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The Trojan Horse called Integrative Medicine arrives at another medical school

Trojan Rabbit

Medicine is a collaborative practice. Hospitals are the best example, where dozens of different health professionals work cooperatively, sharing responsibilities for patient care. Teamwork is essential, and that’s why health professionals obtain a large part of their education on the job, in teaching (academic) hospitals. The only way that all of these different professions are able to work together effectively is that their foundations are based on an important, yet simple, principle. All of us have education and training grounded in basic scientific principles of medicine. Biochemistry, pharmacology, physiology – we all work from within the same framework. As a pharmacist, my role might include working with physicians and nurses to manage and monitor medication use. A team approach is only possible when you’re working from the same playbook, and with the same aim. And in medicine, that playbook is science.

That’s why “integrative” medicine frightens me so much. Integrative medicine is a tactic embedding complementary and alternative medical practices into conventional medical care. Imagine “integrating” a practitioner into the health system that doesn’t accept germ theory. Or basic disease definitions. Or the effectiveness of vaccines. Or even basic biochemistry – perhaps they believe in treatments that restore the body’s “vital force” or manipulate some sort of “energy fields”. Instead of relying on objective signs and symptoms, they base treatments on pre-scientific beliefs, long discarded from medicine. There may be entirely different treatment goals, which are potentially antagonistic to the scientific standard. Imagine a hospital or academic setting where this occurs, and the potential impact on the quality of care that is delivered.

If you integrate fantasy with reality, you do not instantiate reality. If you mix cow pie with apple pie, it does not make the cow pie taste better; it makes the apple pie worse.
- Mark Crislip

Dr. Crislip’s health care “cow pie” is an effective metaphor for the reality of “integrative” medicine. Medicine today is based on a single scientific standard, with an array of providers divided by specialty and expertise. Integrative medicine explicitly seeks to “integrate” providers that do not provide science-based care, and instead offer treatments that run the spectrum of useless to unproven to potentially dangerous. Positioning of these treatments and services as “integrative” is simply a Trojan horse or branding exercise, aimed at distracting governments and health organizations from recognizing the obvious – that “integrative” products and purveyors can’t meet the established standard of care.

The branding of alternative medicine as “integrative” medicine has been a marketing tactic for at least a decade, with proponents continually citing it as the future of medicine (a future, perhaps, with compromised scientific standards), and opponents simply pointing out that there is no compelling need to “integrate” treatments into medicine that are not grounded in high-quality science.

There is no alternative medicine. There is only scientifically proven, evidence-based medicine supported by solid data or unproven medicine, for which scientific evidence is lacking. Whether a therapeutic practice is “Eastern” or “Western,” is unconventional or mainstream, or involves mind-body techniques or molecular genetics is largely irrelevant except for historical purposes and cultural interest. We recognize that there are vastly different types of practitioners and proponents of the various forms of alternative medicine and conventional medicine, and that there are vast differences in the skills, capabilities, and beliefs of individuals within them and the nature of their actual practices. Moreover, the economic and political forces in these fields are large and increasingly complex and have the capability for being highly contentious. Nonetheless, as believers in science and evidence, we must focus on fundamental issues—namely, the patient, the target disease or condition, the proposed or practiced treatment, and the need for convincing data on safety and therapeutic efficacy.
- Phil B. Fontanarosa & George D. Lundberd

Turning the clock back

Medicine wasn’t always grounded in rigorous science. In fact, it was very different just 100 years ago. Formal medical education varied dramatically from school to school prior to 1910, when the American Medical Association commissioned Abraham Flexner to evaluate American and Canadian medical education and make recommendations on their improvement. Flexner was highly critical of the education standards he observed, and recommended consolidating schools, increasing education prerequisites, enhancing the scientific rigor, and embedding the role of research in education. Flexner was also highly critical of dubious “alternative medical practices” and recommended the closure of under-performing institutions that continued to offer education and training based on principles other than science. Not all schools were evaluated to be weak. Highly rated schools included Michigan, Case Western Reserve, Johns Hopkins, and in Canada, McGill University and the University of Toronto.

The effects of the Flexner report on medical education and the practice of medicine (and affiliated professions, like pharmacy) can’t be overstated. Medical education, now grounded in a rigorous foundation of science, rejected and abandoned unscientific practices like naturopathy, homeopathy, chiropractic, and osteopathy. The result is the medical education and care you see today – and the consistent framework for health professionals. Of course, the purveyors and proponents of these now-rejected practices never fully disappeared. They retreated, regrouped, and fought back, craving the public legitimacy and credibility now offered to medicine and its related health professions. What was quackery became “alternative” medicine, and then “complementary and alternative” medicine (CAM), implying these practices could be used alongside other treatments. Today’s CAM is called “integrative” medicine. Old wine in a new bottle. Regardless of the qualifier, it’s simply an end run around the scientific standards that were defined back 1910.

All of this brings me to my hometown Toronto, and my alma mater the University of Toronto, and this job posting from the university:

Director – University of Toronto Centre for Complementary and Integrative Medicine
The Faculty of Medicine and the Leslie Dan Faculty of Pharmacy at the University of Toronto seek a Director to lead their new interdisciplinary program in complementary and integrative medicine, which will be housed in the new Centre for Complementary and Integrative Medicine (CCIM). The Centre will begin with two primary foci: Traditional Chinese Medicine and natural health products. It will support research and health professional education. Applications are invited for the position of Director for a 3-year renewable term effective January 1, 2014.

The mission of this new Centre is to facilitate, conduct, and obtain support for collaborative basic, clinical, and health services research in complementary and alternative medicine; to serve as an educational resource and to develop integrative curricula and educational programs on complementary and alternative medicine; to work collaboratively with other departments within both Faculties and their hospital partners to support the integration of evidence-based complementary and integrative medicine into existing clinical settings and clinical research programs.

Candidates must have a MD and/or PhD degree(s), a strong track record of scholarship and history of peer-reviewed extramural funding. The Director will be expected to maintain a vigorous and independent extramurally funded research program; to build productive collaborations within the University of Toronto and other local and global partners; and to grow CCIM into a nationally and internationally recognized Centre for natural products and complementary medicine education and research.

In addition to a record of academic excellence in a relevant area of research, the successful candidate will possess outstanding leadership, administrative management, communication, and relationship-building skills. The individual will bring an inclusive scholarly vision and strategies to enable the Centre to build and to sustain effective academic partnerships. Candidates should have demonstrated experience in multidisciplinary and collaborative academic environments. Candidates should have a track record of successful and innovative leadership in research and education, and must be eligible for academic appointment at the rank of Associate or Full Professor.

Much has been already been written at this blog about what’s been described as “quackademic” medicine. (Check out David Gorski’s talk on quackademic medicine and the evolution of quackery). Gorski started compiling a list back in 2008 of academic medical centers that offered one or more alternative medicine modalities. Disappointingly, U of T isn’t alone in its plan to push CAM, although this one is the first I’ve seen that includes two faculties: pharmacy and medicine. It’s a clever strategy: If the intent is to change the medical playbook, and the scientific foundation for medical care, you have to hit both the pharmacists and the physicians. Otherwise one will call out the other for quackery. Normalize it for both groups, and there’s less likelihood that either will notice. Most worrying is the explicit objective of pushing CAM interventions into university-affiliated hospitals. Again, normalize the pseudoscience with students, and then embed it in teaching centres, where other health professionals will see it. And finally, change the standard of care. The first salvo will be Traditional Chinese Medicine and then natural health products. None of this is surprising, given the Canadian context.

TCM: The invented tradition

“Even though I believe we should promote Chinese Medicine, I personally do not believe in it. I don’t take Chinese Medicine.”
- Chariman Mao, quoted in The Private Life of Chairman Mao

Traditional Chinese Medicine (TCM) is a collection of beliefs and practices that was accurately described in the 1930′s by a Chinese medical school dean as a “weird medley of philosophy, religion, superstition, magic, alchemy, astrology, feng shui, divination, sorcery, demonology and quackery.” Current practices that are labelled as TCM include herbalism, acupuncture, massage, energy therapy, and dietary interventions. Treatments are based on the idea that they are restoring “balance” or eliminating “energy blockages”. TCM moved from folklore to government embrace when Chairman Mao realized the potential for TCM in the 1950′s as a means of both boosting Chinese pride, but also to address acute physician shortages in a country of 500 million. Without Mao, there would likely be little TCM, so TCM is very much an “invented tradition”.

The “Traditional” qualifier in TCM gives away the game right away: TCM is simply an appeal to antiquity, the belief that because an idea has persisted, it automatically has merit. And just like the term “integrative”, it is yet another qualifier introduced to rationalize away the requirement to treat based on science-based principles. TCM is comparable to Traditional Western Medicine, except traditional “Western” practices that were demonstrably useless (e.g., bloodletting) were discarded from “Western” medical practice – in part because of Flexner’s work.

The remarkable thing about science-based medicine is that it knows no geographic boundaries. If it works, it works. The idea that the Chinese would respond differently to objective, scientific medicine is as absurd as thinking that “Canadian” medicine would differ significantly from “American” medicine simply because we Canadians love maple syrup, Tim Hortons coffee, and socialized health care. If a treatment objectively works, it’s simply called medicine – no qualifiers are needed. Artemisinin is an excellent example. The Chinese identified the herb Artemisia annua in the 1970′s as potentially effective against malaria. This wasn’t testing to see if it could unblock chi: researchers were looking at how effectively parasites were cleared from the body. Scientific research in China subsequently identified the active ingredient and isolated it. The use of the drug has spread worldwide – not as TCM, but simply as medicine. Unlike the herb, however, the drug is now synthetically manufactured, so the dose can be calculated precisely. And chemical variations of the drug have been developed that are consistently absorbed, resulting in a vastly safer and superior product than the herb itself.

Despite the problematic and unscientific basis for TCM, those that offer it must be licensed in Ontario. The two acts which practitioners are permitted to perform are:

  • Performing a procedure on tissue below the dermis and below the surface of a mucous membrane for the purpose of performing acupuncture.
  • Communicating a traditional Chinese medicine diagnosis identifying a body system disorder as the cause of a person’s symptoms using traditional Chinese medicine techniques

So TCM in Ontario encompasses two functions: The first is the ability to deliver a theatrical placebo which lacks any objective effects. The second is a reference to “traditional” diagnoses and treatment with “traditional” techniques – again, code for practices which are not based on scientific principles, but on historical one. In short, TCM in Ontario means objectively useless needling, as well as giving diagnoses of disease based on prescientific concepts, and giving treatments based on those principles.

TCM and natural health products

The support for TCM isn’t just coming from provincial regulators. Health Canada, the Canadian equivalent to the FDA, administers the Natural Health Product (NHP) Regulations, which are somewhat similar to the American Dietary Supplement Health and Education Act of 1994 (DSHEA). The NHP regulations, like DSHEA, effectively exclude the manufacturers of natural health products from meeting the regulatory standards for drugs. While the Canadian regulations have implemented important steps to improve manufacturing quality, the requirement to show product efficacy was effectively eliminated in the regulations. It’s a boon to manufacturers, but problematic to consumers, as there’s no guarantee that any product approved for sale actually works. Canadians now have access to hundreds of homeopathic remedies deemed “safe and effective” by Health Canada: even homeopathic insect repellent. On the supplement side, failed prescription drugs have been rebranded and marketed as a “natural supplement”, simply because there’s no barriers in place to their sale. And there are now hundreds of TCM products approved for sale. Health Canada approved the following labeling for horny goat weed (Epimedium sagittatum):

Traditional Chinese Medicine used to tonify the kidney and fortify the yang, for symptoms such as frequent urination, forgetfulness, withdrawal, and painful cold lower back and knees. Contraindicated in patients with fire from yin deficiency. If dizziness, vomiting, dry mouth, thirst or nosebleed occur, discontinue use.

In the science-based, reality-based world, there is no yang that needs to be fortified, just as there is no such thing as a yin deficiency. Yet your licensed TCM practitioner can sell you horny goat weed which is Health Canada approved to treat your forgetfulness and cold lower back. And if the University of Toronto is successful with its new Centre for Complementary and Integrative Medicine, this type of material may soon be “integrated” into its medical and pharmacy education. The entire concept is absurd. As an alumnus, I’m appalled and embarrassed. I like to think my pharmacy education was a good one. It was rigorous and grounded in the basic sciences (too much organic chemistry, I thought at the time). And I’ve trained alongside (and work with) many graduates of U of T’s medical school. The Faculty at both schools are among the best and brightest in Canada, and U of T has an international reputation for excellence in education. So it’s deeply disappointing to see this move by the university.

Conclusion

Moves to embed CAM into academic settings start with the assumption that “integrative medicine” is a good thing, in the absence of any data to show that is the case. Based on the information that does exist, it’s reasonable to assume that increasing the levels of “integrative” medicine at the University of Toronto will reduce and compromise the quality of medical and pharmacy education, and ultimately, the quality of care offered to patients. It’s sadly ironic that the University of Toronto, with a medical school lauded by Abraham Flexner in 1910, is now turning its back on those qualities, 103 years later.

Posted in: Acupuncture, Medical Academia, Science and Medicine, Traditional Chinese Medicine

Leave a Comment (129) ↓

129 thoughts on “The Trojan Horse called Integrative Medicine arrives at another medical school

  1. windriven says:

    Outstanding! First tier post.

    Now, what do we do about it?

    1. David Gorski says:

      Any academic physicians in the Toronto area (or willing to move to Toronto) who might want to apply for the position? :-)

      1. WilliamLawrenceUtridge says:

        It would be fantastic if every such position were filled with an Edzard Ernst. That could be the toothpick in the heart of all these tiny parasitic departments within scientific universities.

  2. Stephen H says:

    I was of the understanding that medicine was integrative. My doctor needs to know a bunch of stuff about me before doing any serious diagnosis. She refers me to people who know more than her about certain things (specialists). She looks at my medical history and considers my current health in that light. My pharmacist is a professional who asks questions about the drugs I have been prescribed, and provides advice about non-prescription medications.

    Unfortunately, medicine is a money-making enterprise. If you have enough people wanting to believe in fairies, then someone will invariably turn up with a video of said fairies and instructions on how they can help you (for a fee). The move by legitimate medical institutions to embrace a bigger market is understandable, but is very short-sighted and will ultimately backfire.

    If people cannot trust their medically trained doctors not to be pushing wolfsbane or discuss their chi, then the entire practice of medicine comes under a cloud of suspicion. In much the same way as politicians have an enormous image problem, and nobody trusts journalists, grabbing the dollars is fantastic for some in the short term but undermines the entire profession.

    Institutions that decide to stay above the money-grubbing will survive, and ultimately retain the respect of their clientele at the expense of those whose treatments hark back to curing humours and bleeding.

  3. Sheepmilker says:

    Banting and Best must be rolling in their graves!

  4. windriven says:

    I believe you’ll find the reality a bit more nuanced. Money is certainly an issue. But it isn’t quite as stark as “money-grubbing” suggests. In my experience* there are a range of perspectives at work. For a very few it really is just money-grubbing. But there is a much larger element that combines a misplaced effort to give patients what they want, a politically correct live and let live collegiality and shruggieness.

    “Money-grubbing” demonizes the very people who we need to persuade to the righteous path ;-). Urinating on them is a poor tactic to further that objective. They tend not to be cut from the same cloth as anti-vaxers, homeopaths and other loonies for whom urinatee status is an improvement.

    *Yeah, yeah, Dr. Crislip.

  5. James says:

    My biggest issues with the way medicine is practiced in the US today is the following.

    * Most of the time diet, sleep, exercise, and stress are never addressed.

    * Doctors do not use the best known psychological techniques to help people to incorporate healthier habits.

    * Doctors overwhelm themselves trying to see as many patients as possible or are so disorganized that it becomes are for them to provide a good service.

    * Doctors tend to focus on the short term cure not the long term effects of the treatment.

    * Most doctors really do not understand statistics.

    * They are dismissive of vague symptoms which could be indications of bigger problems.

    * They mistake policy for science.

    There are many more things I could list but it will not further the .

    The mistrust of doctors in the US is because they are not really helping people improve there overall health.
    If a doctor come off as dismissive, rude and uncaring about a patient no wonder people are flocking to alternatives doctors because at least they listen.

    Doctors in the US have it rough I do not envy the situation they are in.
    However most of the issues are self inflicted wounds.

    1. Is there any evidence that alternative practitioners have “improved people’s overall health”? Listening is nice and may result in a temporary improvement in perception of well-being, but is the actual health of the patient improved? Does s(he) lose weight, exercise more, etc. Doctors tell people to quit smoking, lose weight by consuming fewer calories and emphasizing fruits and veggies, exercise more, get enough sleep, and so on. Most of it falls on deaf ears. I think if we could develop a strong support system for doctors to help people try harder and stay with a program, it might be a good step, but to blame doctors for people’s inability to follow advice, because they are pressed for time (a result of our system, not their lack of caring) is unfair at the least.

    2. windriven says:

      “* Most of the time diet, sleep, exercise, and stress are never addressed.”

      You need a different physician.

      The rest of your comment ranges from silly to stupid.

      On what basis do you make your categorical pronunciations on doctors? Got any studies there, Sparky? Or is this a personal anecdote? If so how many physicians do you personally know? What is the total number of hours that you have spent in conversation with a physician over the past, say, 24 months?

      1. James says:

        I speaking from personal experience after trying to figure out my own personal health issues. So yes I am biased.

        At that time I little choice of my doctor because location reasons.

        I had to push to get the test done since he did not listen to my concerns.
        I had to become an asshole just to get to healthy.
        It turned out that I had the following.

        * Narcolepsy
        * low testosterone.
        * High blood sugar
        * Low Vitamin D

        When I was diagnosed with high blood sugar what was his recommendation nothing.
        Not even a pamphlet.

        This experience is not uncommon from a survey of friend and family where they were having serious health issues.

        I have a degree in mathematics so stats is very important to me and my conversation with doctor on this subject has not always been very encouraging.
        http://www.bmj.com/content/294/6576/856

        Doctor’s Beside manners to matter

        http://healthland.time.com/2011/07/19/your-doctors-bedside-manner-could-affect-your-health/
        http://resources.physicianassistantsolutions.com/the-psychological-importance-of-bedside-manner-trust-and-teamwork/

        http://www.ihealthbeat.org/articles/2013/5/2/poor-bedside-manner-is-most-common-critique-in-online-doctor-ratings

        Telling someone that they need to fix lifestyle issues without providing them the best known methods to do so is not helpful.

        Read the book “Willpower Instinct” which goes into the how and why of willpower.

        Also the book “Factory of One” is a great short read on productivity which has a lot of examples from the health industry.

        1. windriven says:

          How did you not know you were narcoleptic?

          1. James says:

            Are you a doctor who specializes in Narcolepsy?

          2. James says:

            If you just took a few second looking up Narcolepsy you could learn something.

          3. James says:

            windriven

            It is funny once I did provide evidence your only response was to question why I did not know I had narcolepsy.
            However you never once tried to discuss the evidence I provided.
            Please so I could understand your motivation why did you feel the need to do so?
            I really do not expect you to reply to my post it just an interesting observation.

          4. James says:

            Windriven

            I am not sure your question really about wanting to know or your just being a jerk.

            So let me know if you really want to know and I will be more than happy to explain.

          5. James says:

            I guess you are not man enough to deal with your own biases

        1. “Bedside manner are the #1 complaints about doctors.”

          Uh…so? This really is a backpedal from your prior post. There exists a primary ordinal complaint for doctors….and every other position on earth. Also…

          The Forbes link provides little useful information. The online posts about doctors are self-selected and not a good source of validating information. That poor social skills are correlated with complaints is not necessarily relevant to the ordinal position of “bedside manner”.

          “Doctor are bad at stats”

          You linked to Ioannidis’s article here instead of the BMJ article. Why?

          The BMJ article is a reference to a 1987 Danish mail-out survey in which they concluded that Doctors don’t have enough statistical knowledge to draw right conclusions from medical journals. This result is at least questionable as it applies to Dane’s as usually we test people using more than nine multiple choice questions before relegating them to the “unable to determine right from wrong pile”. We don’t know anything at all about the questions or how they were validated against actual outcomes…like being able to detect a correct from incorrect journal article and of course since your original post specifically mentioned the US it might not apply at all.

          Also since the only reference point was other doctors. You could just as easily use the same results to argue: “Doctors are better at statistics than the vast majority of people they treat”.

          “Less than half of doctors provide specific guidance on diet, physical activity, or weight control”

          You should have read the article instead of just Googling your premise.

          “Fewer than 50% reported always providing specific guidance on diet, physical activity, or weight control. Regardless of patients’ chronic disease status”

          That is RADICALLY different than less than half the doctors provide specific guidance on diet, physical activity or weight control. When I go to get vaccinated my doc doesn’t talk to me about weight control. In fact if you had read the actual study you would have learned…

          “Likelihood test results indicated that all PCPs were more likely to often or always provide counseling on physical activity than on diet or weight control “

          1. James says:

            Thank you for reply. Great feedback.
            I will look read the studies a bit more deeply and get back to you

      2. Ella says:

        “Windriven”—Someone makes a legitimate comment here within his full right as a reader, and you jump right to insulting, mocking, and calling him “Sparky” What the mother–ck is wrong with you? Anger control issues? Or are you just a dramatic, unemployed science bully?

        Give it up, James. The rude, ad hominem attacks you are encountering here cannot be quelled by logic, links to studies with evidence or pleas for people to get real. I know this from one pathetic comment in which several of these regulars began fixating on whether or not I could verify with journal articles something I clearly stated was merely my personal experience. While at the same time, mind you, clearly expressing unsubstantiated opinions of their own.

        This entire thread demonstrates, and reconfirms for me, why this blog is full of arrogant, bloated know-nothings who pretend they own keys to the “scientific universe” when in actuality they are more biased, uninformed and blatantly insecure than the very people they attack, demanding from them they provide “scientific evidence” for any statements with which they disagree. I know they “front page” by waving all kinds of letters after their names or claims to academic purity, but somehow, I smell “academic failure” on most of the poster’s here. It’s pretty pathetic to watch this go down, and unfortunately, James, you have been a victim of their bad behavior.

        Oh, and by the way, James is right. Too many doctors in this country turn to the prescription pad when what their patient’s need is to change their lifestyle habits, diet, seek counseling or alternative means to balancing their lives. It’s easier and cheaper for them than truly being healers who are willing to spend time (aka, money lost) with their patients in order to build a relationship with them in which they can persuade, advise, and coach them towards optimum health. That is why we spend more per capita on healthcare in this country and get far worse outcomes.

        1. James says:

          Thank you for the comment there Ella.
          The funny thing is I never said anything about alternative medicine being better.
          I was just talking about why people go to alternative doctors.
          All well life goes on.

          1. WilliamLawrenceUtridge says:

            Hi James,

            Much like your diagnoses, on this way if you were purely playing the numbers, the likelihood of your comment(s) leading to an unwarranted criticism of the medical system followed by praise for the alternative industry and it’s endless, uncritical support for nigh-all spurious conditions is fairly close to 100%. It’s hard to lift yourself out of that groove, and skeptics are all still human, thus prone to all the biases that infect our reasoning. While I dearly love the skeptical community, I am realistic enough to recognize that it is not perfect and it is just as prone to errors of reasoning including ad hominen attacks as any other human endeavor. Do you know who Rebecca Watson is? If so, I need say no more.

            However,

            This entire thread demonstrates, and reconfirms for me, why this blog is full of arrogant, bloated know-nothings who pretend they own keys to the “scientific universe” when in actuality they are more biased, uninformed and blatantly insecure than the very people they attack, demanding from them they provide “scientific evidence” for any statements with which they disagree.

            That’s bullshit. Arrogant, perhaps, but know-nothings, that is far from the truth, and the majority of contributors, editors or commentors, know orders of magnitude more than the credulous CAM promoters. Their vitriol is the result of frustration at the quality, and repetitiveness of the SCAMsters.

            The error and failing in this case is that it is not really a scientific question, it’s an assessment of an anecdote.

          2. James says:

            @WilliamLawrenceUtridge

            Hi William,

            Thank you for your reply I always appreciate your input.
            First thing I do not know who is Rebecca Watson.
            People make mistake that is understandable.
            My irritation is that after evidence was presented the people who spoke the loudest mainly @Windriven and some what of @Carl really showed no integrity in my opinion.

            However I do disagree with your statement

            “The error and failing in this case is that it is not really a scientific question, it’s an assessment of an anecdote”.

            The scientific question is why there was a failure and error in my case.
            What are the best practices that should be used to reduce such errors.
            How can doctors reduce ego depletion and decision fatigue.

            As for my previous doctor do I think my doctor he is an evil person no.

            I do believe he was in over his head at his practice basically did not know how to dig himself out of his situation.
            I was stuck with him because finance & location reason.
            So it was hard for me (not impossible) for me to get out of my situation.

            All in all I would say this entire process did help me realize how to improve posting here and did provide me with different perspective

            James

        2. windriven says:

          Oh Ella, you cut me to the quick. How can I ever go on?

          This is a blog about conducting medical practice within the bounds of science.

          I have read “James” whiny comments but have no idea what his actual complaint is, how that complaint bears on science based medicine, or what he would have the science based medicine community do to respond.

          Somewhere in these pages James claims to have narcolepsy, low testosterone, vitamin D deficiency, and something, I’ve forgotten just what, else. James’s list of diagnoses sounds like a shopping list from a quackateria. And that does cut right to the heart of SBM.

          I have asked James to state his claim, the argument supporting it and his recommended solution.

          If you find my tone toward him condescending, it is. Intentionally. And it will remain so until he frames a meaningful argument.

          1. James says:

            Windriven
            I understand you belief that I my conditions smell of something a CAM practitioner would say.
            However my diagnosis came about through a sleep study and the proper blood work and the interpretation of them by a trained professional.
            Which is how science based medicine should work.
            My problem was always with the process it took to get there.
            In my peek of my frustration with my previous doctor when we where finish figuring out one problem.
            I ask about tackling another problem that was place to aside because of more pressing issues.
            He asked me “Do you think I am a magician?” my reply was simply this.

            No I expect you to be a scientist
            Come up with an hypothesis.
            Collect data and test
            Rinse and repeat
            If you do not know the answer then send me to someone who might.

            I never asked any doctor to be perfect I would have been ok if we ran down the wrong path.
            However my problem was that the car was in park.

            As for my rant about what doctor don’t do; I know realize the source of that is because since I am black and most of my friends & family are black.
            So survey of of friends & family were biased because my audience was also biased.
            However the reason for their bias is valid.

            I my case I do not believe the doctor unconscious or conscious racism was in play it was just the fact the he was just bad.

            However understanding the source of my bias still does not allow me to escape the “honey badger”.
            I have to be the best advocate for my health since statistically I will get worse service (Well I in Canada now so I am not sure about the stats here).

            As for my remedy for the medical system.
            Basically the following.

            * Reduce Ego depletion and Decision fatigue and other willpower failures of medical professionals.
            * Have doctors understand better the concept of ironic rebound http://dash.harvard.edu/handle/1/9961303 to help them deal with their own uncomfortable thoughts.
            * Increase the understand of willpower failure for PCP so they can in turn help patients deal with the challenges of habit change.

            I am not under the illusion we just need to this and everything will be butterflies and unicorns.
            However I do think this a good place to start since it tackles the mental and physical environments of medical professionals.

          2. WilliamLawrenceUtridge says:

            I hope your experience in Canada is different. My experiences with doctors have been pretty uniformly good, even when I was younger and a huge, arrogant, CAM-believing, conspiracy-mongering douche. Having a genuine health care system really seems to help – doctors seem to be less rushed (compared to the complaints I’ve heard on-line from Americans – terrible sample but I bet there are some stats out there) though there are lots of complaints about wait times for specialists and the popular perception is that it is easier to get service in the US (’cause money talks far more readily).

        3. “I know this from one pathetic comment in which several of these regulars began fixating on whether or not I could verify with journal articles something I clearly stated was merely my personal experience.”

          Not exactly. You claimed that you found something “useful”. I find many things useful which are also well substantiated. For example I find T-Statistics useful when I have a small sample and a null hypothesis which is t-distributed.

          Harriet appeared to take “useful” to mean that you believed it to have predictive power. That seems reasonable to me.

          “While at the same time, mind you, clearly expressing unsubstantiated opinions of their own.”

          Actually you pointed out exactly one and only one opinion. Which you seemed to think was requiring substantiation. It wasn’t a very good example as I pointed out in my prior post.

          Perhaps now you could pick an example that actually makes your point rather than stomping off and relegating some of us to those who can not be “quelled by logic”….or continue to express your displeasure by sniping remarks from the sidelines. Whatever makes you feel better I guess.

    3. Carl says:

      James says:
      August 29, 2013 at 11:14 am
      My biggest issues with the way medicine is practiced in the US today is the following.
      * Most of the time diet, sleep, exercise, and stress are never addressed.

      Obviously you have no idea what you are talking about and are just repeating BS tossed about by quacks.

      1. James says:

        I do not understand are you suggesting the following.

        * That sleep, diet, exercise and stress has no impact on peoples’ health?

        * Bedside manner of doctors do not make people avoid going to the doctor?

        * Every health policy in the US is based off good evidence.

        * Doctors never dismiss a patient’s complaint only to find out it was something bigger

        * That doctors always look at the long term effect of the treatments they prescribe.

        * That being a Doctor is very relaxing job?

        * That doctors have a strong grasp of stats?

        * That doctors gives good advice on how to create better habits in people lives.

        Please explain to me what I got wrong?

        I would prefer people to see doctors then the alternative ones.
        However as a patient who had to fight with his doctor to get healthy.
        I am pointing out a big part of the problem is the lack of trust that patients have with doctors.

        1. Joao says:

          I dont live in the US but I have a hard time believing doctors there neglect to a point of causing harm : sleep, stress and exercise. Not even here they shut their mouths for a second about that. And about weight and tobaco and such.

          For a matematician fond on stats you rely to much on anedotal evidence to make your point. And seem to ignore that reference values are not to be taken as a binary result. It must be Bayesian. You got to include clinical information.

          From portugal, best wishes for your health.

          1. windriven says:

            @Joao-

            ” I have a hard time believing doctors there neglect to a point of causing harm : sleep, stress and exercise. ”

            Good. Because they don’t. I discuss my diet and exercise with my physician nearly every time I see her.

            I’ll be visiting your lovely country in May. I’ll spend most of my time in the Douro valley but also short stays in Porto, Lisboa and the Algarve. Any thoughts on ‘must see’ things that don’t make the major guides?

          2. Joao says:

            To Windriven:

            Great that you are coming to visit Portugal, I hope you enjoy. You will find people are friendly and most speak english. I dont really know whats on the travel guides, but I dont think I can come up with something unique to advise. I can give you some of my personal preferences though. Lisbon : Mosteiro dos Gerónimos and Torre de Belém area, Castelo de São Jorge. Algarve: Ria Formosa – try at Cancela Velha the view over most of it and to spot walking paths in low tide. Googling this things will reveal their location and photos. I am also fond of Serra de Sintra, a small moutain near Lisbon. In Douro, traveling upriver on a cruise its said to be great. I havent done it. Yet.

            I think museums as a rule, dont meet the standards I have found abroad, I hate to say, and although they need visitors, I would advise to spend precious time elsewhere, unless you search for something specific. I think the best off our country to visitors, is the hospitality of the people and the varied landscape (for such a small country).

            To all others, sorry for the offtopic.

          3. windriven says:

            @Joao

            Thank you very much taking the time to share your thoughts on my upcoming trip. I will check each of your recommendations. But I will probably also still visit some of your museums :-)

        2. Carl says:

          James says:
          August 29, 2013 at 3:48 pm

          I do not understand are you suggesting the following.

          * That sleep, diet, exercise and stress has no impact on peoples’ health?

          No, I am saying that you are a total BS artist for claiming that doctors “never address” those things. Your statement is false and ridiculous.

          Doctors never dismiss a patient’s complaint only to find out it was something bigger

          And this part confirms your dishonest and childish tactics. OF COURSE I am not saying they “never” do it. Nothing “never” happens, that is a straw man (that means you fabricated something to argue against, rather than responding to anything I actually said). And for you to imply the opposite with sarcasm is just a meaningless platitude.

          1. James says:

            Carl please point out to me in my original post where I said “doctors never address those things”. I did not say that you did.
            However I should have not have used the word “Most” that is unfair.
            And yes using irony in my response was childish.

            However what I do not understand what is the BS you are claiming I said.

            * Bedside manner are the #1 complaints about doctors.

            http://www.forbes.com/sites/peterubel/2012/11/02/do-starbucks-employees-have-more-emotional-intelligence-than-your-physician/
            http://www.renalandurologynews.com/poor-bedside-manner-service-top-patient-complaints/article/292884/
            http://www.drbriffa.com/2007/09/05/poor-bedside-manner-associated-with-increased-risk-of-complaints-against-doctors/

            * Doctor are bad at stats
            http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0020124

            * Doctors are overwhelmed
            http://www.ncbi.nlm.nih.gov/pubmed/22053736
            http://www.amednews.com/article/20111220/profession/312209994/8/

            * Why people seek alternative treatment
            http://jama.jamanetwork.com/article.aspx?articleid=187543

            * Less than half of doctors provide specific guidance on diet, physical activity, or weight control
            http://www.ncbi.nlm.nih.gov/pubmed/21665061

            I know we stated on the wrong foot.
            I really do appreciate your reply.

          2. James says:

            Carl you called me dishonest & childish.
            I willing to accept childish because I was.
            I was never dishonest.
            However you did misquote me.
            Were you dishonest or did you make a mistake?
            Do you the integrity to admit you were wrong?

          3. James says:

            Does your seeking of the truth stop when some calls you out?

          4. WilliamLawrenceUtridge says:

            Hello again James,

            While bedside manner can be important (it enhances placebo effects and increases trust between you and your doctor) it is also largely irrelevant to diagnosis and treatment bar their ability to get a valid list of symptoms out of the patient. I would rather a Dr. House than a Dr. Wilson; not that Wilson wasn’t a good oncologist, but House was the better diagnostician (in this fictional example). Sure, in an ideal world all doctors would be all these things – but this is the real world and sometimes brilliant doctors are asses. In a way, part of it does come down to preference – some choose their doctor on the basis of their bedside manner. Some choose their doctor on the basis of their statistics (patients cured, number of successful surgeries, number of complaints, etc). In your case, it seems part of the issue was the inability to choose.

            I’m not sure what your overall point is anymore – that doctors need to improve? I agree with that. That doctors aren’t perfect? Agreed again. That the US needs a real health care system that is publicly funded? Hallelujah, praise Monkey Jebus!!! In many ways this site is about how doctors often fail to deliver on the promise of their profession, how they fail to live up to the deep power and profound promise of science. It’s aspirational, it’s a rallying cry, and it’s recognition of medicine’s failures (and the occasional success). What many unfair and CAM-promoting commenters do, however, is to ignore these valid concerns and attempts to improve medicine in favour of caricature and fallacies. You may have been unfairly and prematurely shunted into that category. But I do give you kudos – while you are expressing your disappointment at how medicine (well, a single doctor) failed you, you don’t lapse into rhapsody for CAM as a solution.

            Also, Ioannidis’ article isn’t about doctors being bad at stats, it’s about the overall research enterprise being geared towards false positives. Some doctors are very, very good at stats (and they use this ability to polish a lot of turds). Dr. Crislip has repeatedly stated he’s terrible at stats :)

            Anyway, I think we overall agree more than we disagree.

      2. weing says:

        “The scientific question is why there was a failure and error in my case.”

        The doctor may not have been familiar with the illness in question. The presentation may have been unclear. We recognize constellations of symptoms and signs. When a patient comes in with such a constellation we look for a match to our prior experience and almost effortlessly have a provisional diagnosis from the history and the exam will refine it further. Sometimes we have to do lab tests.
        Other times the presentation doesn’t fit a pattern that we recognize. Then we have to really work and go over every symptom and sign and the diagnostic possibilities of each. A very labor intensive process that all of us remember from medical school.

        Physicians are human and susceptible to confirmation bias and other cognitive biases just like everyone else. They may be tired and if he had several patients like the latter, then he would suffer from ego depletion, never mind the time constraints.

        “What are the best practices that should be used to reduce such errors.”

        To recognize that we may be wrong and be aware of the various cognitive biases which may be in play and deliberately avoid them by, for example, looking for dis-confirming evidence instead of ignoring it. Have the patient come back another time for evaluation.

        “How can doctors reduce ego depletion and decision fatigue.”

        The same way you do. Get plenty of rest, decrease the number of decisions, take breaks. I try to have a tiny snack between seeing patients.

        1. James says:

          weing
          Thank you for your reply.

          I am will to accept that it may take many iterations to the right answer.
          I work as a software engineer so I understand that it takes multiple iterations to
          get to the right answer.

          Also I very willing to accept that my description of my symptoms are lacking.
          Customers give very vague request and sometimes want things that make no sense.

          My problem is seemed that he was not even trying or cared to get to the underlining cause.

          Looking back at the entire process I realized a big part of the problem was his lack of organization and his work load was a major cause of the problems.

          Unfortunately given my family medical history I know that I need to see doctor very often.

          However since this is not a one way street both parties should to understand the best approach to the optimal outcome.

          So in your professional opinion what is the best way for a patient to prepare themselves to see a doctor when they have health issues?

    4. Cervantes says:

      There is truth to what you say. It is true that physicians in general are not trained in behavioral counseling. I think they do generally tell people to eat right and exercise, but they will probably be the first to admit that they are not very effective in getting people to improve their health-related behaviors. But it’s not really clear that this can be accomplished in a few minutes out of an otherwise crowded 15 minute office visit.

      You are for sure right about not understanding statistics. That’s a huge problem, it’s really scandalous. Doctors do not understand Bayes Theorem and confuse the specificity of a test with its positive predictive value, among other common errors.

      True, patients are not reassured when doctors dismiss their complaints. That’s not to say that time and money should be invested in investigating everything that worries patients, but doctors can do a much better job of explaining to people why it makes sense to watch and wait. Many problems just go away on their own. To be sure, physicians sometimes make mistakes and fail to follow up when they should; but overinvestigation and overdiagnosis are really bigger problems.

      All that said, just because medicine could be practiced with more communicative and relational skill, is no reason to seek out the useless nostrums of quacks. Despite its shortcomings, medicine has in fact contributed a great deal to improving overall health, at least in the past 25 years or so. (Not so much before that.) It’s frustratingly slow but it is getting better.

    5. WilliamLawrenceUtridge says:

      The fact that you contextualize your comment to the US is the most prescient and useful part; this is very much a problem within the US’ frankly broken health care system that lacks a publicly funded health care option. Other countries, with real health care systems seem to have fewer problems. Certainly where I live I haven’t encountered many of these problem, my doctors have been quite willing to listen and have good (if neutral) bedside manners. I’m usually disappointed when my doctor doesn’t praise my diet and exercise regimen more though :(

      They are dismissive of vague symptoms which could be indications of bigger problems.

      The problem is, in most cases vague symptoms are indications of nothing. Doctors usually don’t make rare diagnoses because they are rare, and patients with clusters of overlapping rare conditions all of which cause rare symptoms are even rarer. Doctors need to run through a diagnostic process to eliminate certain rare-but-probable conditions, and it’s an unfortunate reality that some diagnoses will be missed simply because of their improbabilities (like the one-in-a billion-chance of a patient getting three one-in-a-thousand-chance conditions. House and similar shows have effects similar to CSI – they systematically distort the appreciation of diagnosis and base rates among the general public and foster the belief that they just need to get the one magic-bullet diagnostician who can figure out what’s wrong with them (assuming there is something wrong with them) rather than realizing that sometimes life sucks and a very rational reasoning system happens to break down in very rare circumstances.

      Man, it would be nice if medicine were perfect.

      1. James says:

        Thank you for your reply.

        You are right the internet, CSI, House had made it more difficult for doctors to practice.

        When I say vague does not mean rare.
        The I am always tired could mean so many different thing.

        * You cat is jumping in your bed at night.
        * Sleep apnea
        * You partner snores
        * Vitamin deficiency
        * Narcolepsy
        * You do not sleep enough.
        * You have a low grade infection.

        I before I was diagnosed with narcolepsy.
        My doctor did not even run down the list of possibilities with me.
        I was the one who had to ask for a sleep study get my blood test done.
        I almost felt I diagnosed myself he just ran the test to confirm.

        Yes I was diagnosed with something rare but none of the other options were not even discussed or I was not even offered to see a specialist.

        1. WilliamLawrenceUtridge says:

          Yup, you could have had a shitty doctor, it could be the medical system, it could be something systematic in the training of doctors, or it could be you. I don’t know, and nobody else here does – we lack information (and you lack perspective). There’s no way of knowing who is in the right or wrong, and what none of us should do is to mock or belittle your condition or the process it took to reach a diagnosis. We shouldn’t pretend medicine is perfect any more than SCAMsters should pretend it is irredeemably flawed (and they have the answer). The anecdote also cuts both ways – it proves that shitty doctors can exist, but it also doesn’t prove that it’s systematic. Reality doesn’t conveniently lump into neat piles :(

    6. Xerxes says:

      James says: “My biggest issues with the way medicine is practiced in the US today is the following.

      * Most of the time diet, sleep, exercise, and stress are never addressed…” and a whole lot of other nonsense…

      I am an overweight late 30′s med school applicant (either MD or DO)with a full-time stressful job with bad eating habits and up to two weeks ago, no time nor desire for exercise.

      I have just gotten excellent health insurance through my job (PPO) which allows me to see wonderful specialists for sudden onset allergies (Dr. Baum, you are awesome!) and I have just gotten an internist as a primary care physician. Both physicians stressed to me that I should really try to get my blood pressure down by exercise and a healthy diet, my PCP did not want to start with high blood pressure medication, not even diuretics – he just stressed healthy diet and exercise and gave me some pointers on what that looks like. Both gave me parameters (low sugar, low fat, etc.) and fast paced walking to begin with towards gradual jogging, etc. Both asked about stress re MCAT, med school application, job, relationship, etc., but overall they focused on the stuff that was bothering me: my high blood pressure and sudden onset of allergies (both have gotten better, without needing needles poking me while chanting and imagining beaches or waterfalls, or other such stupid nonsense. No, exercise and a healthier diet as recommended by both physicians and prescriptions for medications have helped me tremendously.

      I moved to the US from the Netherlands when I was 18 and have always had great experiences with US physicians, some had better bedside manners than others, and whether they were MD or DO, they gave me great care. The vilifying of US physicians (reductionist or whatever crap woo people come up with…) irritates me to no end.

      I know my experience is just anecdotal, but it has been my experience since I have been an adult, most physicians (real physicians – MD or DO, NOT ND or DC) have been great, shown some interest in knowing what my life is about but they weren’t there to by my parent, wise man/woman or guru – they were there to help me get better from what was/is ailing me. I don’t need a physician for self-realization or self-esteem, I need them for when I am sick, injured, etc.

      1. James says:

        Thank you for your reply
        You had a straight forward case and the doctor did their job correctly which is wonderful to hear.

        However in my case was not straight forward the doctor had to be pushed.
        It felt I was pulling teeth just to get healthier.

        Every case is different.

        I was so happy when I got rid of that doctor.

        1. WilliamLawrenceUtridge says:

          James, was/were your subsequent doctor(s) better?

  6. I get a monthly magazine (Today) from Froedtert & Medical College of Wisconsin. The theme this month is “Advanced care for complex heart disease. Explore one patient’s journey with a total artificial heart as she awaits a transplant.” The content is all cutting edge medicine and developments

    In the middle is a supplement called “My Health-Classes” which lists courses such as “Living Well With Chronic Conditions”, “Pituitary Tumors”, “Pancreatic Cancer”, and “Bladder Blues”, which give way to the slightly eyebrow raising, “Coconut, Sunflower and Grapeseed, Oh My!” which promises to, “discuss how you can effectively utilize each in your daily life”; on to, “Beginning Meditation which is, “known to have benefits to health and wellness including improved immune function and reduced pain, stress and anxiety”. (really?). Next up is the more eyebrow-raising. “Cancer and Nutrition”, which promises to “discuss current guidelines and ways to incorporate cancer fighting foods into your diet…”

    And the piece de resistance : (don’t know how to do italics)

    COMPLEMENTARY MEDICINE AND CANCER
    CLINICAL CANCER CENTER, ROOM M
    PRESENTED BY: JACQUELYN PAYKEL, MD, OBSTETRICIAN/GYNECOLOGIST WHO IS CERTIFIED IN INTEGRATIVE MEDICINE

    You have many choices to make before, during, and after your cancer treatment. One choice you may be thinking about is complementary and alternative medicine. We will discuss what is available and who is a good candidate.

    ——

    Hopefully, no one with cancer.

    I’m thinking of getting “certified” in “Skepictology” so I can offer a course in critical thinking next term.

    1. Skeptical Badger says:

      I just threw that on my table. I guess I will have to go back and read it. As students at MCW, there is an integrative medicine organization. I have been to a few of their events and find it unnerving that some of my classmates buy into that stuff. Luckily, the vast majority that I have talked to see it for what it is.

  7. P.S. – I’m so sorry for U of T. I spend some time most years in Toronto and always visit the campus and associated museums. This is a sad development you report SG.

  8. R. Wade Covill MD, MTDoc says:

    In my area the problem is the hospitals. They have bought up most of the private clinics, and most of the physicians are now employees. The medical staff used to have substantial influence on hospital policy, but its hard to tell the boss what to do.Our “wellness program” even includes an aroma therapist, all hospital supported. And the local medical society stopped having meetings when the government labelled physicians a monopoly.

  9. Would love to see a trojan science-based MD or DO get in there with the purpose of dismantling or upending the department … makes me smile just to think of it!

    1. Joao says:

      Yeah… Give them a Edzar Ernst move.

      1. stuastro says:

        Or, maybe let the quacks take over the asylum and see how their stats look after a week or 3. Not good at all is my prediction. Surely it is legal to have a hunting season on quacks. Isn’t it? Yes?

  10. Rob says:

    Some clarification on the NHPD regulations vs. DSHEA. In Canada it is pre-market approval for supplements, while in the US it isn’t. Also, this part “the requirement to show product efficacy was effectively eliminated in the regulations.” is not entirely true. There are two ways to get a natural health product approved in Canada – with an evidence based license or a traditional use license. Research must be submitted in the former and traditional use references for the latter.

    The health claim for the former is based on what the research shows. DHA for example carries the claim: “When used during pregnancy and breastfeeding, DHA supports healthy neural and vision development of an infant. Helps support cognitive health by improving memory and learning functions in an aging population.”

    For traditional use, it simply carries a claim like “Traditionally used in herbal medicine for…”. This isn’t saying it is effective though – just acknowledging it has been traditionally used for whatever the case may be. There are also regulations on establishing safety. For homeopathy the only claim statement is “homeopathic preparation”. For these examples you can certainly make the argument that they are being sold without any evidence of efficacy, but there are also many research based products that are licensed as well. I believe Health Canada was going for a balance between proven efficacy while still allowing access to things some people apparently want, as long as they are safe (relatively speaking). The regulations culled tens of thousands of products from the market (probably a good thing if they couldn’t even meet the basic requirements for an NPN license) and markedly improved the standards required for manufacturing. I would say it is definitely an improvement over what existed before.

  11. James says:

    The question is not whether alternative practitioners have “improved people’s overall health”.

    But why people go to them in the first place?

    You said “Listening is nice and may result in a temporary improvement in perception of well-being, but is the actual health of the patient improved?”

    My response to this it is an issue of trust and does this doctor care about me has my best interest at heart.

    I have had that feeling that a doctor did not really have my best interest at heart so I did not take their advice seriously. I am speaking from experience.

    If doctors lack of listening skills are encouraging people to make unhealthier decision.
    Then it begs the question why aren’t doctors using evidence based techniques in dealing with their patients.

    Telling someone they need to lose weight by consuming fewer calories and emphasizing fruits and veggies, exercise more, get enough sleep, are just an empty statement that has no real meaning and is not enough.

    My question is what are the evidence based techniques in helping people make healthier habits?

    I assume most doctors understand that how they talk to patients matter but they just do not know how to do it so they just wing it.

    I am not trying say doctors are evil and alternative practitioners are good.

    I am saying that the approach that doctors take with patients matter.
    Also if the fundamental issue of trust is not dealt with then it will not get better for doctors.

    Remember evidence based medicine does not stop at the pill.

    I would recommend two books to help.

    * The Willpower Instinct: Very good book on why people fail to make changes in their lives.

    * The factory of one: Great Book on productivity with a lot of examples from the healthcare industry.

    1. WilliamLawrenceUtridge says:

      But why people go to them in the first place?

      Because CAM practitioners are not limited by standards of care, and they are perfectly willing to tell patients exactly what they want to hear – “There is something you can do about it, what you have is not merely part of the inevitable decline of an imperfect body.”

      Then it begs the question why aren’t doctors using evidence based techniques in dealing with their patients.

      A doctor not arriving at a diagnosis of “you’ve got four rare conditions” is actually doing a pretty good job of using evidence-based techniques. The problem seems to be you are at the very small nexus of a Venn diagram of four overlapping circles.

      Telling someone they need to lose weight by consuming fewer calories and emphasizing fruits and veggies, exercise more, get enough sleep, are just an empty statement that has no real meaning and is not enough.

      No, it’s not. But there’s really not much else a doctor can do. It would be nice if you could access a personal trainer and dietitian (or AIDES) through your doctor and tax dollars. But you can’t. And even if you do – it will take a lifetime of vigilance and denial to maintain a healthy weight and lifestyle. Yep, it’s hard, and what works for one person might not work for the next.

    2. “The question is not whether alternative practitioners have “improved people’s overall health”.” – James

      “The mistrust of doctors in the US is because they are not really helping people improve there overall health.”

      Sure seems like it’s your question but hey you’ve kind of moved the goalposts a few times from what I can see.

      “Telling someone they need to lose weight by consuming fewer calories and emphasizing fruits and veggies, exercise more, get enough sleep, are just an empty statement that has no real meaning and is not enough.”

      Your arguments are kind of lame, and empty.

      What does “no real meaning” mean? It is the truth, if you reduce your energy intake and increase your energy consumption you will lose weight AND that is correlated with a number of health issues. Similarly “is not enough” lacks a clause to make it an useful argument. Such as telling us exactly what it is not enough to do. To motivate you? me? most people? people which a high chance of success?

      It is clearly, enough to make some people start to lose weight and gain health advantages.

      “I am saying that the approach that doctors take with patients matter.
      Also if the fundamental issue of trust is not dealt with then it will not get better for doctors.”

      Considering that doctors are, for the most part telling people the truth. I find it interesting that the implication here is telling people something less than the truth to effect a result. Personally I consider that unethical.

      1. James says:

        Jonathan

        I did not say or imply doctors should lie.
        I said approach matters.

        When I tutored math I would teach different techniques to students depending on their skill level for the same type of problem.
        The resulting answer was always the same.
        However one techniques required a different type of thinking than the other.
        Since I understand where the student was at I was able to adjust the techniques to match the student.

        The same implies with patients some patients do not have the same abilities as other.
        So arming them with techniques could increase their chances of implementing the proper changes in their lives in my mind is a good thing.

        Willpower is a limited mental resource for everyone.
        So arming people with techniques to decrease ego depletion and decision fatigue when incorporating habits is just another way to increase the chances of patients compliance.

        Here is an article showing how one such technique helped people decrease the amount of cigarettes they were smoking.

        http://www.psychologytoday.com/blog/the-science-willpower/201111/how-mindfulness-makes-the-brain-immune-temptation

        This what I mean when I say approach matters.

        1. “However one techniques required a different type of thinking than the other.”

          Fair enough. People reach understanding through different paths. I recall that pretty much everyone I knew in my class recalled the moment when they understood Bolzano’s definition of a limit.

          I agree that there may be things that are reasonable to tell patients which, may help them achieve their weight goals. However it doesn’t really support any of your original points.

          “Here is an article showing how one such technique helped people decrease the amount of cigarettes they were smoking.”

          My advice is you need to check your assumptions more. While the “wave” experiment is a little interesting. It doesn’t appear that it was very rigorous and while it may have produced useful data what’s printed in the article is just an average which is pretty close to useless. Given all those obvious (to a mathematician) flaws you don’t have even the tiniest amount of self-skepticism in your sentence.

          Not even getting to some of the pretty broad assumptions being made about “willpower”.

  12. windriven says:

    “I am saying that the approach that doctors take with patients matter.”

    Finally, a coherent statement. But do you take into consideration that physicians are a diverse group with many different personalities and approaches to patient interaction. Take some personal responsibility for your health care and find a PCP with whom you relate, one who understands your health care goals and has an approach that is not inimical to your own.

    If you were on trial for your life and you and your attorney had very different ideas about how to manage your case, what would you do? So man up. Your comment comes across – at least to me – as whining. If you need diet guidance, go to a certified dietician. If you need help with stress, go to a psychiatrist or psychologist. In short, if you can’t manage your life then hire appropriate professionals to help you. Your PCP is not your fairy godmother. She isn’t going to change your oil or mow your lawn. She is going to assess and monitor your health, keep you vaccinated, give you advice about lifestyle changes that are appropriate to your physical condition and send you to specialists when the need arises. A PCP is not a lifestyle coach.

    1. James says:

      “A PCP is not a lifestyle coach” Your are right they are not.
      However at the same time doctors are trying encourage lifestyle changes.
      So why not use the best techniques to do so if sending them to a specialist can be avoided.

      The problem I personally had is that I had to be asshole with my doctor in order to get him to do anything and I did not have a choice of my doctor at the time because of location reasons.

      However if a doctor’s personality is getting in the way of the health of their patients then they should quit or fix their personality.

      Also the evidence show that it is in the best interest be nice to their patients.

      http://www.drbriffa.com/2007/09/05/poor-bedside-manner-associated-with-increased-risk-of-complaints-against-doctors/

  13. Pure Noiz says:

    Blame the top brass and insurance companies.
    I was listening to TWiM this week and a listener brought up a valid point about scrubs being worn outside the workplace. This doesn’t happen elsewhere because those who manage the hospitals find the cost savings of eliminating laundry for scrubs and locker rooms to be real, where as the cost associated with scrubs going to and fro from hospital has not been fully investigated and therefore does not have a concrete price tag. I have fallen in love with another science podcast, TwiM!!!

    1. windriven says:

      @Pure Noiz

      And your comment is apropos of … what?

      Moreover, what does your comment have to do with its first sentence?

      I am lost as a blind dog in a meathouse.

  14. Carl says:

    Perhaps if Science built a large badger…

  15. stanmrak says:

    What’s really scary is that no one here understands why someone would abandon science-based medicine for anything else. Folks, the world is not going to end if we broaden our options.

      1. Joao says:

        No its not going to end. Its just gona have worse health.

    1. windriven says:

      Broaden away, Stan. Do it as an informed citizen. You’ve obviously followed SBM for a while so you know the arguments against woo. If you still feel that pursuing woo is a better health care option, I’d be the first to encourage you.

      What I can’t abide are wormy little bits of flotsam who wax rhapsodic about acupuncturists and homeopaths and aromatherapists until they are faced with a serious disease – then off they run to a filthy, money-grubbing, closed-minded physician to save their sorry asses. Why not let your homeopath handle your kidney transplant? Or your naturopath? They claim to have essentially the same training.

      1. Joao says:

        Part of the fraud of alt med is that they pretend to have those complete diferent explanations for diseases, but they learned (most) not to pretend to solve anything serious for themselfs. They just want to be there doing they’re stuff while someone does the really importante work, so theres nothing to lose.

        They really are putting themselfs in the position of taking credit for the scientific medicine accomplishments.

        So much for occam, so much for logic and our limited resources. So much for education, clarity…

        Man, one day I’ll jump in. Damn principles.

    2. WilliamLawrenceUtridge says:

      Folks, the world is not going to end if we broaden our options.

      If by “world” you mean “the lives of patients with cancer”, then yes it might. The brain works quite hard at maintaining a representation of the world within the patient’s skull, and that world ends when they die. Each patient that dies early of untreated cancer, or eczema, or collapsed lungs is the snuffing out of an entire world, a whole universe within a few thousand cubic centimeters.

      And then there’s the fact of the “options” we broaden ourselves to embrace are pretty much a complete waste of money and time, a net economic loss to the world, a tax on the stupid and trusting, a completely invalid opportunity cost that amounts to billions of dollars per year. I understand why patients do it – and part of it is due to the fact that CAM practitioners are too greedy, stupid or arrogant to realize or care that what they are doing is worthless.

    3. James says:

      Here is the problem with having an open mind.

      https://www.youtube.com/watch?v=T69TOuqaqXI

  16. Denise says:

    Who at these medical centers is behind the push to promote these offerings – is it doctors or is it strictly business people?

  17. Patricia says:

    WTF, U of T. I’m flabbergasted that an institution whose researchers often claim to be Canada’s best would want to dive into rubbish this way. Even if purely mercenary, where are they planning to get research grants from? Not CIHR, surely, either for the “complementary” researchers or anyone admitting to collaborating with them on anything not evidence-based. And U of T’s prestige rests heavily on research $. Even if there are some alt-med foundations with big bucks, I can’t see the evidence-based medical researchers wanting to “integrate”.

  18. Birdy says:

    I’m tempted to let out a rather theatrical sigh about U of T. I’m applying to their faculty of medicine next year (as well as Queen’s, McMaster, and Ottawa) and was hoping to avoid this nonsense in my medical education, if I manage to get in, but that is looking like it may be a fading dream.

    For what it is worth, a lot of Canadian med students and premeds give no quarter to quackery, at least the ones I talk to, but clearly it’s starting to make inroads nonetheless. My university has an ‘integrative nursing’ class which set me to eye rolling when I saw it on this year’s timetables. Because wasting the time of already overburdened nursing students somehow makes sense to these sorts.

    This is disappointing news, but I can at least hope that the students I talk to will maintain their desire to see science and reason continue to be at the forefront of medicine, as they should be.

  19. (omg Timmy Ho’s shout-out, eh?)

  20. Hadfield says:

    Whoever takes the post will certainly not be able to lambast ‘big pharma’, not with Leslie Dan’s name on the building!

  21. daveruddell says:

    Dammit, U of T is my alma mater.

    Dammit

    1. stuastro says:

      Oops I posted to Harriet instead of posting a reply to “forabetterworld”.
      So here is my reply:

      It’s called “alternative medicine” because it doesn’t work. If it is found to actually be safe and effective it is then taken on by real doctors and is called “Medicine”

  22. Forabetterworld says:

    Poor ol wind driven, so sorry someone disagreed with your point of view. Your seething anger is visible.
    I think that integrative medicine is a wonderful opportunity to get the best out of these therapies and methods, some of which have been around for thousands of years.
    Maybe we will learn new ways to make this world a better place. In a university, the will be the opportunity to do the research required to understand how they work.
    The reason people are flocking to alternate therapists is that they are not getting results in from western medicine.
    The story of Dr Charles Krebs is one that is well worth reading. He is now doing search into Kinesiology after a near death diving accident. The only prognosis from western medicine was that he would be permanently wheelchair bound.
    Thanks James you made some very valuable comments.

    1. Harriet Hall says:

      It is commonly asserted that “The reason people are flocking to alternate therapists is that they are not getting results in from western medicine.”
      But the evidence doesn’t support that.
      This study found that dissatisfaction with conventional medicine did not predict use of alternative medicine: http://www.ncbi.nlm.nih.gov/pubmed/9605899
      In another study, people who turned to alternative medicine did so for the following reasons: 54% thought it would be interesting to try, 13% had it suggested to them by a conventional medical professional, 20% did it to save money, and 21.6% thought conventional medical treatments wouldn’t help. http://www.biomedcentral.com/1472-6963/10/220/

    2. stuastro says:

      It’s called “alternative medicine” because it doesn’t work. If it is found to actually be safe and effective it is then taken on by real doctors and is called “Medicine”

    3. WilliamLawrenceUtridge says:

      Windriven is doubtless frustrated at the naked, loudly proclaiming the warmth, comfort, waterproofing and attractive patterns of their woven garments, only seen by the profoundly wise. I know if I were someone who spent years learning all I could about the body, from molecules to gross anatomy, and I had to listen to some moron wax eloquent about the healing powers of crystals and lavender essential oils, I’d be short too. CAM proponents love to talk about how arrogant skeptics and doctors are, just because they spent 10 years of their life studying the body and how its functioning goes awry.

      Bloodletting and prayer to Thoth have been around for thousands of years, should we integrate them as well? The issue I have is, if these “thousand year old remedies” are so effin’ effective, why do they keep failing testing, again and again? It’s almost as if they were thought up by people who had no access to a microscope, and weren’t even aware of bacteria or viruses!

      In a university, the will be the opportunity to do the research required to understand if they work.

      I’ve fixed that sentence for you. Science attempts to falsify, pseudoscience tests to confirm. Also, do you know who Edzard Ernst is? Because you pretty much described his job for the past couple decades. Do you know what kind of results he got?

    4. windriven says:

      “Poor ol wind driven, so sorry someone disagreed with your point of view. ”

      I love it when someone with a powerful argument disagrees with me. This forum has helped me refine my thinking on a number of issues and has led to massive shifts in my point of view on a few. Nothing pleases me more than an articulate argument for a point of view different than my own.

      On the other hand nothing pisses me off more than half-baked, poorly considered, whiny wheedling drivel.

      Integrative medicine is a stinking pile of weasel shit masquerading as the belle of the ball. The fact that you admire her dress marks you as a credulous dufus in the most generous characterization.

      Homeopathy is plain stupid. It has zero basis in reality, zero plausibility and zero chance of improving the lot of humanity one iota. The same for subluxations, qi, and the belief that praying to Our Lady of the Suppurating Stigmata is going to cure your cancerous liver.

      Wallow in the reeking dung heap, Forabetterworld. And while you’re picking bits of in undigested corn and straw from behind your ears ask yourself exactly what benefit any of your integrative nonsense has brought to humanity while medicine has brought antibiotics, surgical procedures that save thousands of lives every year, therapies that save 600 gram babies, radiological scans that disclose minute carcinomas and technologies that bring the beauty of procreation to countless struggling couples.

      What benefit? Integrative medicine is a collection of poseurs, wannabes and delusionals who are unwilling or unable to do the hard work of science. They are a blight on humanity, draining desperately needed resources away from true professionals and spreading fantasy and illusion to the gullible. Eff them in the eye with a fork.

  23. weing says:

    I suspect that the reason people turn to alternative medicine is because of magical thinking and they are looking for a shamanistic ritual to make them better. I guess you could call it an atavistic behavior. The only evidence I have for that is the presence of witch doctors in various cultures.

    1. James says:

      Some other reasons

      * My friends are doing it.
      * Being treated badly by some doctors.
      * Seeing someone they know being hurt or kill by traditional doctors
      * Cultural (Grandma’s homemade remedy or Grandpa’s windex)
      * Cost
      * The snowflake effect (Same reason people play the lotto)
      * They read it online or saw it on TV.
      * They know someone who was cured by using it.
      * They know someone who knows someone who knows someone who was cured by using it.
      * Values systems

  24. windriven says:

    There is a wonderful opinion piece in today’s Washington Post

    http://www.washingtonpost.com/opinions/obama-should-take-lessons-from-sweden-to-g-20/2013/08/29/2a48a5fa-10c0-11e3-bdf6-e4fc677d94a1_story.html

    examining Sweden’s approach to economics and the reforms that brought it out of an economic tailspin in the 80s.

    This is appropriate to this conversation in two ways. First, Sweden remains a single payer health care provider – though unlike many of its European neighbors it has privatized the delivery of many healthcare services.

    Second, a couple of years ago a woo-happy Swedish doctor was put on probation by Sweden’s Medical Responsibility Board for prescribing a homeopathic remedy to a patient. The doctor went to court and won paving the way for other Swedish doctors to prescribe nonsense while staying within the bounds of acceptable practice. The good news is that the Swedish Medical Association (perhaps thinking but not saying as Dr. Gorski did that the law is an ass), stands by its position that homeopathic remedies have not been scientifically proven effective.

    http://www.thelocal.se/36332/20110924/

    Less good news is that a Swedish Medical Association spokesperson weaseled around the issue saying in effect that doctors had to stay with evidence based medicine but they could go along with a patient who wanted to try a homeopathic remedy so long as they disclosed to the patient that there was no scientific evidence for its efficacy.

  25. Garett says:

    At its heart, science is about understanding. Many integrative practitioners seek to actually understand the systemic problems that are causing symptoms rather than simply treating the symptoms and sending patients on their way. For a researchers perspective, I find the idea of treating symptoms without understanding their root cause as entirely unscientific. I like Chris Kresser’s argument that if your ‘check engine’ light comes on, you try to figure out why that happened rather than putting a piece of tape over it. The same goes for medicine. Too many practitioners are content with just ‘putting tape over it’ and sending patients on their without taking care to understand the root causes of the symptoms, which may actually cross systems that may be beyond their expertise.

    My understanding is that “integrative” refers more to theoretical perspectives on medicine. If you conceptualize health along a continuum ranging from disease to health, western medicine focuses on the disease end. That is, they try to remove disease and move people towards the neutral portion of the spectrum. They are not diseased but they may still be far from health. Integrative practitioners are interested in moving patients further along towards the actual health end of the continuum. Thus, each has their own distinct theory about what health means. That’s not to say that either cannot be scientific or evidence based – they are simply trying to provide evidence for their particularly theory. I will concede that many TCM ideas are too vague to be falsifiable and thus cannot be scientific, but plenty of others make precise predictions that can be evaluated empirically. I point again to Chris Kresser, an integrative practitioner. His grasp of the medical literature is truly amazing and he has synthesized that literature into an integrative theory for health and that’s how he treats patients. He does not treat patients with anything that he does not have direct scientific support. When you argue that integrative medicine cannot be scientific, you seem to argue that integrative medicine cannot provide evidence for your theory of health, which may be true. However, this is like saying an astrophysicist cannot provide evidence for the validity of quantum theory. Both are scientists in their own right and both study physics, but each approaches questions for their own theoretical perspective and each provides evidence for their theories.

    This probably isn’t the most cogent argument, but I think it is important to consider that evidence isn’t valid in and of itself – evidence is valid only to the extent that it supports inferences based on your theory. In this respect, what’s considered valid evidence depends on the question at hand. Integrative medicine seeks evidence for a systemic view of health and Western medicine seeks evidence for the treatment of symptoms. Both may have evidence that supports their theories of health but that does not invalidate either theory. I agree that such evidence much be based on specific, testable hypotheses, but this does not necessarily preclude all of integrative medicine – only the extremely vague that will always be correct (e.g., adrenal fatigue, TCM).

    My two cents.

    1. weing says:

      @Garret,
      Watch out for flames. You put up so many straw men, that you may catch fire. If your MD doesn’t figure out or at leat try to figure out the cause of your symptoms, look for another one.

      1. Garett says:

        @weing. I certainly am not trying to put up straw men so I apologize if that seems like the case (clever phrase though).

        First, I don’t doubt that many MDs went into medicine because they were interested in solving problems and helping people figure out the root of their problems. However, if you look at the real world where the incentives lie (I’m a psychologist-in-training who studies motivation so this is where I look) MDs are not particularly rewarded by the quality of their care (i.e., finding the cause). Instead, they are incentivized by quantity (i.e,. number of patients seen). Based on that, I think it’s reasonable to say that MDs will not act a manner consistent with finding the cause. For a classic piece on this in management, http://tamuweb.tamu.edu/faculty/bergman/kerr1975.pdf. There is a significant amount of empirical evidence to show that people will act in a manner consistent with what is rewarded (e.g., the entire field of behavioral economics including Daniel Kahneman’s Nobel Prize winning work).

        Second, I look to medical education. I see diagnosing as a extremely complex problem solving scenario. However, I don’t feel that medical schools have quite figured out how to train such problem solving. An interesting trend, anecdotal albeit, is that many schools of medicine are hiring industrial/organizational psychologists (http://en.wikipedia.org/wiki/Industrial_and_organizational_psychology) to work in Medical Education departments (I am an I/O in training). We have expertise in figuring out exactly what is required to successfully perform a job and to design training programs that ensure overlap between the training and work demands (think airplane cockpit crews – we do a lot of that type work as a field). For this type of problem solving, I see a key process as being “open minded” and the ability to integrate information across sources. For this reason, I think some integrative practitioners may actually do better at diagnosing (again, anecdotal) because their training actually encourages broad information processing (perhaps too broad at times). For an interesting examining, see the late Alice Isen’s work. She shows that physicians are better problem solvers when they experience positive affect because they are more likely to integrate information and less likely to anchor on an initial diagnoses. In other words, they are more willing to be wrong. In my experience, integrative practitioners are more willing to be wrong and thus they may process information more integratively. This is simply a theory and I have not done an adequate literature review to see what the research says, but this would be my hunch (maybe a nice fall project :)

        Isen’s work:
        http://www.sciencedirect.com/science/article/pii/S0749597897927345
        http://link.springer.com/article/10.1007/BF02856470

        In closing, I don’t necessarily see this as a question of which theory is better, but which skills are more effective at accurate diagnoses (but that’s the I/O psychologist speaking). At this point in time, I do not think that conventional MDs have the upper hand if for no other reason that they have may more situational constraints.

        I appreciate any and all thoughts though. This should be an open dialog – that’s how knowledge is advanced!

        1. James says:

          This a great post.
          However my concern with any systemized approach is making sure the feedback loop is properly designed to allow enough wiggle room to deal with change and enough structure to support that change.

    2. Harriet Hall says:

      “Many integrative practitioners seek to actually understand the systemic problems that are causing symptoms rather than simply treating the symptoms and sending patients on their way. For a researchers perspective, I find the idea of treating symptoms without understanding their root cause as entirely unscientific.”

      You’ve got this entirely wrong. Conventional medicine strives mightily to understand the underlying problems. Alternative medicine strives to attribute symptoms to underlying problems that don’t exist, like subluxations and disturbances in Qi.

      1. Garett says:

        I beg to differ. I really think you should look Chris Kresser. He’s an integrative practitioner and he certainly does attribute symptoms to fake problems. I don’t buy into the subluxations and disturbances, nor does Chris, but he does by into a systemic view for health problems.

        I would agree with your comment given one small change. “Conventional [medical research] strives mightily…..” I don’t think the same can be said for conventional medical practice. There is a tremendous science/practice gap in medicine (as in many fields) and many MDs are desperately out of date with their information. I can’t tell you how many times I’ve received information from an MD just to spend 5 minutes on PubMed and find out that their perspective is critically outdated.

        1. Harriet Hall says:

          I looked at Chris Kresser’s website. I was not impressed. He accepts a lot of things that are supported by “some” evidence but that don’t stand up to the kind of rigorous scientific standards of evidence we advocate here on SBM. He advocates questionable things like raw milk and home births, and cherry-picks the evidence to suit his preconceived beliefs. He also sells over-priced vitamins and supplements. He recommends 16 supplements for his “high cholesterol action plan,” everything from vitamin D to whey. He talks about “detox” and “superfoods.” He has no evidence that taking his 16 supplements results in better (or even equivalent) outcomes than conventional treatment of high cholesterol, which has been proven to reduce the risk of heart attacks and deaths. If he is a good example of “evidence-based” integrative medicine, it doesn’t say much for the concept.

          1. Garett says:

            And may I inquire what precisely are your “rigorous scientific standards of evidence” at SBM? On more than one occasion, Chris cites meta-analyses of randomized controlled trials as evidence for his stance. Is that not a “rigorous scientific standard?” I’m clearly no expert on the literature, but his account of cholesterol particle size and count being more important than total cholesterol seems to align with what I’ve seen and the approach advocated by Berkley Heart Labs (http://www.bhlinc.com/). Yet, all I’ve ever seen MDs talk about (both with myself and many friends and family) is total cholesterol count. How rigorous and up-to-date is that?

            Also, what evidence do you have that he cherry-picks data? That’s a pretty significant claim and as Carl Sagan popularized, “Extraordinary claims require extraordinary evidence.” I don’t see what he would have to gain by cherry-picking data. Sure he sells supplements but I doubt that’s where he makes his money. He actually closed his practice to new patients to ensure that he could give enough time to review research and ensure his recommendations are grounded in research. I don’t many practitioners who do that.

            Again, I’m no expert on the literature, but doesn’t the argument that “conventional treatment of high cholesterol, which has been proven to reduce the risk of heart attacks and deaths” require a qualification? Isn’t it the case that conventional treatments (e.g., statins) do work *in individuals who already have heart disease*? That is, statins don’t help prevent heart attacks in otherwise healthy individuals with high cholesterol (i.e., individuals who don’t have heart disease)? You’ll note that Chris’s recommendations are focused on individuals who do not currently have heart disease.

            1. Harriet Hall says:

              Statins have been proven to work for primary prevention as well as secondary prevention. See: http://www.ncbi.nlm.nih.gov/pubmed/23447425
              That’s only one example of a consistent pattern of omitting evidence that contradict his beliefs.

            2. Harriet Hall says:

              Cholesterol particle size and count are not more important than total cholesterol and HDL. See http://circ.ahajournals.org/content/125/20/2412.full

          2. Garett says:

            I was not allowed to reply to your comment below so I will do so here. Thanks for the paper and I stand corrected on point. It seems like an interesting paper and I am excited to take a look. That paper certainly is newer and has a very large N. However, I might counter with these two papers, which although older, provide contradictory evidence to the one you cite. Furthermore, this journal appears to have a much higher impact factor (~9) than the journal you cited (~3) so one might question the relative quality of your cited paper (although I haven’t read it so I can’t be sure – I take some liberties in leaving that to reviewers of a top-tier journal).

            http://archinte.jamanetwork.com/article.aspx?articleid=411344
            http://archinte.jamanetwork.com/article.aspx?articleid=416105

            I don’t mean to be brash, but I really must insist on a better example of Chris cherry-picking data. If the data he cherry-picks is from a top-tier medical journal, I’m not sure I would agree with that your definition of that term. After all, we have to set some quality limitations on evidence lest we quickly succumb to information overload.

            I am afraid I really must insist that, as an evidence-based website, you provide some more concrete evidence for your claim that Chris cherry-picks data.

            Without such evidence, I’m disinclined to believe your claim that, “That’s only one example of a consistent pattern of omitting evidence that contradict his beliefs.” After all, we are evidence-based so I cannot just take you are your word, can I? :)

          3. Woo Fighter says:

            Doesn’t the fact that Kresser is an acupuncturist negate any claims to him being “science-based”?

            Acupuncture is not held in very high regard here.

            See the other current thread here on SBM “Acupuncture Doesn’t Work.”

            And, he endorses the GAPS diet. Strike two.

          4. Garett says:

            @Woo Fighter, not necessarily. I’m not a believer that one’s credentials are enough to determine your ability to master a literature. In fact, I think it’s a fallacy. It sure might make things easier, but many fields see cross-discipline work that allows them to master a new literature. One of the top neuroscientists studying emotions was actually trained as a clinical psychologist. Similarly, many researchers are crossing medical domains to become experts in multiple disciplines (e.g,. neuroendocrinology). Thus, although he was trained as acupuncturist/integrative physician I don’t think that is enough to pass judgement on his ability to digest scientific material.

          5. weing says:

            @Garret,
            I really haven’t found LDL particle number or size give me more information than just the usual lipid profile with calculation of the non-HDL cholesterol. I think those are fine tests and should be used in research. But for everyday use, the current profile is fine for the average person. I’m sure Berkley labs loves him.

          6. Garett says:

            Thank you @weing for a though provoking point. I find your point interesting. I guess the question isn’t really LDL particle tells anything more in a purist sense but more so about the inference doctors would make. That is, would an MD make a different decision about treatment (e.g., medication, lifestyle changes) based on the results of the two different tests. Your arguing that no it doesn’t for your practice. Perhaps that is the more interesting question for a study here. Would physicians make different diagnoses/treatment based on regular lipid profile versus particle count, and if so, would those decisions be more or less accurate? That sounds like an interesting study to me :)

            I do see an interesting parallel between your point and another topic discussed on SBM – “adrenal fatigue” (note I acknowledge that’s not real). It seems that many researchers spanning multiple fields do use diurnal cortisol tests to study their questions of interests. From a practical point, however, they are worthless for diagnosing actual problems with the adrenals so it doesn’t make sense to use them in practice since they wouldn’t give you any information that would change the inferences you draw about your patients.

            Thanks again for comment. It actually did flash on some “light bulbs” and gave me a new perspective. That’s why I love intelligent conversations with well-informed people! I am wholeheartedly ready to change my opinions if I am presented with convincing evidence and/or viewpoints and I think you’ve provided that precisely, so thank you again!

  26. Forabetterworld says:

    It will be good to do the research and discover whether any of these therapies work. By placing them in a university environment we will be able to do this research. Science is a voyage of discovery, there is so much that we still do not know. Just because we don’t understand how it works does not mean that it doesn’t work.
    This could be the cutting edge of new research.

    1. Lynn says:

      “It will be good to do the research and discover whether any of these therapies work. ”

      Clearly you have missed all the existing research that says these therapies do not work. Why should we fund even more?

      1. Forabetterworld says:

        Are you sure they have researched all of them? Can you detail some results please ( links). One of the obstacles to researching them is that they cannot be patented. Has accupuncture been totally disproven? Are herbs just a placebo? Can food be your medicine?

        1. James says:

          * Researching all of them will never be done since there are new ones being created all the time.
          Also some may never be researched since no one will touch it or fund it.

          * Can food be your medicine yes it depends on what you have.

          * Has acupuncture has been proven but the only contributing factor was how caring and charismatic the practitioner.

          * Which herbs are you talking about and for what condition?

          1. Forabetterworld says:

            This is trial run by the World Health Organisation.
            http://apps.who.int/medicinedocs/pdf/s4926e/s4926e.pdf

        2. Chris says:

          Herbs are not really a placebo because they actually contain measurable amounts of chemicals. Whether or not they do has advertized is a completely different question.

          There is an type of pharmacology that looks into the medicinal uses of herbs, plants, etc. Many time a folk use of herbs is used as a starting point to find a component that becomes a pharmaceutical (aspirin, digitalis). Though often a plant is tested to see if it has a biological effect (taxol).

          And yes, they can be patented.

      2. windriven says:

        Just so Lynn. NCCAM has spent well north of $1 BILLION investigating nonsense and has validated none of it. In a world of unlimited funds I would say sure, investigate the utility of tincture of cowshit in the treatment of genital warts. But in a world of shrinking research funds, let’s invest in avenues with prior plausibility.

  27. Garett says:

    Whoa. Did my comment get deleted? Last I checked censorship wasn’t really in the MO of science. If there is no dissenting opinion, there cannot, by definition, be scientific advancement.

    1. Scott Gavura says:

      No. For some reason all comments seem to require approval, and we’re moderating as fast as we can.

      1. Garett says:

        Oops. Sorry about that. I didn’t realize how it all works. Thanks for approving my comment though!

  28. weing says:

    “* Less than half of doctors provide specific guidance on diet, physical activity, or weight control
    http://www.ncbi.nlm.nih.gov/pubmed/21665061

    I can give you my take on that. I quickly learned, when I first started practice, that if I put obesity as the diagnosis for the visit the claim would be denied. That means the insurance wouldn’t pay for the visit. Try getting patients to pay out of pocket. Once burned, twice shy. So any guidance provided to the patient was incidental to dealing with other issues or as part of a physical exam. It was only this past June that the AMA declared obesity a disease. Hopefully, that move will change things.

    1. James says:

      Thank you for that insight I understand there are very real constraints on doctors and patients wallet.
      Since I was never overweight I never realized that obesity was never consider a disease until recently.

      Thank you for giving me something to think about

      James

      1. Joao says:

        James:

        So it seams obesity should be more adressed for in private consultations, I change my mind for evidence. But it starts by being a public health issue.

        So I cannot avoid to think this – and dont be upset, please, not meant to be personal.

        Obesity is something people should not need a doctor to know that they are on the unhealthy side of the scale. I suspect that many doctors may not touch that subject because it is many times obvious. These doctores may assume that it can go unstated, and that if the obese person dont bring it up, maybe its better not to mention it.

        Information about that is everywhere, and of course, I can know that in the US too.

        Theres not controversy about that issue, not enough to justify confusion on peoples minds for not knowing what to believe. The issue is also very frequently presented in media by doctors, nutricionists, etc.

  29. Joao says:

    Even if Science Based Medicine is practiced by human beings, with all its flaws, it does not mean any other thing proposed is true. Or better.

    I find that pointing errors in true medicine is not relevant for this post. It just does not make the Alt medicine true. Its a falacy.

    Its better to make some mistakes doing the right thing that being perfect at doing the wrong one.

    Go figure! But that’s what we can find evidence for.

  30. Aardwark_bgd says:

    Even though this thread appears to be almost exhausted, and all that needs to be said appears to have been said, I do feel the need that we all remind ourselves of another point regarding the concept of “evidence basis”.

    Namely, evidence basis is not a simple, dichotomy-friendly issue – there are different kinds of evidence and their relative importance varies in a context-dependent manner. For instance, proving that drug X causes some desirable change in some health-related parameter Y in a population of patients with condition Z defined by definition D under conditions P,Q,R is evidently important in order to approve X for use. However, this type of evidence basis is not the most important one for the discussion of SBM vs. CAM.

    Infinitely more important is the evidence basis for the advocated understanding of the underlying PROCESS (in my opinion, the key word in this, and most other, matters). In other words, the reason why I strongly reject CAM (with an open mind toward some possible exceptions and an awareness that some of it is actually ‘re-branded’ SBM) is not merely the lack of ‘X causes Y to change’ types of proof. After all, Ys change all the time, and if we accept the zero-hypothesis significance level of 0.05 (not all MDs are poor at statistics, though I have also encountered many that clearly are), we will, purely by chance, have the desired change in Y in approximately every 20th trial we make. Excellent for headlines.

    No, the former type of evidence is important for solving technical issues, but for accepting or rejecting CAM modalities, I think, one needs to prove that the underlying theory of the (physical) process involved is correct. Or, more simply, do not talk to me of what this or that TCM pill or ‘supplement’ or ‘relaxation method’ does. Prove me, instead, that there are really such things as Yin and Yang and demonstrate beyond reasonable doubt that they are involved in the process that makes me ill. This is, as far as I am concerned, the only way.

    And this is NOT a purely philosophical issue with ‘every opinion equal’ sort of view even remotely justified. Either there is a Santa Clause or there is none. After you have mapped all of the Arctic Circle and put it in Google Earth – and found no sign of Santa – then his (or, indeed, her, for why should we automatically assume a contemplated entity to be male?) non-existence is a fact and the opinion that (s)he does exist is factually incorrect.

    So – back to the point – what we are really dealing with are attempts to integrate factually incorrect claims into accepted practice. This is not surprising, and there are reasons people wish this, but we should resist the allure not just because of potential health harms, but because – as Socrates had put it two and a half millenia ago – Life with misconceptions about Life is hardly livable to a thoughtful person.

    So – process, process, process. It is all about understanding the process. (Not just because I happen to be inspired by works of Franz Kafka).

    1. I tend to phrase this as a conditional probability. Every (statistically independent) test increases (or decreases) the likelihood of X causing Y.

      Which is the reason that even if someone showed me a large N, well-blinded study for a homeopathic treatment for cancer it wouldn’t equally answer the question: “Does therapy X produce outcome Y” as an IDENTICALLY POWERED study for a known treatment.

      The prior probability for homeopathy is virtually zero. Whereas the prior probability for an existing treatment is along the lines of P(animal studies|in vitro studies|chemical properties).

  31. windriven says:

    You have touched on an important difference between EBM and SBM.

  32. embeetee says:

    Thank you for this *excellent* post. I’ve sent a message to the Dean of Medicine at U of T on this topic. It’s a shameful step on the university’s part.

  33. Jo says:

    Firstly:
    Oregano oil
    Antibacterial effect of oregano essential oil alone and in combination with antibiotics against extended-spectrum β-lactamase-producing Escherichia coli. FEMS Immunology & Medical Microbiology. Volume 53, Issue 2, pages 190–194, July 2008

    thyme / clove oil
    The antimicrobial activity of thyme essential oil against multidrug resistant clinical bacterial strains. Microb Drug Resist. 2012 Apr;18(2):137-48. doi: 10.1089/mdr.2011.0080. Epub 2011 Nov 21.

    Antibacterial Effect of Cinnamon Oil Combined with Thyme or Clove Oil. Agricultural Sciences in China Volume 10, Issue 9, September 2011, Pages 1482–1487

    Educate yourself people before swallowing what someone else tells you, when its what you want to hear so you can ridicule something. Please go to http://www.scirus.com and look at *science* papers on the subject. Any subject – see what testing and results for *alternative* medicines have actually been done.

    Often the reason you cite for these things being delusional is the lack of evidence. Unfortunately that is because there is often a lack of testing (on humans – there is plenty of testing on food and in the petri-dish). Im all for the testing of them – because a lot of them work. Pharmaceuticals don’t want cheap easy remedies for people (thats not paranoid, thats fact – i used to work for one). That’s why they only test them in food safety type papers – or papers where the application is commercial to make money. Not to be helpful. There are *hundreds* of papers on the effectiveness of oregano oil as a powerful antimicrobial and antifungal. Anyone who cares – go to http://www.scirus.com and type it in. You can check results for yourself.

    If you don’t believe in these things – a good way to do it is *try it yourself* . Go infect yourself with ring worm or athletes foot – then test the oils. You know you can get rid of it conventionally if they dont work.

    Women out there – if you have terribbly heavy periods and pain (or polycystic ovaries) try boiling 1 table of coriander seeds in a cup of water boiled down to 1/2 a cup, strain and drink – do it 3 times a day on your period and the bleeding and pain *will* be substantially less. (my period went from 7 days down to 4 days, with no flooding events anymore and collapsing on the floor with pain).

    1. WilliamLawrenceUtridge says:

      Hey Jo,

      That oregano oil, were the tests done in petri dishes? Because it’s easy to kill cells in a petri dish. How does it work in humans? Do the oils survive passage through the highly acidic digestive tract? How about the first pass effect of the liver? Are they toxic to liver cells as well? How about kidneys? Do they pass through the blood-brain barrier? If so, what are their effects on the brain and spinal cord? Do they induce autoimmunity?

      If all it took to cure cancer was to kill cancer in glass dishes, nobody would die of cancer. The same principle applies to E. coli.

      Did you notice your paper on thyme oil has an abstract that ends with “The use of phytopharmaceuticals based on an investigated essential oil from thyme in the prevention and treatment of various human infections may be reasonable”? If all it took was glass dish studies to prove a drug worked, Big Pharma would have millions of compounds on the market. How would you feel about Pfizer saying “we just killed a fuckton of cancer cells in glass dishes with our new drug, so we’re going to start selling it in pharmacies next week.” Would you object to such an approach? I would. But then again, I think it’s a good thing if we have reasonable evidence to suggest drugs are not lethal, but somewhat effective. It’s great that you think you can stop at the bench test stage, but the FDA has a slightly different opinion.

      Do you know what made it past the bench test stage before being used in humans? Thalidomide. Perfectly safe in rats, turns out slightly less good for humans.

  34. Jo says:

    didnt have room on the previous post but for the coriander, buthere are some links:

    Effect of Coriander (Coriandrum sativum L.) Seed Ethanol Extract in Experimental Diabetes
    http://www.sciencedirect.com/science/article/pii/B9780123756886100477

    Review of Pharmacological Properties and Chemical Constituents of Pimpinella anisum
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3405664/

    Not exactly sure how it works on the stemming of blood flow, a couple of my own ideas are possibly its effect on blood sugar levels/insulin. High blood sugar levels result in more testosterone being produced. Also it has a high magnesium, manganese and copper content – a deficiency in manganese is associated with problems with menstruation and excessive bleeding. look it up if you dont believe me :)

  35. Your criticism is pretty random. What thesis are you attacking? That some oils in some concentration have anitmicrobial action? What does that have to do with integrated medicine?

    “Antibacterial effect of oregano essential oil alone and in combination with antibiotics against extended-spectrum β-lactamase-producing Escherichia coli”

    All three oil studies are petri-dish science. Probably the second weakest form of evidence. Also the place where you will likely see the greatest effect.

    “see what testing and results for *alternative* medicines have actually been done.”

    None of these are tests on alternative medicine. You could perform the same experiments with 85% ethyl alcohol and get similar results. In fact if you had done what you claim with oregano oil you would see that much of the research isn’t about anti-microbial action in humans but on surfaces and in foods.

    “If you don’t believe in these things – a good way to do it is *try it yourself* . Go infect yourself with ring worm or athletes foot – then test the oils. You know you can get rid of it conventionally if they dont work.”

    Actually that’s not a good way, it’s kind of a dumb way. Athlete’s foot self-resolves in 30-40% of the cases. So a sample of one isn’t going to provide any information. Heck you could treat yourself successfully three times and you would still have (at worst) a 1 in 20 chance of the result having nothing whatsoever to do with the oil.

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