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Update on CPSOs Draft Policy

Four months ago David Gorski wrote about the  College of Physicians and Surgeons of Ontario’s (CPSO) draft policy on “non-allopathic” medicine. He pointed out:

It’s obvious from the wishy-washy approach to the scientific basis of medicine, the waffle words when it comes to whether an “allopathic” physician should support “non-allopathic” therapies, and the apparently inadvertent use of language favored by quacks that there were far too many “alternative” practitioners involved in drafting this policy.

I agree.  The proposed policy addresses the issue of so-called complementary and alternative medicine (CAM) and has drawn serious criticism from Canadian physicians (at least those who are paying attention and have the slightest clue about what is going on). The backlash is good to see, but it is not nearly vigorous enough.

There is now an update to this story as the CPSO has published a revised policy proposal. There are some improvements, based on the criticism, but still there are problems with the policy.

The original proposed policy contained several recommendations that are right in line with CAM proponents – who keep trying to achieve through legislation and intimidation what they cannot achieve through science and evidence, namely acceptance and access. The proposed policy is a good example of this, as well as demonstrating how CAM proponents wish to carve out a double standard for themselves, so that they can be free to practice whatever nonsense they wish without being held to all that pesky science and evidence.

The very category of CAM is a contrived marketing strategy, not a genuine discipline. The truth is that there is science-based medicine and there is everything else. All therapies and modalities lie someone along the spectrum of safety and efficacy, and are backed by various amounts of evidence, and may even have evidence for lack of efficacy.

That is all that matters – but when one common sense and science-based standard is applied, almost all of CAM collapses and crumbles to dust. That’s why it’s CAM – if it worked it would just be medicine. So CAM proponents have desperately tried to make the debate about anything else: healthcare freedom, conspiracies, Big Pharma, protectionism or elitism, they cry that they are being treated unfairly, or that science doesn’t work – that they need a new kind of science. It’s all an elaborate game of, “ignore that man behind the curtain.” It has been distressingly effective, as the CPSO proposal indicates.

The parts of the proposed policy that have caused the most concern are those that encourage physicians to work with “alternative” practitioners, granting CAM practitioners a status they have not earned and do not deserve. The Canadian Medical Association has responded, criticizing this aspect of the proposed policy. They state:

“It is a matter of concern for us, that CPSO’s draft policy appears to require of physicians a high level of knowledge regarding [alternative medicine], and a high level of acceptance for its routine incorporation into practice,” the CMA said.

I don’t think it’s a bad thing for physicians to have greater knowledge of CAM, the better to inform their patients about it properly. But physicians should not be encouraged to incorporate unscientific practices, or refer to those who do. This is definitely a step toward requiring physicians to practice CAM or refer to those who do, as I wrote about recently.

Perhaps the most disturbing part of the original proposed policy is this statement:

The College expects physicians to respect patients’ treatment goals and decisions, even those which physicians deem to be unfounded or unwise. In doing so, physicians should state their best professional opinion about the goal or decision, but must refrain from expressing non-clinical judgements.

This is a thinly-veiled attempt to silence criticism – to silence any doctor who has the sense to understand that it is their duty to protect their patience from unsafe or ineffective treatments. CAM proponents are as clever as creationists in couching their true goals in language that seems inoffensive, but the goal is obvious to anyone who has been paying attention.

Then there is this:

In its original form, it said doctors should respect patients’ wishes to try non-conventional care and require “sound evidence,” but not necessarily clinical trials, to back up any alternative treatments they use.

Here we have the double-standard. They want different standards of evidence for CAM than for conventional medicine – a lower standard, one that allows treatments that are unscientific and not backed by sufficient evidence to be accepted by science-based practitioners.

The revised draft policy has some positive changes:

The new iteration of the Ontario draft suggests everything a doctor does should be informed by “evidence and science.” It removes a suggestion the type of evidence required to justify a therapy depends on the nature of the treatment. It also removes a statement that seemed to allow doctors to employ therapies whose effectiveness and safety are unknown, so long as they act “in a cautious and ethical manner.”

The original proposed policy makes the agenda of CAM proponents clear. They want to create a double standard, with a lower bar of evidence for their preferred practices. They want to silence critics. They want doctors who may be skeptical of CAM practices to just shut up and refer their patients to CAM practitioners. They want to pressure physicians with accusations that they are being unfair, when in fact it is the CAM proponents who are being unfair.

At the end of his original report on this issue David offered his recommended policy with regard to CAM. Here it is, with my tweaks:

  • Medicine should be science- and evidence-based. “Alternative” vs “evidence-based,” “allopathic” vs “non-allopathic,” “conventional” vs “unconventional, ” “Western” vs “Eastern” are all false dichotomies and should not be recognized as legitimate categories. All healthcare interventions should be evaluated, regulated, and practiced according to one science-based and ethics-based standard of care.
  • Competent adults have every right to seek out non-science-based medicine if that is what they desire. However, informed consent mandates that physicians who encounter such patients provide an honest professional assessment of such treatments based on science. Physicians should sufficiently familiarize themselves with unscientific yet popular healthcare products and practices so that they can properly inform their patients.
  • Physicians should always inquire about the use of non-science-based medicine when evaluating their patients, so that they can take into account possible interactions with medical treatments.
  • Physicians are in no way obligated to refer patients to “alternative medical” practitioners or to recommend non science-based options. For many forms of “alternative medicine” doing so is unethical because such modalities are not science- or evidence-based.
  • Physicians, individually and as a profession, should actively advocate for and promote the science-based standard in medicine – in academia, regulation, and practice.

Posted in: Politics and Regulation, Public Health

Leave a Comment (32) ↓

32 thoughts on “Update on CPSOs Draft Policy

  1. Janet Camp says:

    In addition to the recognition that they crave, the CAM people, if successful, would be eligible for reimbursement, which would seem to be a primary motivation. After all, we let chiropractic get away with it–why not acupuncture? Reiki anyone? Urine therapy? Where WOULD it end?

  2. cervantes says:

    It removes a suggestion the type of evidence required to justify a therapy depends on the nature of the treatment.

    Alas, that suggestion is true. Think about it — do we require the same standard of evidence for, say, clamping a spurting artery that we do for a new medication? The BMJ famously ran an April Fool story about an RCT of parachutes for prevention of death in falls from airplanes. Some kinds of interventions are essentially impossible to blind; the strength of experimental evidence we require to feel that a treatment is credible depends on the prior biological plausibility; some interventions may have relatively weak evidence of efficacy, but also have a very low probability of adverse effect so we may go ahead and try them, whereas others appear more risky so we would require much stronger evidence of efficacy. And of course, some efficacious treatments may have limited effectiveness because they are just hard for people to undertake, but effective implementation is a problem we don’t know nearly as much about nor do we have good methodologies. Then there is heterogeneity of treatment effect, differences in the urgency of a problem . . . I could go on and on.

    Of course the type of evidence required to justify a therapy depends on the nature of the treatment. Anyone who would deny that is just, well, willfully obtuse. None of this in any way favors CAM, but somebody seems to be missing the point.

  3. rbm42 says:

    One of the few worthwhile things the current Government of Ontario did was to de-list chiropractic from OHIP (government health insurance in ontario). This was quite a while back, actually, and I can’t remember what the public rationale was. Probably purely financial, since they de-listed optometry exams at the same time. Anyway, given today’s fiscal climate, that’s not likely to be reversed any time soon.

    Sadly, most employer benefits do cover chiropractic and other quackery, to a limited extent, with no option to opt-out and increase coverage on actually useful things.

  4. cervantes – this is a somewhat complex issue. Of course “type” of evidence depends on what is being studies. We don’t do sham double- blinded surgical procedures, for example.

    But some CAM advocates go beyond the practical issues of what kind of evidence we can obtain to make special pleading arguments that CAM modalities require softer evidence standards, for some magical reason that they do not adequately define or defend. They then muddy the waters with false analogies to surgery.

    So – homeopathic remedies are pills. They should be studied in a double-blinded fashion.

    Sham acupuncture enables us to study acupuncture the same way.

    CAM advocates want to change the rules as needed to favor their preferred treatments. It’s pure pseudoscience.

  5. cervantes says:

    Sure I get that. But that’s more complicated than saying that the type of evidence required doesn’t depend on the nature of the treatment. That just isn’t true.

  6. David Gorski says:

    Of course “type” of evidence depends on what is being studies. We don’t do sham double- blinded surgical procedures, for example.

    Actually, we do sometimes. Well, not double-blinded sham surgeries, but single blind sham surgeries in which the patient doesn’t know which operation he or she got. They’re really difficult, but they have been done. Examples include a trial testing the injection of stem cells into the substantia nigra as a treatment for Parkinson’s disease, or the comparison of internal mammary ligation or pericardial poudrage to sham sternotomy for the treatment of angina (which showed that neither of these latter two operations provided any better relief of the symptoms of angina, by the way). I’ve even written about an example:

    http://www.sciencebasedmedicine.org/index.php/vertebroplasty-for-compression-fractures-due-to-osteoporosis-placebo-medicine/

    Of course, the problem with blinding or doing sham surgical procedures is generally one of ethics more than anything else, given that the potential harm done to subjects undergoing the shame intervention is not insubstantial, depending on the nature of the procedure. It’s a point I make sometimes. For the vast majority of CAM interventions, the sham is not so potentially harmful; so the ethical objection is a lot less potent.

  7. humesghost says:

    There’s been some good press on this issue in the last couple of weeks, including a strong editorial in the Toronto Star:
    http://www.thestar.com/opinion/editorials/article/1089492–don-t-muzzle-our-doctors
    http://news.nationalpost.com/2011/11/29/ontario-medical-college-votes-for-tougher-scrutiny-for-alternative-medicine/
    The skeptical community played a strong role in bringing about these changes: with over 600 responses, this policy got more feedback than almost any other policy at the CPSO, and a large proportion of the responses indicated that they were referred by skeptical sources. For more on this, see:
    http://www.skepticnorth.com/2011/11/cfi-canada-wins-battle-over-cpso-cam-policy/

  8. ConspicuousCarl says:

    We also have more evidence for arterial clamping than is implied. It seems so obvious now, but acting on that system without good evidence gave us bloodletting. The evidence doesn’t have to be randomized trials from scratch in every slightly different application if you already have a thorough understanding of the relevant systems from prior investigation. We know clamping is a good idea because we already know what is going on with blood circulation.

  9. @cevantes – I think you are spot on.

  10. cervantes says:

    Right Carl, precisely what I said — the more prior biological plausibility, the less convincing you need. That’s bad news for woomeisters, but it is not the case that the evidentiary requirements are the same regardless of the therapy. People keep raising up straw men in response to what I said. Just admit I’m right, okay?

  11. cervantes “but it is not the case that the evidentiary requirements are the same regardless of the therapy”

    I think the problem is wording, specifically the vagueness of “therapy”. The evidentiary requirements should be the same regardless of whether the therapy is CAM or SBM. Meaning there may be variation of evidentiary requirements dependent upon feasibility, plausibility, safety etc, but the guidelines that oversee that variation should be universally applicable to SBM or CAM.

    It’s hard to find the right word
    ‘the evidentiary requirements are the same regardless of discipline.’
    ‘the evidentiary requirements are the same regardless of ….(?)’

  12. ConspicuousCarl says:

    cervantes on 30 Nov 2011 at 1:11 pm

    Right Carl, precisely what I said — the more prior biological plausibility, the less convincing you need.

    Yes, but the difference here is that I think the existing understanding of how blood circulation works is evidence/convincing. That’s all I’m saying.

    Just admit I’m right, okay?

    I really want to, I do. I even searched for randomized trials to support the fact that you are right, but…
    http://www.ncbi.nlm.nih.gov/pubmed?term=cervantes%20is%20right

    Hmm, “no items found”.

    But when I look for trials supporting MY position…
    http://www.ncbi.nlm.nih.gov/pubmed?term=carl%20is%20right

    274 results! I win.

  13. Scott says:

    @ cervantes:

    It seems to me that your point is that the standards should be uniform, but that there are a range of possible ways to satisfy those standards with evidence. One treatment’s evidence might be principally based on biological plausibility and dramatic unblinded unrandomized results (e.g. clamping a spurting artery), while another would be supported by large double-blind randomized placebo-controlled trials (e.g. a new statin). But both are held to the standard that the evidence presented should empirically establish that the treatment’s risk/benefit profile are appropriate.

    Is that a fair characterization? If so, I certainly agree with you. But in the end, I’d have to call the original objection semantic nitpicking – there were enough references to standards in the post to make it adequately clear that’s what Dr. Novella was referring to.

  14. Scott says:

    Sorry for the double-post, but…

    Carl, you win the internet for those Pubmed searches.

  15. windriven says:

    Dr. Novella cited:
    “The College expects physicians to respect patients’ treatment goals and decisions, even those which physicians deem to be unfounded or unwise. In doing so, physicians should state their best professional opinion about the goal or decision, but must refrain from expressing non-clinical judgements.”

    And wrote:
    “This is a thinly-veiled attempt to silence criticism – to silence any doctor who has the sense to understand that it is their duty to protect their patience from unsafe or ineffective treatments. CAM proponents are as clever as creationists in couching their true goals in language that seems inoffensive, but the goal is obvious to anyone who has been paying attention.”

    Am I alone in finding this bordering on the paranoid? Is the effort to silence to be found in the expectation that physicians respect patients’ treatment goals and decisions or is it in expecting physicians to voice their clinical objections or concerns but to avoid voicing non-clinical judgments? It is one thing to say, for instance, that studies demonstrate X% 5 year survival for Y treatment of cancer of the toenail while faith healing offers no such results. It is quite another to say that faith healing is stupid – even though it is.

    Having attained legal age and being of what passes as sound mind – people have the reasonable expectation of agency in matters of their care. I’m not sure how CPSO could have drafted less problematic language on this particular issue.

  16. @windriven “Am I alone in finding this bordering on the paranoid?”

    No. I thought the same thing.

    I guess it would be useful to hear an example of what kind of non-clinical judgement statements this guideline would potentially silence.

  17. You have to put that comment into context. This has been a theme of CAM promotion for a long time – trying to silence criticism by saying doctors should not express opinions about CAM choices, or that they need to respect the public’s freedom to choose whatever they want. I have been on the receiving end countless times of criticism from CAM supporters saying that I don’t have a right to criticize a particular bit of CAM nonsense for similar reasons.

    Like many policies, how such things get applied is what matters, and when you know the history and the context you know exactly why such a statement was included. Similarly, it’s not paranoid to worry that academic freedom laws are really about promoting creationism.

    Why else do you think that language was included – and why did the CMA ask to have it removed? It is already part of standard medical ethics that doctors do not impose their personal beliefs onto the patients, and respect their patient’s beliefs. Why would a policy about CAM feel the need to include this?

    It’s so when I express my scientific opinion about homeopathy that can be twisted as attacking my patient’s philosophy, or if I criticize the evidence for acupuncture then I am against “Eastern” medicine, etc.

  18. humesghost says:

    @micheleinmichigan “I guess it would be useful to hear an example of what kind of non-clinical judgement statements this guideline would potentially silence.”

    A large part of the problem is that it simply isn’t clear what “non-clinical judgement” means. The result of vagueness is that a cautious physician, not wanting to get hauled in front of a complaints committee to find out what the rule means, will self-censor. In such cases, the tendency is to over-censor, so we should expect physicians to refrain from offering judgements that would arguably fall on the clinical side.

    So a physician might think it’s permitted to say “homeopathic preparation X has not been demonstrated to be effective in treating Y”, but impermissible to say “homeopathy is a scientifically implausible system of treatment that is almost certainly no more than a placebo”. It may also seem forbidden to state the simple fact that homeopathic remedies are diluted to the point that nothing is left. (Is that a “clinical” judgement?)

    What compounds the problem here is that we all know that the alt-med practitioner is going to be falsely telling the patient that their treatment is scientifically proven, while disparaging the “poisons” put out by Big Pharma. So this policy amounts to a unilateral disarmament in the medical information wars. Why should those who actually have sound medical knowledge be the only ones who are required to hold their tongues?

    The right to choose is a right to an informed choice. Doctors can provide that information. Any legitimate concerns here could be addressed by 1., forbidding doctors from dropping patients just because they use alt-med, and 2., common sense respect – i.e., don’t call your patient an idiot for falling for the quacks.

  19. windriven says:

    “It is already part of standard medical ethics that doctors do not impose their personal beliefs onto the patients, and respect their patient’s beliefs. Why would a policy about CAM feel the need to include this? ”

    Point taken, Dr. Novella. While I still probably read the CPSO statement differently than you, I clearly see your point that it is an unnecessary reiteration. I just don’t see it as being necessarily nefarious in intent. But then I am not a physician and read it from a different vantage.

    To continue with your analogy, academic freedom is principle worth upholding despite the fact that it is sometimes invoked in the service of imbecility. I am concerned that skeptics sometimes fall into the same trap visited by passionate advocates of a variety of philosophies: finding commies behind every bush and Jesus’s image in toasted cheese sandwiches. To misuse an oft repeated medical maxim: when you hear hoofbeats think horses not zebras.

  20. pmoran says:

    I was also about to comment on what to me looks like an overly embattled response to what is an extremely complex and sensitive matter.

    I’m also not sure what the CSPO means by “non-clinical judgments”. Perhaps they mean using words like “fraud” and “quackery” when talking to patients who might like to try out “alternative” methods in times of significant unmet or ill-met medical need (they don’t do it that much otherwise) , without necessarily themselves having high expectations of a good outcome. It is NOT a scientific issue for them — CAM is usually merely something to try out on someone else’s recommendation.

    Much of the CAM we will encounter in our daily practices will be carried on by well-meaning, if variably misguided practitioners, and it will also be regarded as helpful by the patients, which is difficult in practice to always distingish from them actually being helped in some ways. Any rational response to CAM MUST allow for that.

    I favour a fatherly, but advisory tolerance that stiffens in proportion to any risks that the patient may be exposing themselves to. Measured tolerance may get us better trusted and listened to where it really matters.

  21. Janet Camp says:

    I’m totally in Dr. Novella’s court on this. The wording clearly is a slippery slope to forbidding physicians from saying anything that could be construed as pejorative about CAM. I wonder if those of you who find this “paranoid” have had the level of exposure to in-your-face CAM that Dr. N has (and I have)? Would you feel the same way if your child came home and said the teacher talked about “the controversy” today? Keeping CAM out of SBM, is an uphill struggle for SBM and someone has to be clear with people about CAM. One of the things that turned me from a flirtation with CAM was the repeated head-shaking and tsk-ing of my MD’s when I would ask about some herb or “method” I’d heard about. I may have thought them snobbish or unfair at the time, but it began to sink in fairly quickly and got me reading some good skeptic books like Trick or Treatment.

  22. Ken Hamer says:

    When I go to my doctor, all I want to hear is her *opinion*. I hold that in very high esteem.

  23. kathy says:

    What about Scientology or Christian Science beliefs re medical matters? Must a doctor remain silent even when he sees harm being done?

    Apart from these formal religions, there are dozens of small informal belief systems that include “natural” remedies or “spiritual” interventions. For instance, what does a doctor say when a patient insists he is possessed by the devil and needs exorcism not scientific treatment?

    There are some CAM treatments that are strongly linked to religious/cultural beliefs. Advising against these could land a doctor in hot water.

  24. pmoran – yes, you are free to choose whatever style you wish when dealing with patients. That’s the point – I also want to choose my own style (which is actually not far off from yours – but when there is clear fraud, I am not afraid to label it as such).

    Of course no one here is against academic freedom or health freedom. The point is that these principles are being actively exploited by those who wish to water down and even eliminate standards in education and medicine, respective, because they have a very specific agenda and ideology to promote.

    I do not oppose academic freedom – I oppose academic freedom laws that are specifically crafted to promote creationism, and it’s naive to think that these proposed laws are not part of such an agenda. Eugenie Scott, who has been battling this for years, proudly states that she has developed great skill in sniffing out stealth creationist agenda in seemingly innocuous laws. She is not paranoid, she is astute and experienced.

    Similarly, of course I agree that physicians should obey patient autonomy and not infringe on their beliefs, but I oppose exploiting this principle to silence CAM critics or put a chill on the free discussion of dubious practices.

  25. pmoran says:

    The point is that these principles are being actively exploited by those who wish to water down and even eliminate standards in education and medicine, respective, because they have a very specific agenda and ideology to promote.

    What agenda? What ideology? Who are these people?

    You are as aware as I am of the intensely powerful illusions of treatment efficacy including probable placebo responses that operate within day-to-day medical practice. These have misled many eminent physicians.

    Why do we need to look beyond those, seeking “reds under the bed”?

    Many honest, well-meaning people believe, despite everything that we throw at them, that these treatments do work . That in turn gives rise to the seemingly devious, scientifically naive rationalizations. These are typically quite fluid, switching easily from one stance to another depending upon the challenge.

    The true frauds are simply along for the ride. They don’t engage in serious debate at all, beyond the requirements of marketing.

    So I suggest that there is no evidence of any consistent anti-science agenda, other than that these folk are forced to retreat further and further into mysticism when under sustained solid attack.

    We will not be effective against the dangers of CAM unless we have a clear-sighted understanding of it.

  26. Harriet Hall says:

    I don’t see it as a conspiracy, but as individuals who have fallen for various illusions, who believe their pet treatment works and who want to eliminate the standards that make it look bad.

  27. weing says:

    They may be victims of a wicked learning environment. Robin Hogarth in Educating Intuition gives the example of a physician in the early 20th century. He was able to predict, with uncanny accuracy, who would develop typhoid. He did this by palpating their tongues. He did not use gloves, nor did he wash his hands. He was also a carrier.

  28. puddinhead says:

    Cervantes,

    I think you are missing the point. Indeed, suggesting that all medical interventions require the same “type” of evidence of efficacy and safety is quite absurd. The evidence that a clamp stops the flow of blood by a readily observed mechanical mechanism is going to be different than the evidence required to support claims of efficacy of a molecular agent. No argument there. However, both require an *appropriate* demonstration of validity, irrespective of the parameters tested to demonstrate that validity.

    The whole point of the this thread is to inform on the wording of a specific policy which has the potential to regulate the practice of medicine in Canada. There are clearly people involved with the wording of the draft who have an agenda to mandate the integration of CAM into medical practices as a point of policy. What is being suggested is that CAM practices should be promoted, even if there is no/limited evidence of efficacy and safety (or, in many instances, evidence which directly refutes the same), or any reasonable mechanism by which these practices could be proposed to work. Pointing out that the efficacy of a clamp and a pill are assessed by different strategies doesn’t speak at all to Novella’s point.

    Allowing wording which suggests that CAM should be judged by different standards seems to be a veiled attempt at opening the floor to all of the insidious ploys often used by the CAM crowd to avoid scientific scrutiny. Lionel Milgrom comes to mind. Milgrom likes to explain away any evidence which refutes homeopathy by suggesting that “quantum entanglement” prevents us from observing the effects of homeopathy. His suggestion is that “it works, but only if you don’t try to observe the effect”. Suggesting that CAM modalities should not be held to the same standards as conventional medicine (meaning, propose a reasonable mechanism of action and establish efficacy and safety with properly culled and analyzed data) simply opens the door for these arbitrary hand-waiving explanations which no-one bothers to validate.

  29. weing
    “They may be victims of a wicked learning environment. Robin Hogarth in Educating Intuition gives the example of a physician in the early 20th century. He was able to predict, with uncanny accuracy, who would develop typhoid. He did this by palpating their tongues. He did not use gloves, nor did he wash his hands. He was also a carrier.”

    But wouldn’t his method only work if he predicted ALL or most of the patients he examined would die from typhoid?

  30. oops, develop typhoid, not nessasarily die from, I guess.

  31. Kim Moir says:

    Good news, they seem to have retreated in favour of evidence based medicine

    http://www.cmaj.ca/site/earlyreleases/9dec11_ontario-college-beats-retreat-on-alternative-therapies.xhtml

    It’s not perfect, but much better than the original draft.

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