM supporters are so fond of “energy” and misappropriated examples from physics, the next time you attend a “CAM” symposium I suggest you take a physicist with you so he/she can call the pro-CAM speaker out on this stuff. Just for fun.

  22. nixar says:

    « Dr. Katz mentioned that according to astrophysicists (or perhaps one in particular that he had read or heard speak), there is more empty space between the elementary particles in each of our bodies than exists in the entire universe. »

    Dr. Katz sure is shockingly ignorant of basic quantum mechanics. I only studied it briefly in college, but at least I’ve heard of a certain Heisenberg. Steven’s reply is only half of the story; yes for all intents and purposes, at the scale of interest atoms and molecules are not full of nothing.

    But there is a fundamental reason why it is so: electrons, nucleus, and even atoms and molecules are fuzzy — except when you’re not interested in their exact position / speed / spin and want to measure their size. So you can tell that a nucleus is very tiny compared to a whole atom, and the electrons are even smaller, so if you naively compute the “empty space” in the atom, it’s 99.999..% empty … except that, from another point of view, the nucleus is spread all over the place but a little more in the center, and the electrons are also all over the place but more likely to be in some orbital region that you can compute with fancy equations to get lovely pictures such as this one: http://fr.wikipedia.org/wiki/Fichier:Electron_orbitals.svg

    In other words if people like Katz can’t be bothered to learn some basic physics they should just STFU about science.

  23. BillyJoe says:

    Lawrence,

    Our time zones are such that it takes 24 hours to get a response. You have just wasted 24 hours.
    Amd now I have to waste another 24 hours responding to your wasted post.
    In order not to waste yet another 24 hours, I’ll make it clear:

    Your speculations have nothing to do with that quote from Dr. Novella.

    …anyway, I think this thread has already dropped off the radar.:(

  24. BillyJoe says:

    Okay this thread has dropped off the radar, but for the record:

    What Lawrence said was no different from what’s been happening for nearly a hundred years already when physicists conduct experiments in quantum physics. Any physicist who performs the double slit experiment is seeing the results of Heisenberg Uncertainty and Decoherance on their photographic plate. Does this mean that Dr. Novella was wrong when he said that the “…counter-intuitive concepts in quantum mechanics and cosmology do not apply to the macroscopic, everyday world…”?
    Of course not.

  25. Dr Benway says:

    CAM is special pleading and motivated reasoning. “Hey it might work” is enough to justify an industry of therapeutic touchers invading our hospitals. It would never be good enough to justify prescribing a BigPharma drug.

    “But touching can’t hurt while a drug might.”

    That’s the myopic view. TT in the hospitals means TT training centers charging thousands for bogus certifications, professional organizations demanding the licensing of TT specialists, lobbyists advocating for insurance coverage of TT, the elaboration of TT into a set of bogus energy “procedures,” and finally the rise of organized crime where it always takes root: in the selling of nothing as something with no risk of being called to account.

  26. Dr Benway says:

    “As a long-retired physicist, my only quibble is that the remarks at the symposium and here speculating on the nature of cosmic and quantum spatial realities are (a) not germane and (b) lack a grasp of the subject.”

    Cool story, bro.

    From now on we’ll tell the CAM promoters not to bother with the medical literature until after they’ve got their work published in a journal of the American Institute of Physics.

  27. BillyJoe says:

    Dr. Benway,

    Lawrence: “As a long-retired physicist, my only quibble is that the remarks at the symposium and here speculating on the nature of cosmic and quantum spatial realities are (a) not germane and (b) lack a grasp of the subject.”

    Dr. Benway: “Cool story, bro. ”

    No, just easy to say.

    I have not seem him demonstrating posts “lacking a grasp of the subject” especially not explaining where these posters have erred. He has also not bothered to demonstrate that the comments are not germane.
    So, in my opinion, his contribution has been worthless.

    And his response to Steven Novellas statement that
    “counter-intuitive concepts in quantum mechanics and cosmology do not apply to the macroscopic, everyday world of clinical medicine”, is (to use his own words back at him) “not germane”. This was his irrelevant response:

    “My prediction is this: within one hundred years, probably less, this assertion will seem quaint. The medical doctors of the future will look back on the early 21st century and, in a dignified yet astonished way, cringe when they read the history and see that their predecessors had to deal with patients on a primitive “molecular” level. The real “integrative medicine” of the near future will integrate these alleged “counter-intuitive concepts” into practical medical applications. And the changes will be as profound as those from the ancient healer who threw rocks at his charge to drive away the miasmas to today’s laparoscopic outpatient surgeries.”

    Anyway, this esteemed physicist is not about to explain himself to this lowly layman, so I’ll stop now…

  28. Lawrence C. says:

    William Joseph,

    Your effort to counter what you perceive as worthless with the obviously pointless is fruitless. :)

  29. BillyJoe says:

    Lawrence Cornelius,

    I am glad to see you at least have a sense of humour. :)
    …even if it is only for the purpose of evasion ;)

  30. LindaRosaRN says:

    When Dr. Katz referred to effects of TT on cells in tissue culture, he’s doubtlessly referring to the recent study done by cell biologist Gloria Gronowicz at the U. of Connecticut. This study had no testable hypothesis and engaged in outrageous data cherry picking. Amused skeptics can point out that the CAM proponents who praise this study seem oblivious to its shockingly reductionistic protocol. I took a look at this study here:

    http://www.randi.org/site/index.php/swift-blog/355-hands-licensed-to-kill.html

    When Dr. Atwood observed that “accurate terms are replaced by those that seek to reassure and soothe,” I thought of an extreme example of this that exists in nursing today. One of nursing’s “major theorists” is Jean Watson, Ph.D. — inventor of the Theory of Human Caring, author of “Caring Science as Sacred Science,” and founder of Watson Caring Science Institute:

    http://www.watsoncaringscience.org/

    (Watson also has been a big time promoter of Therapeutic Touch, serving as dean of the University of Colorado’s Nursing School when that department was engaged in the rampant promotion of TT.)

    Anyway, the message of Watson’s “grand theory” seems to be that if nurses just care enough and trust in cosmic forces, there is no need to worry about any patient outcomes.

  31. Linda,

    Jean Watson covered a bit here and here (with a nod to you!).

    KA

  32. JMB says:

    Dr David Katz from Yale Medical School has an interview on ABC news website, under. “But what do doctors think?”

    http://abcnews.go.com/WN/health-care-reform-passes-doctors/comments?type=story&id=10169802

    I would assume it is the David Katz referenced here.

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