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The new Surgeon General nominee and CAM: Is there a problem here?

Our fearless leader, Steve Novella, has informed me that he is traveling today. Unfortunately, I am preparing a talk for later today, and no one else seemed able to come up with a post; so I decided to adapt a recent post from my not-so-super-secret other blog and see what a different readership thought of it. I realize that I’m risking subjecting you all to Gorski overload, but, hey, if the world needs more Mark Crislip, why wouldn’t the world need more David Gorski too? Steve will return next Wednesday, as usual.

I don’t normally give a lot of thought to the Surgeon General because, quite frankly, in recent years it hasn’t been a position of much authority or influence. That’s why I didn’t noticed late last week that President Obama had nominated a new Surgeon General. Normally, my failure to notice isn’t such a big deal, because there really hasn’t been a Surgeon General who has really been particularly well-known or had much of an impact since Dr. C. Everett Koop, although back when President Obama first took office Dr. Sanjay Gupta’s name was floated as a possibility for the position. Obviously, he didn’t get it. (I’m guessing that being a neurosurgeon and CNN’s chief medical correspondent probably pays much better than being Surgeon General.) To be honest, I didn’t even know that the prior Surgeon General had stepped down, but apparently she did in July, leaving the position filled by an interim Surgeon General until a new one could be nominated.

The other day, I learned whom President Obama nominated to be her successor, Dr. Vivek Murthy, a faculty member at the Harvard Medical School:

President Obama will nominate Dr. Vivek Murthy of Harvard Medical School and Brigham and Women’s Hospital as surgeon general of the United States, the White House announced Thursday night.

Murthy is a hospitalist at the Brigham and is co-founder and president of Doctors for America, a Washington, D.C.-based group of 16,000 physicians and medical students that advocates for access to affordable, high quality health care and has been a strong supporter of the Affordable Care Act.

If he’s confirmed by the Senate, Murthy would replace acting surgeon general Boris Lushniak. The surgeon general serves a four-year term and the post is essentially a bully pulpit to speak out on public health issues.


The official White House biography of Dr. Murthy reads:

Dr. Vivek Hallegere Murthy is the Co-Founder and President of Doctors for America, a position he has held since 2009. Dr. Murthy is also a Hospitalist Attending Physician and Instructor in Medicine at Brigham and Women’s Hospital at Harvard Medical School, a position he has held since 2006. In 2011, Dr. Murthy was appointed to serve as a Member of the Advisory Group on Prevention, Health Promotion, and Integrative and Public Health. Dr. Murthy has been the Co-Founder and Chairman of the Board of TrialNetworks, formerly known as Epernicus, since 2007. Dr. Murthy co-founded VISIONS Worldwide in 1995, a non-profit organization focused on HIV/AIDS education in India and the United States, where he served as President from 1995 to 2000 and Chairman of the Board from 2000 to 2003. Dr. Murthy received a B.A. from Harvard University, an M.B.A. from Yale School of Management, and an M.D. from Yale School of Medicine.

So far, at least on the surface, there doesn’t appear to be anything particularly alarming about Dr. Murthy. He’s very accomplished for his age, which is only 36. The group he leads, Doctors for America, seems to have fairly conventional moderate-to-left views and has lobbied for Medicaid expansion, to protect Medicare, and to support the Affordable Care Act. In general, it supports expanding access to health care coverage to the entire population. Of course, no one would expect President Obama to nominate a doctor for Surgeon General who doesn’t support the ACA, and, since it’s the law of the land now, one would expect the Surgeon General to support it.

Although opponents of the ACA might not like Dr. Murthy’s staunch advocacy for the ACA, that’s not a problem for me. If anything, it’s a point in his favor. What worries me about Dr. Murthy is his connection to so-called “complementary and alternative medicine” (CAM), otherwise known these days as “integrative medicine.” My skeptical antennae started twitching when I saw that Dr. Murthy has been serving on the U.S. Presidential Advisory Council on Prevention, Health Promotion, and Integrative and Public Health since 2011, along with Dr. Dean Ornish. (Come to think of it, it’s disturbing that President Obama would have appointed Ornish to such a committee.) Also on the council is Janet R. Kahn, PhD, who is described as a having been a “Faculty Preceptor in the Fellowship Program in Complementary, Alternative, and General Medicine at Harvard Medical School” since 2000 and having served on the National Advisory Council for Complementary and Alternative Medicine at the National Institutes of Health since 2009. You know who also serves on that particular advisory council? Brian Berman. There’s also an acupuncturist, Charlotte Kerr, on the U.S. Presidential Advisory Council on Prevention, Health Promotion, and Integrative and Public Health.

OK, OK, none of this proves anything about whether or not Dr. Murthy has far too much credulity towards quackademic medicine. After all, there are also perfectly respectable science-based health care practitioners on that council, although it is truly disquieting to see an acupuncturist there, even more so than Dean Ornish. Ornish, after all, has managed to make himself seem scientific to the point where many physicians don’t realize how far down the road of woo he has traveled. In contrast, there’s no excuse for an acupuncturist to be on a President’s health care council—any President. Annoyingly, the advisory council has issued reports that cite the problematic section 2706 of the ACA that mandates nondiscrimination of health plans to urge consistency between state and federal law. Translation: The council wants the ACA to be interpreted to guarantee that any quacks that states license (like chiropractors and naturopaths) count as valid health care providers whose services should be reimbursed by insurance companies selling policies through the government exchange. Meanwhile, the 2011 National Prevention Strategy, which Dr. Murthy contributed to, emphasizes “evidence-based” CAM, an oxymoron if ever there was one.

More concerning is what Dr. Murthy said in this article, published in Harvard Magazine in 2003:

Murthy’s combined expertise in medicine and business (and he still might pursue an advanced degree in public health) makes him well qualified to follow through with one of his dreams: to develop a system that provides proven, affordable, integrated (traditional and alternative) healthcare in a standardized fashion.

His interest in alternative medicine stems from his own cultural background—both his parents emigrated from India. Although he grew up in Miami, Murthy’s frequent visits to his parents’ homeland allowed him to witness that country’s ancient art of healing, Ayurveda (Sanskrit for “the science of life”). “I have tried various alternative medical therapies myself,” he reports, “and I have found that many alternative modalities are based in principles that make sense, and seem to frequently be effective with patients.” Research in recent years has made important strides in investigating alternative medicine in the United States, Murthy says, but much more needs to be done, and he would like to be a part of that process.

Oh, dear. “Based on principles that make sense?” That’s the sort of thing no physician whose practice is science-based should ever utter about Ayurveda or other “alternative medicine.” He also seems to have been prone to the same sorts of deficits in reasoning that lead all too many people to confuse correlation with causation or placebo effects for real effects.

In fairness, I realize that this is a ten year old interview, and Dr. Murthy was very young at the time, but it’s concerning nonetheless, although elsewhere, in a book entitled The Yale Guide to Careers in Medicine and the Health Professions, Dr. Murthy was quoted as a fourth year medical student as being interested in integrative medicine. Has Dr. Murthy followed through with his youthful interest in “integrative medicine,” or, as I like to call it, integrating quackery with real medicine? Is he practicing and/or supporting CAM or integrative medicine? It’s hard to tell. There’s not much that can be found about him with regards to this question on the Harvard Medical School or Brigham Women’s and Children’s Hospital websites. I’ve also been Googling my little brain and fingers off, and I haven’t been able to find any “smoking gun” that indicates that Dr. Murthy is still as enamored of quackademic medicine as he was 10 to 15 years ago, although there are niggling little indications. But who knows? Maybe he’s reformed himself.

In my perfect world, if I were a Senator asking Dr. Murthy questions, I wouldn’t ask so much about Medicaid, Medicare, the ACA, or other health policy. Well, I would, but that wouldn’t be my primary line of questioning. I figure that Dr. Murthy has political views compatible with those of President Obama, otherwise President Obama wouldn’t have appointed him. Presidents rarely appoint people with highly incompatible views to theirs to positions that are very public, like that of the Surgeon General. What concerns me more is that the Surgeon General should be a voice of science-based medicine, even if it means bucking the prevailing views, existing government policies, the pharmaceutical companies, whatever. Think of the Surgeon General in 1964 warning that cigarettes cause cancer, even though cigarettes were popular (not to mention extremely profitable) and the tobacco companies were doing everything they could to bury or counter the developing body of evidence linking smoking tobacco to lung cancer and heart disease. What we don’t need is a Surgeon General who will be a voice in favor of the ongoing pollution of science-based medicine with quackery.

If Dr. Murthy is that kind of doctor—and there are far too many of these doctors around—then to me he should be disqualified from being the Surgeon General. Perhaps what’s more distressing is that the President’s Advisory Group on Prevention, Health Promotion, and Integrative and Public Health has Dean Ornish and an acupuncturist on it. It’s just another example of how much quackery has “integrated” itself into legitimate medicine.

Posted in: Acupuncture, Politics and Regulation, Public Health, Science and the Media

Leave a Comment (44) ↓

44 thoughts on “The new Surgeon General nominee and CAM: Is there a problem here?

  1. Cholerajoe says:

    There are 3 physicians currently serving in the Senate – Coburn, Barasso and Paul. I suggest you contact them to oppose Dr. Murthy’s nomination.

  2. windriven says:

    “Murthy is a hospitalist at the Brigham and is co-founder and president of Doctors for America, a Washington, D.C.-based group of 16,000 physicians and medical students that advocates for access to affordable, high quality health care and has been a strong supporter of the Affordable Care Act.”

    More to the point, Doctors for America was originally founded as Doctors for Obama, an advocacy group that campaigned for the president in 2008.

    From TheWire.com:

    “As Doctors for Obama, the organization of 10,000 physicians and medical students helped to campaign for Obama’s election. The group was relaunched as an advocacy group for affordable healthcare in 2009, and renamed Doctors for America. ”

    I mention this only because it suggests that the appointment of Dr. Murthy had as much to do with politics as with public health policy.

    Dr. Murthy can spend the next four years lobbying for federal funding of hundreds of new residencies, increased funding for medical research, developing and launching pilot programs to explore delivering quality care at costs more in line with our peers. Or he can spend his time flogging the deeply flawed ACA and not rocking the boat.

  3. oldmanjenkins says:

    Is there such a thing as “Gorski overload?” Would that be like adrenal fatigue? Or my favorite new disorder du jour: Shift Work Disorder which is being rammed down our throats by Teva Pharmaceuticals (Nuvigil). Hello! We are diurnal creatures that have a specific sleep/wake cycle biologically programmed into us. “They” have now pathologized sleepiness. What’s next? They have men over 50 running around worried to death about their testosterone levels. Ugh

    1. windriven says:

      “Is there such a thing as “Gorski overload?”

      Occasionally there is Gorski overlong, but not overload. ;-)

      1. Sawyer says:

        Warning: reading too many of Dr. Gorski’s posts may result in inappropriate sexual urges and what is known as an “Oraction”. Contact your doctor if it lasts for more than 4 hours.

  4. goodnightirene says:

    Awful news, but my real gripe is with a medical school as lofty as Yale that produces a graduate who has such poor reasoning skills. This is the result of taking cultural relativity one step too far. I respect Dr. Murthy’s cultural background, but he should have learned to separate his “traditional” and medical lives long ago.

    What Dean Ornish has to excuse himself is beyond me.

    Finally, I very much doubt that we could get cigarette advertising banned today, let alone put on the kind of public health campaign that led to widespread public awareness of the dangers of tobacco and nicotine addiction.

  5. mousethatroared says:

    “but, hey, if the world needs more Mark Crislip, “…

    Drink!

  6. Obama appoints an Obamacare Shill as surgeon general to promote his ripoff insurance plan, amusingly Gorski doesnt like the shill as he made some vague comments about alternative medicine 15 years ago.

    Meanwhile, on Main Street.. this letter dropped into my mailbox: the realities of obamainsurance

    My company, based in California, employs 600. We used to insure about 250 of our employees. The rest opted out. The company paid 50% of their premiums for about $750,000/yr.

    Under obamacare, none can opt out without penalty, and the rates are double or triple, depending upon the plan. Our 750k for 250 employees is going to $2 million per year for 600 employees.

    By mandate, we have to pay 91.5% of the premium or more up from the 50% we used to pay.

    Our employees share of the premium goes from $7/week for the cheapest plan to $30/week. 95% of my employees were on that plan. Remember, we used to pay 50% now we pay 91.5% and the premiums still go up that much!!

    The cheapest plan now has a deductible of $6350! Before it was $150. Employees making $9 to $10/hr, have to pay $30/wk and have a $6350 deductible!!! What!!!!

    They can’t afford that to be sure. Obamacare is killing their will to seek medical care. More money for less care? How does that help them?

    Here is the craziest part. Employees who qualify for mediCAL (the California version of Medicare), which is most of my employees, will automatically be enrolled in the Federal SNAP program. They cannot opt out. They cannot decline. They will be automatically enrolled in the Federal food stamp program based upon their level of Obamacare qualification. Remember, these people work full time, living in a small town in California. They are not seeking assistance. It all seems like a joke. How can this be the new system?

    1. windriven says:

      “Employees making $9 to $10/hr, have to pay $30/wk and have a $6350 deductible!!! ”

      “Employees who qualify for mediCAL (the California version of Medicare), which is most of my employees, will automatically be enrolled in the Federal SNAP program. ”

      This bit of propaganda is inconsistent and idiotic. Employees who qualify for MediCal will NOT have a $6350 deductible. And employees who earn $9 per hour earn about $20,000 per year. Why is it outrageous that they should have food stamp assistance?

      America is, at this writing, the largest economy on earth. Why is it that we should expect some Americans to have substandard food and no regular medical care? Is that what passes for conservatism these days?

  7. Frederick says:

    Right now he got the benefice of the doubt. Even if is believe In quack, it does not mean he’s gonna push it. Or maybe he stop believing. I hope for you country that he does.
    Another job for SBM.org watch dog! :-)

    What really bug me his that Acupuncturist on the board, at least it is not a Chiropractor. Damn CAM virus, unfortunately there no vaccines for it!

  8. William M. London says:

    Former Surgeon General C. Everett Koop was also muddleheaded about “CAM.” See http://www.ncahf.org/nl/2002/9-10.html#Koop

    1. Sawyer says:

      Interesting, considering Koop’s reputation of not putting up with nonsense from anyone. Just to be clear though, the quotes you provided were from 12 years AFTER he was Surgeon General. It’s also possible that his comments reflected a desire to expose CAM to better research standards , but it sure doesn’t come off that way.

  9. dh says:

    Ornish has publish randomized trials and cohort studies in top medical journals such as The Lancet, JAMA and Lancet Oncology. So what that his patients are also treated with stress reduction techniques, meditation, yoga and the like – have you not heard the news that the mind and body are connected? So what that Ornish has written a book on the healing power of love; I know some cancer surgeons who have written books like that. Can you define love using SBM techniques – its dose, timing, route of administration, efficacy and side effect profile? There are some things that SBM and EBM will never be able to capture, measure, study. Those things, they merely dismiss as ‘quackademic medicine’. Perhaps they have not gotten the memo that human beings are complex creatures, cannot always be distilled down to molecular mechanisms, and respond both biologically and psychologically to various therapeutic modalities. In other words, not robots.

    1. Harriet Hall says:

      “Can you define love using SBM techniques ”
      Apparently Dean Ornish can. The title of his book is:
      Love and Survival: The Scientific Basis for the Healing Power of Intimacy

  10. windriven says:

    ” There are some things that SBM and EBM will never be able to capture, measure, study”

    “human beings are complex creatures, cannot always be distilled down to molecular mechanisms”

    Spend some time reading Dennett and Edelman.

  11. Dave says:

    dh, I think you’re missing the point of science based medicine. Much of the medical therapy done historically has been ineffectual or harmful. Randomized controlled trials and EBM are an attempt to sort out which therapies are likely to be helpful, given that any medical therapy entails risk, sometimes a great deal of risk. Used correctly, SBM should help eliminate useless or harmful therapies and promote helpful ones. This is a completely separate issue from the importance of emotional and social interactions to patients, which SBM does not deny or dismiss as quackademic but really doesn”t deal with. If I may draw a parallel, the late Stephen Jay Gould wrote extensively about the interplay between science and religion/philosophy, pointing out that science could tell us about the mechanical workings of the universe but not about the meaning of life or what entails proper behavior of one person towards another. I should point out that SBM is only a part of an ideal medical practice. We are taught in medical school that “The care of the patient involves caring for the patient” along with the science involved in doing so.
    I admit this is one area where modern medicine seems to often fail, for a whole variety of reasons often beyond the control of doctors or nurses, and which I think causes much of the rancor seen in some of the replies to these posts. Things are too rushed and impersonal in a lot of instances (FYI, the doctors and nurses aren’t real happy about this state of affairs either). “Alternative medicine” supplies this wanted personal attention in spades. I dont think anyone would argue that – the question is whether it does anything else, which is a frequent topic in these blogs.

    1. Infuriatingly Moderate says:

      @Dave – you’ve said what I’ve always wanted to say.

      The PRACTICE of medicine is not the same thing as the SCIENCE of medicine.

      As much as I hate the term, “trickle down” is as good as it gets. I

  12. Infuriatingly Moderate says:

    Meh, I botched the post.

    How’s about – “teh ebil allopathic” medicine today is about life as it is NOW, not life as we think it should be.

    Kinda suspect much of CAM isn’t really about the science of medicine. It’s about being special, outside, better than, sticking it to the man.

    Or fear of losing control of one’s own life. I know I get ticked off that much of my life is outsourced to other professionals. It’s the price I pay for living in a 1st world country.

    1. Dave says:

      Thanks for your reply. Two of the recurrent complaints about modern medicine:

      1) “It takes weeks to get an appointment with a doctor.”

      solution – the doctor sees more patients each day. As a consequence each visit is shorter.

      2) The doctor doesn’t spend enough time with me.

      Solution – fewer patients seen per day, consequently longer wait times for appointments.

      In the past a practice could just hire more practitioners. There’s currently a shortage of primary care practitioners. Certainly there are no quick fixes in sight.

  13. d.h. says:

    The SBM site typically dismisses integrative medicine, mind-body institutes, meditation therapy, psychosocial approaches to health care as carried out by alternative practitioners, etc — using catch-all terminology like ‘woo’ and ‘quackademic medicine’. Each needs to be assessed on its own merits and not merely dismissed because a large, hard-endpoint randomized trial has not been done. Wake up people: we lack high quality evidence for the majority of interventions done every day in primary care medicine! Where are the studies to support annual physical exams, for example?

    Qualitative studies in real-world settings involving naturalistic descriptions do have their place in ‘SBM’, although they are frequently dismissed by reductionist physician-scientists as just collections of anecdotes. It is nice to demand level 1 evidence, but it will only take you so far, as large trials are expensive, interventions often can not be patented, regulatory hurdles are enormous — so the most likely interventions tested at that level are brand new prescription drugs being pushed by Big Pharma for common diseases in western societies.

    That is not to say that some alt med trials aren’t crap – they are. But many traditional trials of traditional therapeutics are also crap – this has been pointed out repeatedly, particularly by Cochrane reviewers.

    There are virtually no large hard endpoint trials of lifestyle interventions like smoking cessation therapy, but this has not stopped practitioners from trying to get people to stop smoking (justifiably). Same thing for alcoholics. Parachutes. Seat belts. Air bags.

    It is nice that the SBM site holds interventions to such high standards. It only means that true practitioners of this brand of SBM cannot possibly do anything in their practice, since so few interventions meet these standards.

    1. Andrey Pavlov says:

      That is a very interesting screed d.h.

      You clearly haven’t read this site very much or, if you have, certainly have not been able to understand it very well.

      We are, justifiably, somewhat dismissive of CAM and so-called “integrative medicine”, etc, because there evidence that does exist – ranging from basic sciences to in vitro and in vivo to to all other sorts of testing – tells us the likelhood of it being effective is pretty darned close to zero. Or at least that if it actually is effective, the effect size would be small enough to not care in the first place.

      But that doesn’t mean that data won’t turn us around. But that data has to be more than commensurate with the data against the particular claim in the first place. That is the point of a Bayesian framework. In light of the entirety of hard earned human knowledge, how much and how stringent evidence would we need to change our minds? That’s why things like homeopathy can be immediately dismissed as quackery without further consideration since it is simply impossible to work in the confines of reality as established by the most well verified knowledge we have.

      Next, yelling at us to “wake up people” is a very common sign of ideological fervor rather than reasoned understanding. We people here, the authors and editors here (myself included) and many of the commentors, are highly educated and trained physicians and scientists. We are indeed awake to the many problems of science and modern medicine.

      Evidence for the annual physical? We have been “awake” to that around these parts since at least Feb 2012. We agree that it has limited utility and is a relic of bygones days, with some legitimate scientific role and some legitimate psychosocial role, with limited downsides. In other words, a nuaned view of a moderately complex question.

      You do not need to be a “reductionist physician-scientist” to dismiss a collection of anecdotes. You just need to be a statistician. Or at least have a rudimentary understanding of statistics. Individual unctrolled trials cannot be aggregated into some sort of “meta” trial with any sort of meaning. We say the exact same thing about legitimately large meta-analysis. GIGO. Garbage In, Garbage out. It’s a fundamental principle, like significant figures in chemistry. So yes, anecdotes are useful, but they are so horribly flawed as to be nothing better than hypothesis generating data only. So combining a bunch of really bad data doesn’t make good data. That would literally be magic. I mean, think about it. Otherwise we would never have any need for RCTs and really big, well designed trials. Because if we could get by on simple anecdotes to give us decent evidence (decent enough that I, as a physician, would want to treat my child based on that evidence) we would really have no need for the expense and toil of big RCTs. Yet you yourself admit that RCTs are the pinnacle of evidence, since you clearly understand that your particular CAM isn’t directly refuted by an RCT. It is a “CAM of the gaps” argument, hiding in the shadows. But at their core, the two ideas are fundamentally incompatible. Which you will also see if you give further examination.

      Next you enter a tu quoqe argument wherein the two “sides” are equal because they both have problems. Everything and everyone has problems. The question of problem is important, no doubt, But even more important is the question of benefit. And in actually benefitting people, in truly demonstrable ways, actual medicine wins hands down. Another example of the “CAM of the gaps” is how popular the saying “Western medicine is good for acute things, like trauma and heart attacks. My [insert woo here] is good for chronic conditions, which allopathic medicine is terrible at treating.” It is much harder to ignore the failures of the CAM in acute conditions. People die from heart attacks pretty often. But long term, subjective, fluctuating conditions? It is easy to spin a story for those.

      And next you flip flop and conflate a lack of Level 1 evidence to mean a complete lack of evidence. Of course we don’t have prospective RCTs of smoking. We have enough other evidence converging on it being pretty darned bad. Same for the rest. Parachutes don’t need RCTs, because the laws of physics that govern the question are so firmly clear that not dying from parachute failure is about as expected as homeopathy actually working. And that is the point. If you admit that crashing into a rock at 120mph is bad for you no matter how hard I try to convince you otherwise, you must admit that things as improbable but merely on a molecular level should be the same. And that is the point of Bayesian priors in examing the data.

      And thus, in reality, the vast majority of what we do is indeed supported by very good evidence, some better than others, with a small amount errantly harmful. The difference is we strive to improve in all areas. By minimizing our harm (something I do research in) and improving our help. And it shows. Life expectancy and quality of life have nearly double in merely 100 years from that nasty ol’ “reductionst physician-scientist” paradigm.

      Show us something better. We would love to learn it. But it has to be supported by the evidence. All the evidence, not just the RCTs. Because there is alot more than just that.

      1. d.h. says:

        “You clearly haven’t read this site very much or, if you have, certainly have not been able to understand it very well.”

        Ad hominem attack.

        “because there evidence that does exist – ranging from basic sciences to in vitro and in vivo to to all other sorts of testing – tells us the likelhood of it being effective is pretty darned close to zero. “

        Only if you ignore psychosocial effects, which tend not to be measured in randomized trials. Always dismissed as ‘placebo effect’, but patients receiving alternate therapies do tend to feel better over long run (generalization, may not apply to the highly cynical).

        “That is the point of a Bayesian framework.”

        Thanks for introducing me to Bayesian methods !

        “That’s why things like homeopathy can be immediately dismissed as quackery”

        Straw man argument – I didn’t mention homeopathy in any of my previous postings, did I?

        “Next, yelling at us to “wake up people” is a very common sign of ideological fervor rather than reasoned understanding.”

        Sure, and the health care system, which is made of its members, does not need to wake up …. everything is just peachy and perfect in the world of scientific medicine, as currently practiced …. there’s zero industry influence, on guidelines or trial design, for example, right ? !

        “You do not need to be a ‘reductionist physician-scientist’ to dismiss a collection of anecdotes.”

        “Collection of anecdotes” is favorite term of abuse of reductionist physician-scientists who do not understand qualitative studies, naturalistic studies, or the “whole patient” (who is greater than the sum of their parts – molecules, enzymes, even organ systems).

        “It is a “CAM of the gaps” argument, hiding in the shadows. But at their core, the two ideas are fundamentally incompatible. Which you will also see if you give further examination.”

        A “CAM of the gaps” argument? Not really. It’s rather the fact that papers like those of Ornish, in very high impact journals, involving alt med techniques and classic trial designs, are still dismissed by classic SBM cynics.

        “And in actually benefitting people, in truly demonstrable ways, actual medicine wins hands down. “

        Really, and population rates of type 2 diabetes, obesity and hypertension have not increased one iota in 40 years, if you are willing to ignore every source of public health statistics produced during that timeframe.

        “My [insert woo here] is good for chronic conditions, which allopathic medicine is terrible at treating.”

        The problem is that most therapies for chronic conditions are being approved solely on the basis of being able to improve surrogate markers that have little causal connection with patient-relevant outcomes. But I suppose SBM is above all that….

        “If you admit that crashing into a rock at 120mph is bad for you no matter how hard I try to convince you otherwise”

        Sounds like an anecdote to me! Hmm.

        “And thus, in reality, the vast majority of what we do is indeed supported by very good evidence, some better than others, with a small amount errantly harmful.”

        You have not been keeping up with mainstream medical journals. Just to take two examples, large systematic reviews of medical evidence suggest the half-life of our interventions, before being refuted, is about 5 years. There have been huge reversals of medical evidence in virtually every field after techniques became mainstream. Yet we do not dispute mainstream medical practice as being scientifically-based, when it is anything but. It just depends on whose science you listen to.

        “Life expectancy and quality of life have nearly double in merely 100 years from that nasty ol’ “reductionst physician-scientist” paradigm.”

        Actually the biggest contributors to this have been nutrition and sanitation, which the Romans and other Ancient civilizations knew about more than 2000 years ago. Claim these as SBM achievements if you wish. That is a great way of rebutting CAM.

        1. weing says:

          “Really, and population rates of type 2 diabetes, obesity and hypertension have not increased one iota in 40 years, if you are willing to ignore every source of public health statistics produced during that timeframe.”

          Interesting. DM, obesity, HTN, rates are an indictment of SBM because…..? The gunshot wound arriving in the ER is also an indictment of SBM for the same reasons. How successful is CAM in treating these?

        2. Andrey Pavlov says:

          Wow. Well, I had written about 90% of a rather long and highly referenced response that has taken me the better part of the last 30 minutes to put together and managed to completely lose it through a glitch.

          I don’t have the will to rewrite it, but suffice it to say d.h. just search for all the terms you claim we don’t address here on the site and you will find we have addressed them rather well.

          I apologize I won’t give you the better response I had hoped to, but Dave did hit many of the topics I was going to as well.

          1. dh says:

            This is all very enlightening. But my original question was what does Dr Gorski have against Dr Ornish sitting on the presidential advisory committee he alluded to in his commentary. Dr Ornish is a respected, published scientist who has shown that comprehensive lifestyle modification (involving a vegetarian diet, stress reduction, smoking cessation counselling, exercise, yoga, group support, etc) regresses coronary stenosis and reduces the risk of cardiovascular events by 2.5-fold compared with a control group not receiving same therapy. He has published these randomized data in JAMA and The Lancet, and his multisite coronary risk reduction projects have been published elsewhere (e.g. American Journal of Cardiology). I am sure that the beef Dr Gorski and others have with Ornish is that some of his methods appear to border on scientifically unverifiable concepts – e.g. the notion that encouraging people to love themselves and not denigrate their own self-worth may be pivotal to things like telomere extension and atheroma regression. Of course, any mention of “yoga”, “meditation”, “holistic medicine”, “healing power of love” makes hard core SBM commentators go nuts – it is almost like an involuntary, knee-jerk gut response. That just shows you what kinds of bias people like Ornish are up against. The fact that no trial of medication for the treatment of established coronary artery disease (such as statins) ever had an ARR or RRR anywhere close to that of Ornish’s makes them even madder (but why wouldn’t comprehensive lifestyle modification produce decent results?).

            I do think it’s when people like Ornish start talking about the healing power of love that people solely in the scientific paradigm go beserk. What is odd is that there is an extensive psych literature dealing with much of these paramedical processes, likely that they are not even aware of. Some of it is even randomized! (e.g. the approaches that incorporate mindfulness-based therapy).

            They don’t like when people like Ornish team up with Nobel Prize laureates to publish research in Lancet Oncology showing telomere extension in patients with prostate cancer who get the full kitchen sink treatment of Ornish et al. Even though that is a surrogate outcome and not as real as say PSA or need for radical prostatectomy.

            No, no. A serious scientist would probably not even deign to study such modalities, since they are so far outside the traditional mainstream medicine approach of treating people as diagnoses to be medicated, incised or irradiated. Interestingly, many medical school curricula crafters are beginning to realize that the general public is sometimes fed up with the traditional medical approach and thus have expanded their curricula into these detestable woo-like areas labelled ‘integrative medicine’ or ‘mind-body medicine’ or ‘biopsychosocial patient-centered medicine’. God forbid that someone like Weil, Kabat-Zinn or Ornish could influence mainstream curricula with their outlandish approaches to treating people as whole beings and not merely disease processes.

            An interesting debate would be to pit the reductionist scientists who think we are all just bags of enzymes against the holistic healers like Weil and Ornish. Even a cheap bastard like I would pay money to see such a thing.

            1. windriven says:

              I was going to give you a reasoned response until I read:

              “… reductionist scientists who think we are all just bags of enzymes against the holistic healers like Weil and Ornish.”

              Stick your telomere extensions in the aperture of your choice.

              A few citations clearly demonstrating decreases in mortality in an Ornishy-treated population versus standard medical care, please. Meaningful n, blinding, etc. You know the drill. I’m going to watch the game with the sound off so don’t bother spinning your citations with color commentary. We can all read.

              You either have meaningful citations or you have bupkis. Which is it?

              1. weing says:

                “… reductionist scientists who think we are all just bags of enzymes against the holistic healers like Weil and Ornish.”

                Good luck finding those scientists. Let us know when you find them. I checked out the Ornish papers you mentioned. They reminded me of what I heard about how some people use statistics like drunks use lamp posts. For support rather than illumination.

            2. Dave says:

              I don’t get this rant.

              All the mainstream doctors I know advocate exercise, smoking cessation counselling (these are required in my system), a plant based diet, have absolutely no objections to yoga and spend a lot of time with patients who have problems with anxiety and depression not to mention drug and alcohol abuse. Every week my hospital gets patients admitted for suicidal ideation/attempts and for alcohol detoxifications – the bad ones can be quite frightening. You think we’re clueless about the results of stress? You must be joking. If my patients get less stress by meditating, getting massages or joining a bowling league, whatever, I think that’s great and so do all the doctors I know. The only time I’m upset is when they use Jim Beam,Johnny Walker or illicit drugs to reduce stress. If Andrew Weil gives people advice on being happy, that’s fine. If he pushes and charges for a useless remedy, that’s not ok.

              I can also attest that it’s much easier for me to deal with patients who have functional, loving families than when they have dysfunctional ones and a stressful home situation. One of a doctor’s worst nightmares is having a terminally ill patient with some daughter or son who hasn’t seen their parent in 25 years suddenly show up and then raise hell with the medical team to assuage their guilt feelings (and yes, this happens. Ask any ICU nurse). It’s also a lot easier to care for people when they have a good support system. Try arranging home oxygen for a patient who doesn’t have a home, dh. If you spent a week in discharge planning rounds at a hospital it would be a real eye-opener for you.

              I swear, there must be some parallel universe out there.

        3. weing says:

          “It just depends on whose science you listen to.”
          Elaborate please. Advances in science are not supposed to make you change what you do? Interesting concepts you have.

        4. Dave says:

          Wow!
          Lets look at a few chronic conditions

          Hypertension: Uncontrolled hypertension increases the risks of strokes, heart attacks, congestive heart failure and renal failure. If extremely high it can cause acute CNS problems such as intracranial bleeds.Even when I went to medical school 30+ years ago we treated hypertension to prevent these things from occuring. We’ve learned a lot and are still learning more about what levels we should treat and nuances of medications. We still treat it to prevent outcomes. Do you REALLY think we treat it just to lower the blood pressure?

          Diabetes. This is treated to 1) prevent DKA or hyperosmolar coma, and 2) to prevent microvascular complications (retinopathy, neuropathy, nephropathy) and macrovascular complications (heart attacks, strokes, peripheral vascular disease). A1C levels are a surrogate marker, but we don’t treat it to lower the A1C, but to prevent the above mentioned complications.

          Hyperlipidemia. We treat this to prevent vascular complications such as MI’s. We’ve made progress in secondary prevention, not so much in primary prevention. Note that the recent recommendations do not recommend following lipids (the surrogate marker – who gives a rats’s ass what the cholesterol is except insofar as it afffects the vasculature) after a statin is started.

          Parkinson’s disease. Meds for this have greatly improved the quality of life of patients with this condition. We need better therapy, still. No surrogate markers here. Treatment is guided by how the patient does.

          Seizure disorders. I don’t think I need say much about why we treat this. No surrogate markers here. Seizures are either controlled or not.

          I’m treating several patients with chronic inflammatory demyelinating polyneuropathy. They are pretty functional due to their treatment. One would have died of respiratory failure were it not for IVIG. No surrogate markers here. Ditto with myasthenia gravis or multiple sclerosis.

          Congestive heart failure. Treatment for this has markedly improved since I was in med school, when all we had was lasix and dig. People live longer and feel better with the current treatment. No surrogate markers here.

          Inflammatory bowel disease. Uncontrolled, this can cause GI bleeding, severe diarrhea, bowel obstruction, fistulas. Treatment is directed to prevent these compications and improve the patient’s quality of life and is directed by how the patient’s doing. No surrogate markers here.

          Rheumatoid arthritis. Uncontrolled, can cause joint destruction and a variety of other problems, some of them, such as atlantoaxial subluxation, potentially fatal. Disease modifying agents were unhear of when I was in training. Now treatment is more effective but often quite expensive. There are surrogate markers of inflammation but the treatment is guided by symptoms, not by sed rates or crp levels.

          AIDS. Once fatal in a short time, now a chronic disease. HIV titers and CD4 counts are relevant, not exactly surrogate markers.

          I could go on.

          You continually allude to situations where we have no clear scientific evidence as to the best plan of action, where we have to make a treatment decision without good trials to base the decision on. Let’s take an example, which I alluded to in a previous post. Say you have a patient with a previous stroke, not due to arrhythmias and without vascular disease which can be addressed surgically. She is on a good antiplatelet agent such as plavix, her blood pressure is controlled and she is on a statin, doesn’t smoke, and follows her diet, all to try to prevent (that nasty word which MD’s supposedly never worry abut) a future stoke, but she continues to have TIA’s. She is therefore at high risk of another stroke. What do you do? There are lots of thing you CAN do – you can do nothing but pray and hope nothing happens, use coumadin, change to aggrenox, change to aspirin, add aspirin, add dipyridamole, add niacin or fish oil. Some of these have been investigated and found not helpful. Bottom line, I’m not aware of any good evidence about the best way to handle this problem, though I know some evidence about how NOT to handle it. Rather than deriding science based medicine about this kind of situation you should hope that science based medicine will come up with the answers soon.

          1. windriven says:

            Very nicely done.

            I would like to add that science generally knows what it doesn’t know and is extra cautious when approaching those situations. And so science based medicine is constantly re-evaluating what is done and how it is done and why it is done and most importantly, how it can be done better.

            Compare and contrast with homeopathy or chiropractic, ‘spiritually’ based systems that rely on dogma and that have changed little in the last hundred years. While those practices were searching for subluxations and chewing forty times, science based medicine found drugs to fight infections, vaccinations to prevent them, and surgical procedures that have saved literally millions of lives – to name just a few.

        5. Badly Shaved Monkey says:
          “You clearly haven’t read this site very much or, if you have, certainly have not been able to understand it very well.”

          Ad hominem attack.

          It was certainly an insult (accurately) directed at you. It was not the logical ad hom fallacy. Different thing entirely. Your crying “ad hominem” Inappropriately was accurately illustrative of the deficiencies of your arguments.

    2. Dave says:

      I agree this site heavily leans towards looking at alternative medicine and could spend more time discussing mainstream medical issues. This could also produce a boring blog. I doubt the average reader is much interested in the science or lack of it behind, for example, dvt prophylaxis for routine medical admissions or the optimal level of glucose control in an ICU setting (to name two practices recently changed) , although I’d really like it if it were covered. You point out that there’s no good evidence for things like an annual physical. In point of fact a lot of medical practitioners no longer recommend this, and the recommended screening tests are revised routinely as more data becomes available, often to loud screaming from various parties. Congress has even gotten involved in mammogram policy.

      There’s very much data about the adverse effects of cigarette smoking and what happens to people with copd if they quit vs continue smoking, or the dangers of continued excessive alcohol use. Ditto with your reference to parachutes. Some things dont need a randomized trial.

      Mainstream medicine readily admits the strength of evidence behind various practices – if you follow this blog there are multiple examples of this. If you have bacterial endocarditis you need antibiotics, or you will die. Slam dunk recommendation. Other recommendations have less strength, all the way to recommendations against something.

      Many other questions are being investigated and reported in the medical journals but would be of no interest to general readers here. Examples might include:
      Do patients with TIA’s benefit from adding plavix to aspirin if they are on one of these agents and continue to have symptoms? Answer – no, but they have more bleeding.
      Does adding an ARB to an ACEI improve outcomes in CHF over an ACEI or ARB alone? Answer – no, in fact it’s worse.

      If you’re interested in stuff like this I’d advise getting the most recent MKSAP update, currently 16. Warning – it’s a few thousand pages long and usually quite tedious reading. The point is, mainstream medicine is trying to address the issues you raise. As far as I can see, alternative practitioners are not.

      Some stuff also takes time to investigate. We have multiple meds that lower blood sugar. We have good outcome data on only the ones which have been around a while – insulin, sulfonylureas, metformin, the glitazones. In 10 years we’ll have an idea how good the remainder are in preventing (oops, MD’s never do that, do they?) microvascular and macrovascular events in diabetes. They lower sugars ok, it’s unknown how good they are for anything else. (Personally I think this data should be back before the drugs get approved. There’s some evidence the FDA is starting to agree with this but historically they’ve approved drugs based on effects on surrogate endpoints. Which I think sucks, but I dont make the rules.)

  14. Xplodyncow says:

    Translation: The council wants the ACA to be interpreted to guarantee that any quacks that states license (like chiropractors and naturopaths) count as valid health care providers whose services should be reimbursed by insurance companies selling policies through the government exchange.

    Last time I checked, the NCCN Guidelines (e.g.) don’t recommend CAM for anything. So I’m not sure how pseudo-healthcare providers could persuade insurance companies to cover their non-evidence-based, non-guidelines-based services.

    Besides, people who want payers to cover alternative “medicine” should have to take out a separate, “alternative” insurance policy.

    1. windriven says:

      Actually and sadly, ACA has language opening the door to essentially any state licensed quackery. I guess Nancy figured that would be cheaper than funding new residency programs to train new PCP physicians to care for 30 million newly insured. The Feds haven’t funded a single new residency slot since the middle of Bush II. We can find hundreds of billions to bail out the felons (fraud is still a felony, isn’t it?) who collapsed the world economy but we can’t rustle up a few tens of millions for new residency slots?

      Actions speak louder than words. Stimulus worked. At least for Wall Street. Look at the dividends and share price history of any ten financial industry companies that suit your fancy. But not so much for middle and lower America. The GINI climbs ever higher, workforce participation erodes, the fraction of Americans receiving food stamps and other government benefits is embarrassing. The porkers in Our Nation’s Capitol take tender care of those who fill their trough. For the rest of America, political homeopathy is good enough.

      Rant ends.

      1. weing says:

        We are doing China in reverse. We will have our own barefoot doctors with herbs, acupuncture needles, and a few other folk remedies providing the bulk of the promised medical care soon enough.

        1. windriven says:

          “We will have our own barefoot doctors with herbs, acupuncture needles, and a few other folk remedies…”

          They might be barefoot but they’ll wear a lab coat and have a stethoscope draped around their neck. And they’ll insist on be called ‘doctor.’ ;-)

  15. Dave says:

    One other comment and then I’ll quit. I hear so often that mainstream doctors have no interest in the social aspects of our patient’s lives. Yet I spend a lot of time ordering things like grab bars, toilet seat risers, shower chairs, walkers, wheelchairs, home health visits, home physical therapy, and working with social workers about issues like meals-on-wheels, medical alert bracelets and emergency call buttons, placement issues especially for my homeless patients, and sometimes even getting the adult protective society involved when needed. Does any of this count?

  16. Debbie Duloone says:

    What an asinine article. Who writes stuff like that but a buffoon or a bored, old man? I mean, It doesn’t even make any sense and amounts to someone not trusting another because of an unconfirmed possibility. Wow, the logic in here. You could have said as much and with a hell of a lot more efficiency in three goddamn sentences. A psychologist would have a field day theorizing about how that whole rant is structured and what it reveals about the person behind it.

    D.H. presented an actual argument that is obviously pretty tough to defend except possibly for a point here and there. A couple key points were made by posters against CAM that make some sense. It surely isn’t something we want ruling all medical practice but I don’t see this as a major threat so no big deal. A guy wants to push boundaries and do some new research into unexplored territory. So big deal? SBM does it all the time and they surely fuck up a lot more than anything else on this planet.

    I don’t think anyone with a rational mindset wants CAM to be the only option nor the major option. But as an option open to the evolutions of its craft, technology, etc. Yes, it deserves to be there. Uniformed suggestions that nothing in CAM improved much in the past 100 years along with taking claim for what the Romans did to life longevity are a couple things that are pretty strange coming from so called experts. Life expectancy just had a decrease in American for the love of it all! Or maybe those pesky nutters had to do with it. You know all them herbs people are smoking and eating these days….

    When my doctor prescribes me the next Vioxx and I am dying on the fucking floor I will think of Gorski with my last breathe. Never change. Never grow, old man.

    1. windriven says:

      @Debbie Da Loon

      Ahhh – a movable feast for Shruggie Nation – salted with ignorance and peppered with obscenities.

      “Who writes stuff like that but a buffoon or a bored, old man?”
      That would be David Gorski, neither buffoon nor old but clearly male. One out of three. Is that considered good performance where you go to school?

      ” I mean, It doesn’t even make any sense and amounts to someone not trusting another because of an unconfirmed possibility.”
      It doesn’t make sense? Hmmm, I see remedial reading in your future. Here’s the rub: there is science and then there is … not science. It would be hella nice to have a Surgeon General who toed to the science side. We are all judged more by our actions than by our platitudes*. So too with Dr. Vivek Murthy: he who dances with quacks raises questions about his professional judgment and integrity.

      “You could have said as much and with a hell of a lot more efficiency in three goddamn sentences.”
      Yes, well, Dr. Gorski is many things but rarely concise. On the other hand, delivering his message in three sentences would have taken a feat of exposition unknown in our times.

      “A psychologist would have a field day theorizing about how that whole rant is structured and what it reveals about the person behind it.”
      Curious. I had a similar reaction after reading your diatribe. About you, of course.

      “D.H. presented an actual argument…”
      dh presented silliness just as Ornish presents silliness. Vegetarianism as treatment for CAD isn’t going anywhere.

      ” I don’t see [sCAM] as a major threat so no big deal.”
      Well we’re all relieved that sCAM has the Debbie DuLoone seal of approval. But before we pack up our tents and go home we should remember that the raison d’etre of this blog is to center the practice of medicine in science. sCAM is a big deal because it gives the appearance of legitimacy to superstition and magical thinking. This isn’t 1470, it is 2013. Time to put away our childish things.

      “A guy wants to push boundaries and do some new research into unexplored territory. So big deal?”
      No. Not a big deal. This is done every day. That is how science gets done. But science is more than jacking around with boundaries and new territory. Just as every art has a form, science has a structure that has proved to be brilliant at separating the wheat of truth from the chaff of nonsense. Explore! Publish! Defend! But follow the rules of ethics and science so you don’t take unnecessary risks with other people’s lives and so that other scientists can check your work and call bullshit if it is wrong.

      “SBM does it all the time and they surely fuck up a lot more than anything else on this planet.”
      Here more than anywhere else in your mess of a comment you telegraph your total vacuity. Science based medicine has brought everything from the germ theory of disease to positron emission tomography. SBM has touched every human being on the planet – if in no other way than by the complete eradication of smallpox. You will likely live long enough to become a bitter old hag because of the hard work of tens of thousands working in science based medicine. Has SBM had failures? Of course. But science is brutal about examining and re-examining everything we do. sCAM just sort of runs with its idea du jour so long as some mark somewhere will buy into it. And if some sCAM artist thinks s/he has the one true cure for X? Fine. All we ask is that they prove it.

      *Dr. Gorski has cast light on breast cancer through his work in research, saved countless lives in his work as a surgeon and worked to bring more scientific rigor to the practice of medicine through this and other blogs, speeches, and appearances. And you’ve done just what besides exposing yourself as foul mouthed and scientifically tone deaf?

    2. WilliamLawrenceUtridge says:

      Debbie, CAM shouldn’t be an option at all. CAM is inherently unproven, or disproven, or downright stupid methods of “treatment” that waste money, time, and in some cases will kill directly. Vioxx, for all that it had unappreciated and unreported cardiac risks (similar to other painkillers by the way), actually worked as a painkiller. Almost no CAM modalities, upon testing, do a goddamned thing. The exceptions are some herbal remedies (which are really just dirty drugs of uncertain potency and pharmacokinetics, and often with hitherto-unrecognized side effects) and spinal manipulation for low back pain (the sole chiropractic modality with any proof behind it, and now that proof of efficacy exist a century after it was proposed, it’s being adopted by physiotherapists). Meanwhile, homeopathy is just expensive water (or lactose), acupuncture is placebo, naturopathy is a hodge-podge of whatever quackery the naturopath can charge for, and the list goes on.

      It would be great if the Surgeon General were just in favour of testing CAM modalities; if CAM modalities could be tested (and discarded when inevitably they are found to not work) before being used, I think most on SBM would be happy. The problem is, they are not. They are being used, customers are being charged, and in some cases people are dying, all in pursuit of treatments that make no sense, and are based on theories of biology that are centuries out of date. How can you defend this?

      And don’t pretend the crimes and misdemeanors of Big Pharma in any way excuse CAM. Big Pharma needs to be properly regulated, the FDA needs the authority and resources to oversee this vital industry. That’s absolutely true. But even if all the drugs produced were completely ineffective, how does that have any bearing on the effectiveness of CAM? It’s not a zero-sum game, where one person wins and the other loses. You are engaging in a common talking point used by proponents of CAM to distract from the fact that their treatments are worthless. By pretending Big Pharma is evil, hopefully nobody will notice that CAM doesn’t work.

      Consider defending CAM on the basis of its actual effectiveness; but note that as CAM treatments are proven effective, real medicine adopts them into standard practice like it has for St. John’s Wort and spinal manipulation.

      CAM deserves to be part of real medicine when it proves that it works. Until then, it’s merely a parasite on real medicine, attempting to co-opt its social capital while offering nothing of benefit on its own.

  17. Sawyer says:

    Once again more evidence that CAM promoter not only misunderstand science, they misunderstand job requirements and opportunity costs. Every minute that the Surgeon General spends pursuing nonsensical alternative therapies is a minute he or she CAN’T deal with problems within pharmaceutical companies and mainstream medical facilities. I often wonder if some of the more cynical drug company employees actually like regulators with this worldview, because of the constant distractions will prevent any serious pressure from being applied.

    And where is the Gish Gallop playbook you guys are using? The comments in this blog are getting worse every day.

    1. WilliamLawrenceUtridge says:

      The worsening of the comments is probably a reflection of the increasing popularity and profile of the blog overall.

      I always aim my comments not so much at the person I’m replying to, because they’re usually a waste of time, but at the lurkers who deserve to see that the comments made are spurious and easily refuted.

      And they are easily refuted, because they’re so repetitive. I think it’s less a playbook than the CAM leaders like Gary Null and Joe Mercola are good at spreading propaganda. And like all propaganda, it’s dishonest and more convincing to the already-convinced because of the repetition.

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