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When “CAM” is mandatory: A science-based medical student’s dilemma

Early in the history of this blog, I wrote a rather long post expressing my dismay at the infiltration of unscientific “complementary and alternative medicine” (CAM) or “integrative medicine” (IM) modalities into American medical schools. In it, I listed the medical schools that had embraced pseudoscience through having started a CAM/IM program (a list desperately in need of an update). Moreover, we have also complained vociferously here about a clear effort on the part of advocates of faith-based medicine to infiltrate bastions of science-based medicine and to piggyback their agenda onto President Obama’s health care reform initiative in a clear political strategy to slip CAM/IM into any health care reform legislation as a form of “preventative medicine.” It’s all part of a multi-pronged strategy to claim popular and legal legitimacy in the absence of scientific legitimacy. At one point I even despaired because of the apparent success of half physician, half CAM huckster Dr. Andrew Weil at developing a CAM/IM curriculum that would be part of the mandatory training program in several family medicine residencies, while the rest of us watch Senator Tom Harkin try to promote pseudoscience in the halls of the Senate.

However, since one of our newest co-bloggers, medical student Tim Kreider, arrived, I’ve come to appreciate that medical schools and medical school curriculae are ground zero in the battle for science- and evidence-based medicine. Besides the infiltration of non-science-based modalities into the standard curriculum, another technique for making medical students believe that woo is equal to science is the student “campus CAM group” that invites, for example, homeopaths and naturopaths to give talks to medical students, too many of whom are too timid to challenge them on their pseudoscience. However, a reader of a “friend” of mine wrote me an e-mail that truly appalled me. In fact, it appalled not just me, but all of my co-bloggers who read it. It’s from a medical student in an American medical school. It’s not Harvard or a huge famous medical school. However, it is in medical schools like this one where the vast majority of medical students are trained in this country. If the infiltration of CAM/IM into medical schools continues in this way, we’ll have more than just “integrating” woo into the medical school curriculum from day one. We’ll have more tales like this; eventually, no one will find such tales unusual or even unacceptable anymore. The shruggies will no longer even shrug anymore. Such clinics will become simply the way medical students are educated. The following e-mail is de-identified, and I’ve edited it a bit to make as sure as I can that it is not traceable:

Dear Dr. Gorski,

I’m a third-year medical student going through my clinical rotations. The particular outpatient site I’m at promotes woo. A few of the attendings practice acupuncture, conduct OMM [osteopathic manipulative medicine] clinics, and just started to offer cupping.  Sadly, most of the attendings recommend CAM therapies to patients, the residents incredulously try them out, and I know they’ve recently Matched fourth-year students because this program promotes woo. Laughingly, an attending actually lectured us on how to use acupuncture to control post-partum bleeding!

Unfortunately, I’ve been assigned to participate in acupuncture clinic. I feel like a fraud to these patients and I despise being part of this sham.  I’ve already been asked “where I stand” on the issue of CAM.  As practicing physician I could choose to not hire someone who’d inflict CAM on patients, or as a professor I could fight to de-fund CAM departments, but as a student, I can’t speak up without the real risk of ruining my grade.  What do you think I should do?

If you choose to use this email as part of a post, then please de-identify it.

Thank you for your advice.

Student X

First off, Student X deserves kudos for his realization that being asked to participate in an acupuncture clinic is in essence being asked to subject patients to unscientific, religion-based, placebo medicine that has never been convincingly shown to be more efficacious than a placebo for any condition.

Next, I’m sure most readers of this blog will be as disturbed as I was to read this. At least I hope so. None of these therapies are science- or evidence-based. We’ve discussed why acupuncture is nothing more than placebo medicine on many occasions, although we haven’t discussed OMM at all. OMM is the aspect of osteopathic medicine that most resembles chiropractic, in that it postulates that realigning bones and muscles can somehow cure all manner of ills by physiologically dubious mechanisms. Although it’s still taught in most osteopathic medical schools, it’s more as a historical footnote, and few D.O.’s practice OMM anymore. That’s one reason why D.O.’s have over the years become virtually indistinguishable from M.D.’s, which to me is a very good thing indeed. In fact, the best surgical intensivist I’ve ever had the pleasure to work with is a D.O., and I’ve worked with excellent oncologists who are also D.O.’s. My overall impression is that science-based D.O.’s are somewhat embarrassed by these vestigial aspects of osteopathy, but clearly some osteopathic doctors still practice OMM. Some even practice a form of osteopathy called either “cranial osteopathy,” “craniosacral therapy,” “cranial therapy,” or similar names. Practitioners of these methods claim, as chiropracters claim for the spine, that the skull bones can be manipulated to relieve pain and remedy many other ailments. Worse, they claim that there is a “rhythm” in the flow of the cerebrospinal fluid and that diseases are characterized by changes in this rhythm, which can be used to diagnose many diseases, and that these abnormalities in this “rhythim” can be corrected by manipulating the skull. Student X didn’t mention whether any of these practitioners practiced craniosacral osteopathy.

Finally, before moving on to advice (such as it is) I have to point out that cupping is pure quackery. It is a method from traditional Chinese medicine that involves heating the air within a cup and then placing it on the skin so that it is drawn into the cup as the air within cools. There are two varieties: dry cupping, which involves just the cupping, and “wet” cupping, which involves puncturing the skin before applying the cup over it. “Wet” cupping is said to “draw the toxins out” while all forms of cupping are claimed, like acupuncture, to “unblock” or “realign” the flow of qi and thus restore health. It has no role in science-based medicine and should especially have no role in the education of medical students, which is why I was horrified that students anywhere in the U.S. are being taught about it as thought it were a legitimate therapy.

So what should Student X do? Before I answer, let me briefly summarize what else I learned in my e-mail exchange with him. He’s already midway through the rotation; so leaving or changing rotations is not really an option. Also, he was not aware until recently that he would be assigned to the acupuncture clinic. Finally, he has assured me that this is the only site affiliated with his medical school where students are assigned to an outpatient rotation where, as he put it, the “woo runs free.” Being the cancer surgeon that I am, I can’t help but use an analogy here. It sounds to me as though the cancer needs to be cut out of this school before the “woo runs free” to the point where it invades and metastasizes elsewhere and endangers what Student X assures me is an otherwise very supportive, science- and evidence-based medical school. Indeed, I extensively searched the medical school’s website and was unable to find anything about the clinic described. All I found was that one faculty member has an NCCAM grant to study natural products and that one faculty member had finished an “integrative medicine fellowship” before joining the faculty. In that, at least on the surface, there would appear to be less woo at Student X’s school than now exists at my alma mater. Finally, Student X, although not going into the specialty of the Woo Clinic (which is what I will call it from now on) where he is currently rotating, does not feel that he can risk burning bridges, as he needs favorable evaluations.

Back to what to do. Every fiber of my being wants to tell Student X to go to the dean and complain forthwith about the infiltration of quackademic medicine into his medical school. However, I appreciate his situation, and do not wish to give him advice that’s going to land him in a world of hurt, even though fiber of my being also wants to try to get Student X to give me permisison to name names, to call out his medical school right here on this very blog. Unfortunately, Student X informs me that the dean censors anything said by medical students on blogs or online forums that might bring the medical school into disrepute. Were I to name his medical school and it ever became known who had complained to me, the consequences are likely to be unpleasant. Given that it is known who’s rotating at the Woo Clinic right now, it wouldn’t be too hard for his dean to figure out who had complained to me, especially if he had answered honestly the question of “where do you stand on CAM?” So, I will not reveal the medical school.

That being said, regardless of the dean, the very first step Student X needs to take now is to gather as much information as he can. He needs to document everything: every dubious therapy recommended, every credulous statement, every bit of advocacy of unscientific therapy, and every instance of outright quackery. If the clinic has fliers on various CAM/IM modalities that it hands out to patients, he should collect them as evidence. If the clinic has published handouts, outlines, and notes that it uses to teach medical students about CAM/IM (particularly cupping), he should save those, because if he ultimately does complain he will need as much ammunition as he can get. This very blog and various other sites, such as QuackWatch, can provide material and scientific studies showing how discredited these therapies are. If this all blows up, more documentation is better to cover his behind. What critics of unscientific practices in medical often find out is that most of the faculty has essentially zero idea what is actually being done and taught. When they are informed of exactly what “cupping” is, for instance, they are often appalled that such woo is being taught in their medical school to medical students. Ditto reiki, homeopathy, and a lot of the other “woo-iest of the woo” that falls under the CAM/IM rubric. The best tool to educate shruggies, who refuse to believe that anyone would believe, much less teach, such mystical pseudoscientific nonsense is to show them exactly what is being taught to students in the very words of the CAM/IM practitioners. That is often more than damning enough evidence.

The second step is for Student X to find out if there are other students who agree with him and then to hook up with them. Indeed, he should go beyond that and find out if there are other faculty members in the department to which that outpatient clinic belongs who are concerned about the woo being taught to the medical students alongside scientific medicine. In fact, he should go beyond even that and find out whether there are any faculty in the medical school, period, who are proponents of science-based medicine and willing to take a look at the situation. In other words, he needs to find first those who are not shruggies first and network with them. That has to be done before there is any hope of changing the minds of the shruggies. The dean could easily ignore the voice of one lone medical student, but he could not so easily ignore the voices of several medical students if they are backed up by even a handful of faculty–or even just one senior influential faculty member. Ideally, he should seriously consider writing up a letter of complaint to the dean and getting as many signatures as he can on it. Having discussed this case with my cobloggers, I believe I can say with some confidence that all of us would also sign such a letter; indeed, we’d help Student X draft it.

As I’ve thought about this case over the weekend, I completely understand Student X’s reticience about speaking out. Quite frankly, I don’t know if I would have had the intestinal fortitude to have spoken out about an issue like this when I was in medical school. Fortunately for me, that was over 20 years ago, and the infiltration of CAM/IM had not yet become an issue. Indeed, I don’t remember its even being on the radar screen back then. In that, I and other physicians of my generation were fortunate; we weren’t put to the test. However, now, if we are not yet being tested, we soon will be. With NCCAM providing the cloak of undeserved legitimacy to these modalities, it is hard to speak out without being labeled as “close-minded” or even “bigoted,” given how many of these modalities are part of traditional Chinese medicine, Ayurvedic, or indigenous populations, usually mixed in with the usual appeal to ancient wisdom, a logical fallacy if ever there was one. These charges are a powerful blunt instrument to beat the critics of CAM/IM over the head with, which is why we must acquire thick skins to handle them. My counterargument is to ask why ancient Chinese or Indian medicines should be held to a lower standard as far as evidence goes than ancient Western medicine, like bloodletting and purging with toxic metals, which were ultimately abandoned based on science.

Finally, even as understanding as I am about Student X’s position, I’m going to point out that silence is acquiescence. If no one speaks out, the problem will only continue and likely get worse. The woo will spread and metastasize to other areas of Student X’s medical school. Unfortunately, speaking out can have consequences, but if there’s one thing I’ve learned it’s that CAM/IM infiltration thrives best when it’s under the radar. When the light is shined on CAM practitioners in academia and exactly what they do, they usually do not like it, and, unfortunately, their first reaction is often to try to attack the messenger. However, it is on the frontlines, such as the clinic where Student X is currently assigned, where the battle for science-based medicine in academia will be lost or won.

That is why we at SBM will help any medical student who asks us in whatever way we are able. If that includes writing letters, talking to program directors or deans, or even (if it can be pulled off), arranging for one or more of us to come to give talks at medical schools where students are being subjected to rotations teaching them pseudoscientific medicine along with scientific medicine, then we will do that when we can if asked. If it consists only of advising medical students who are science-based and object to the infiltration of pseudoscience into their medical schools on tactics to slow down or stop the CAM/IM train, we will do that as well. We also ask any faculty of medical schools who will support us in this effort to contact me or Steve. You can either do so by publicly leaving a comment below or e-mailing either of us at the e-mail addresses in the Contact tab above. If it’s feasible, you could even become more active by attending the Science-Based Medicine conference in July and networking with like-minded physicians and scientists. There’s nothing like a little face time to build relationships and alliances.

I now conclude with a request. First, of my fellow SBM co-bloggers, I request your input and that you chime in with your advice to Student X. Second, of our readers, I request the same thing. I also open the comments to any medical students or faculty who may have had a similar experience to that of Student X. It would be better if you used your real name, but I understand if you, like Student X, don’t feel comfortable doing that; you may register under a pseudonym if you like. We at SBM will never “out” you unless you give us permission to do so. Look at this post as a springboard to begin the process of organizing. We at SBM want this blog to be more than just a blog; we want it to be a clearinghouse, the beginning of a movement, a hub where like-minded supporters of science- and evidence-based medicine can gather. The CAM/IM revolution has gone frighteningly far; it’s long past time for the counterrevolution for science- and evidence-based medicine to begin.

Who’s with me?

(Sorry, I couldn’t resist using this scene again.)

Posted in: Acupuncture, Medical Academia, Medical Ethics

Leave a Comment (57) ↓

57 thoughts on “When “CAM” is mandatory: A science-based medical student’s dilemma

  1. Mojo says:

    The same sort of thing is happening in the UK. See, for example, David Colquhoun’s blog:

    http://dcscience.net/?p=555
    http://dcscience.net/?p=1143

  2. storkdok says:

    I guess I was lucky. In my medical school, we had Dr. William Jarvis, among others, who lectured on EBM even when it wasn’t called that, and he taught us how to identify woo/CAM and respond to it.

    I don’t know how much I could help, as a novice here, but I’m willing to try ;0) I would love to come to the conference, but my responsibilities at home keep me so busy, I really can’t fly out at that time.

  3. Absafrickinlootly, to everything. Student X, please document everything and please be ready to name names when you get clear of their influence. Other students, please let us know what BS you are being expected to swallow, and whether you are subjected to a pro-sCAM litmus test, as was Student X.

    In the planning stage, also, is a website that will be a primer (and more) on critical thinking for medical students, with an emphasis on how to evaluate fanciful ‘hypotheses.’

    As David wrote in a discussion amongst ourselves, medical schools sCAMming their own students is “where the rubber meets the road.” As depressing as it is, it may prove to be the straw that breaks the CAMel’s back. Let’s apply some pressure to that straw.

    KA

  4. daedalus2u says:

    Do the “freedom of conscience” laws apply in these cases?

  5. Dr Benway says:

    Med students had a saying in my day, daedalus: “They can always hurt you more.”

  6. I’m beyond appalled. I expect my physician to be intelligent, well-trained, and above all, use evidence based medicine. If I see an oncologist, I don’t want them to even entertain some quack medicine, I want a straightforward, scientific attack on the cancer.

    Please, someone tell me this is rare. I want to think that this isn’t happening everywhere. And how do we get those attendings shipped off to a small island in the Pacific so they may practice on each other.

  7. gr8blessings says:

    Point of Clarification.

    Could someone please tell me who determines med school curriculum in the US and/or Canada? Is there an accreditation body that regulates the curriculum?

  8. daedalus2u says:

    If a med school does this kind of stuff, they should be dis-accredited and required to refund the tuition of the students.

  9. Kultakutri says:

    Now, sun is shining outside and I’m enjoying the beautiful spring in Florence, Italy. Which is a direct consequence of two major clashes with the academia. The first one was so unbelievable that I’ll keep the story to myself; the result was that I went to study somewhere else where I thrived (to a mixture of dismay and surprise of those who… well, did something for which karma will get them one day). Until year and half ago.
    My postgrad advisor is, sorry to say, an arsehole. I didn’t ask for him, it was department’s doing. So, I should consult my doctoral paper with a mysoginist idiot, erm, professor, who was everywhere, saw everything twice, knows all languages and is always right. I want to discuss things, not to hear Oh yes, that’s clear. Oh indeed. Oh I know only too well.
    Even before I got to the postgrad course, I asked him about something general that he may have known. His response was ‘You are really interested in that? It’s all [dramatic pause] crap.’ The first thing he did after I was assigned to him as his postgrad waste of space and air was that he personally offended me.
    So, I got two not extremely generous but prestigious research scholarships for that crap I’m doing, I ran away, I seek help from the wonderful guys here at the local university. I feel lame. I vomit morally every other day that the person who has seen me around three times since I started my postgrad course is being paid for supervising me. I’m sick of the idea that I won’t be able to credit those who actually did something for me and for the rest of my life, I’ll be a student of Professor Arsehole when I haven’t really learnt anything from him.
    It’s not my first crash with the grim reality of academia. The first one is however totally unbelievable, it only sounds like whining of a spoiled girl so I’ll skip that one.
    I cannot deal with it officially. I can deal with it in other ways – to be better than
    them. I write, I have my research… and they notice even if they pretend not to.

    I know that my situation is a bit different, I just fell afoul with some people and the part of system that says ‘Faculty is always right’ – but the result is the same, I can’t stand up and fight. I hope I managed to find a way how to keep my sanity, how to get as much as possible from my studies and making Professor Arsehole jealous of my success is a nice cherry on the top. Otherwise I pretty agree with the previous commenters. Good luck to the poor student.

    (I don’t do medicine, just for the record. )

  10. Actually, the accrediting agency for med schools is REQUIRING that they teach CAM/IM. They are now part of the problem.

    The pro-woo movement has truly infiltrated far and deep, facilitated by the shruggies.

    I think the key concept here is that we need to shine the of day on this entire phenomenon. Most people are just not aware of what is really happening. The pro-woo side has their rhetoric down pretty well – they know just what phrases will pacify academics vs politicians. I have seen it happen before my eyes.

    But a bright light shown directly on the claims and practices of unscientific practitioners has a remarkably clarifying effect. The CAM crowd often hides the details beneath sweet-sounding jargon, like holistic and natural.

    That’s why David’s advice to collect detailed information is spot on – deans and faculty need to be shown exactly what is being taught to their students. In my experience, most will be appalled, and even be converted from shruggie to SBM activist. But they will NOT believe it until shown – they are in denial.

  11. Dr. Skeptizmo says:

    I think to add to the advice given already I would say that Student X needs to arm himself with information not just for ammunition later on but for peace of mind during this tribulation. I am an osteopathic medical student that was taken in with the promise of a “more patient centered approach to medicine” and ended up studying cranial osteopathy. I personally have done hours of research and concluded that I am being fed a line of bulls**t, it makes me feel better to know that I have used science to further my knowledge and can now argue SCIENTIFICALLY with my peers. I am also waiting until I am removed from repercussion range before speaking out publically against these teachings and have many backers; it feels better to know that you are not alone and not crazy while in the foxhole with woo.

  12. Harry says:

    Dr. Gorski, please check facebook to see my e-mail.

  13. David Gorski says:

    Med students had a saying in my day, daedalus: “They can always hurt you more.”

    In my day, during my surgery residency the saying was, “They can hurt you, but they can’t stop the clock.”

    No matter what he decides to do, Student X will eventually be free of the Woo Clinic. Once that happens, I hope he will speak out and name names.

    In any case, to the question of how common this is, it’s becoming increasingly common, with CAM/IM rotations and material at many medical schools, Andrew Weil trying to insert CAM/IM as a mandatory part of the family practice residency curriculum, and Georgetown “integrating” woo “seamlessly” into its curriculum from the very first day of medical school. It’s getting worse, not better.

  14. James Fox says:

    Medical school trustees and members of boards of governors along with informed patients and tax payers need to be aware of this situation and the likely impact of how the effectiveness of the medicine being practiced by medical school graduates will be impacted by CAM/woo instruction. The institutionalizing of credulity is not a good thing.

  15. Kimbo Jones says:

    A similar thing happened to me at my school where I’m getting my master of *science* degree (I emphasize this because of the ludicrousness of what’s to follow) in Occupational Therapy. We were having a discussion about clients/patients seeking out CAM treatments and our role in advising them, since we are not physicians. I brought up the lack of efficacy of acupuncture and the students had all kinds of “rebuttals” to that statement: that’s just my opinion, I’m Western-biased, I have no respect for other cultures, etc. To make matters worse, the OT who was running the discussion joined in. They were not interested in discussing evidence in the context of our role in providing guidance to our clients/patients so much as they were very eager to “defend people’s beliefs” regardless of the topic.

    In my case, there is no possibility for documentation as there are no written documents (that I have seen) advocating the use of CAM in our school — it simply comes up in discussions. However, there is the practice of OTs recommending or giving people acupuncture of the ears to relieve headaches and a number of other ridiculous things. Something which appalled me, but apparently not the student who had participated in such “interventions”. This is a problem with our field in general. It’s bad enough people still call us “basket weavers” and don’t understand what we do, but do we have to give people this kind of fuel for thinking we shouldn’t be taken seriously as rehabilitation therapists? I’d rather we didn’t, but I appear to be in the minority.

    Suggestions for my situation would also be appreciated.

  16. Tim Kreider says:

    Student X, you understandably might not feel comfortable going straight to the dean of the medical school. I recommend you find some other faculty member on campus who will support you and offer advice. Identify an associate/assistant dean or a department chair or such who is likely to be sympathetic to your concerns, and ideally approach that person before risking a conflict with your attending. Even if your faculty contact does not have direct authority over the acupuncturist, you will have an easier time making a stand if you know that someone with influence on campus has your back.

    It can be intimidating. In my experience, most faculty that I suspect wouldn’t tolerate pseudoscience don’t waste any time talking about it, so there’s always that sliver of fear that you might stumble across a professor’s sacred cow. A physician active in research would be a good guess if you don’t know where to start. You could also pick someone with a reputation for being a good mentor or taking care of students with personal problems, since this situation is causing you a lot of stress as you ponder your ethical and professional duties.

  17. overshoot says:

    There’s always the naiive approach: go back to the school with a complaint that they hadn’t adequately prepared you with the basics required for this rotation.

    For instance, how does one calculate proper dosages for homeopathic remedies? How does one propery select the appropriate acupuncture points for various conditions? How does one identify adverse reactions to reiki?

    In order to learn the most in a hands-on learning situation, one needs a conceptual framework to make sense of the experience. Obviously Student X’s school let him down in that regard, and the curriculum should be reviewed (perhaps less time spent on physiology and more on vibrations) to prevent similar problems in the future.

  18. ImperfectlyInformed says:

    There is an intriguing osteopathic method for otitis media called the Galbreath technique that’s been somewhat revived lately. Considering that antibiotics hardly work (http://www.ncbi.nlm.nih.gov/pubmed/10657332), osteopathic treatment appears to have some potential. This (http://www.jaoa.org/cgi/content/abstract/100/10/635) review discusses the method, while this small trial (http://archpedi.ama-assn.org/cgi/content/full/157/9/861) found it promising. A 2006 article (http://www.jaoa.org/cgi/content/full/106/10/605) shows no complications. When one considers that ear infections are one of the most common issues in pediatrics, the method could be very beneficial.

    I don’t see what the problem with Dr. Weil is. He’s practically mainstream in that he actively rejects that many of the common altmed hypotheses cause disease: heavy metal poisoning, fungal/parasite infections, laetrile for cancer, ect. His recommendations for nutrients and herbs are usually prudent. Glancing around, I notice that he recommends too much vitamin E (400 – 800 IU) and fluoride (6 mg/day), but the risk of those still aren’t that big of a deal. He recommends a lot of vitamin A, but it’s in the carotene form is there’s no chance that it’ll be majorly toxic.

  19. wertys says:

    @Student X
    Well done for raising this issue. You and your colleagues are owed an education free from the relics of discredited healthcare practices, and you are being let down. Keep your head down until you get your ticket and then you can be as outspoken as you like. It’s up to the more experienced and those with a bit more tin plating on their back ends to fight the fight at faculty level.

    @Imperfectly Informed, I don’t think I’ve seen anyone on this bolg with a more accurate handle. There is nothing particularly intriguing about using movements of the jaws to encourage opening of the eustachian tubes. Although Galbreath might have been very keen to get his name on a technique, I suspect that as air travel became more popular and available the idea that you can equalize pressure in the tubes by ‘popping’ your ears has become widespread. I see from looking a bit more closely at the articles you quote that the jaoa study was roundly criticised in the same journal for some methodological shortcomings, and the author’s reply acknowledges these. I am heartened to see that the authors appear to have a reasonable and science-based approach, even if the intervention they are recommending is a bit trivial. At least they are not trying to make veiled and mysterious references.

    As for Andrew Weil, if you have been good for 98% of your life, but you drink drive and kill someone, that doesn’t make you any less responsible. Dr Weil systematically departs from the limits of his expertise and his professional norms in large ways, not small ones. Debating the doses he recommends is merely splashing in the shallows while the ocean of his ignorance washes around you.

  20. Peter Lipson says:

    You have an apt name—very appropriate for a concern troll. Every one of your points is terribly mis-informed.

    As far as this “osteopathic” technique, perhaps there is some plausibility in this temporarily relieving eustacean tube dysfunction, but any other idea is absurd.

    The OM study you cite gives a NNT for a particular outcome in OM. It also does not specifically recommend against antibiotics—it does say that antibiotic use may in some circumstances be avoided at the first visit. In fact, the american academy of pediatrics recommends that select children with OM can be observed without antibiotics. I’m not sure what your point is.

    The fact that Weil doesn’t advocate for every single type of woo doesn’t mean he’s science-based. The nutritional recommendations you claim he makes are not simply harmless. Vitamin A/beta carotene supplementation can increase cancer risk.

  21. Harry says:

    @ ImperfectlyInformedon,

    I’m looking at page 378 in Foundations for Osteopathic Medicine, 2nd edition.

    “Decreasing the edema in and around the auditory tube creates an environment for healthy function. Several manipulative techniques have been described to specifically address improved lymphatic and venous drainage from the head and neck (12,16,20).

    Osteopathic manipulative technique, such as Galbreath mandibular drainage, is easily performed and may provide considerable benefit in reducing the congestion that leads to a chronic condition (16,20). Normalizing cervical muscle tone by treating specific cervical somatic dysfunction or using soft tissue techniques may allow for improved lymphatic drainage from around the auditory tube. Infectious processes benefit from improved blood flow, which is necessary for healing and delivery of medications. Arterial blood flow to the ears should be optimized by addressing the effect of somatic dysfunction in the upper thoracic and cervical areas on vasomotor tone. Techniques such as rib raising and lymphatic pump can provide a more general approach to increasing lymphatic circulation and reducing congestion and inflammation in the ears. Treatment of specific rib dysfunction may offer a longer lasting improvement in lymphatic flow. Treatment of temporal bone dysfunction can allow for normal exit of the auditory tube from that bone. Recent studies provide evidence of clinical improvement in children with acute otitis media regarding decreased use of antibiotics, decreased number of infections, decreased need for surgical tube placement, and improved tympanograms (31). Osteopathic manipulation for the treatment of respiratory infections should include techniques to increase lymphatic flow, address viscerosomatic and somato-visceral reflex, and improve thoracic cage motion (27).

    12. Harakal JH. Manipulative treatment for acute upper-respiratory diseases. Ost Ann. 1981;9(7):30-37.
    16. Cathie AG. The sino-bronchial syndrome. Yearbook of Selected Papers. Academy of Applied Osteopathy; 1968:9-11.
    20. Galbreath W. Manipulative structural adjustive treatment in middle ear deafness. J Am Osteopath Assoc. 1925;24:741
    27. Rumney IC. Osteopathic manipulative treatment of infectious diseases. Ost Ann. 1974;2:29-33.
    31. Mills MV, Henley CE, Barnes LLB, Carrero JE. The use of osteopathic manipulative treatment (OMT) as adjunctive therapy for acute otitis media in children. Submitted for publication, June 2002″

    One of the bones I have to pick with OMT is that there are all these magical treatment that aren’t based in anatomy and are 50+ years old. As others have said on this blog, there needs to be anatomical or physiological plausibility for treatments. There is no solid evidence to support Galbreath’s mandibular drainage or show it having the effect that it is claimed to have. There is no evidence to show dysfunctional lymphatic drainage causes diseases other than edema. There is no support to show that diseases have shorter duration with lymphatic pumps. The entire basis of this OMT is magical pseudoscience. Citing the AOA’s newsletter has all the authority that Catherine DeAngelis has when she says JAMA takes conflicts of interests seriously. http://scienceblogs.com/insolence/2009/03/the_ama_investigates_catherine_deangelis.php

  22. daedalus2u says:

    What about the legal aspects of practicing “medicine” using techniques that don’t meet the Daubert standard?

  23. Dr Benway says:

    daedalus, there’s no authority higher than what is taught at our leading medical schools. When they get it wrong, we have to persuade them directly that they’ve gone off course.

    Difficult to do when we have no forum for discourse with medical educators.

    I understand that there are journals and conferences for medical education. Perhaps we might arrange a dialog or debate regarding the problems of integrative medicine?

  24. delaneypa says:

    I went to college in the mid-80′s, medical school in the late-90′s. Between those two periods, the attitude of college students changed from humble learners to entitled consumers. It’s not entirely surprising since the cost of all education is quite high.

    Unfortunately, medical students are indoctrinated to believe that their own medical is somehow special, that they are lucky to have been admitted, and that they should be thankful for everything that they are allowed to do. This was well-lampooned in “House of God”, where one of the characters was a visiting medical student from “The Very Best Medical School”.

    Student X could take another approach…express outrage at the frivolous waste of his time, which at medical school equals a LOT of money. Tuition at my alma mater is over well over $40,000 a year now (meaning about $3,000 for a four-week rotation). Were I being taught belief-based medicine instead of a quality education, I would not be disappointed, but upset and at least demand a refund of my wasted money so I spend it on some CME (trip to Vegas perhaps?).

  25. Mojo mentions the UK case at http://dcscience.net/?p=555 and
    http://dcscience.net/?p=1143

    In the case of Barts and The London School of Medicine and Dentistry (SMD). two of the students started anonymous blogs. At least one other wrote privately to the dean to protest. On their behalf, I went over the heads of the people who organised the woo placements and found that the Dean of Research and the head of the school weren’t aware how bad it had become. They promised to do something about it.

    That approach had some limited success at Yale too. After posting Integrative Baloney @ Yale, and a long correspondence with a senior person there, the woo courses were removed from CME.
    http://dcscience.net/?p=231
    http://dcscience.net/?p=247

    The students may not be able to name and shame. but we can.

  26. Dr Benway says:

    I’m moving away from my plan to connect with med students. They’re too scared of getting in trouble and not getting the letters they need for residency.

    We need faculty contacts we can somehow support.

  27. sowellfan says:

    I’m think there are still some good ways to publicize the problems with CAM in individual schools of medicine, using input from students, without getting particular students in trouble.

    First, I think it’d be good to have an outlet that can be publicized to some extent to medical students. The larger the sample size, the more anonymity that you can provide. As it stands now, the SBM blog is generally going to hear from medical students that are highly motivated, but there are probably 10x more students that think to themselves, “What they’re teaching me today is absolute crap” – but don’t take any steps towards resolving the problem, because they aren’t sure where they would go with their story.

    Second, I think you’d have to guarantee a significant time shift between the report from the medical student, and the publication of details about the vacuous crap that’s being taught at a medical school. It seems to me that it’d need to be somewhat randomized (so people trying to back-track couldn’t just subtract 6 months, and try and remember the snarky student), and long enough to make trying to guess the student quite difficult. This would obviously suck in the short term, but it’s a long-term fight we’re in.

    I’m not at all sure that this would be practical, or attract the data from medical students that you’re looking for, but I thought I’d throw it out there.

  28. Molly, NYC says:

    My day job is editing scientific papers, mostly from authors whose first language isn’t English. A lot of these papers come from China, and these frequently feature attempts to find legitimate pharmacological uses for biologically active components of traditional Chinese medicine. This can be pretty hit-or-miss, as basic research often is, but they’re honest-enough efforts, and although few of them are likely to make it past the rodent-testing stage, for the most part, they come from people who generate real data and have reasonable explanations for why they’re doing what they’re doing and, y’know, act like scientists.

    Honest-to-Pete, up until fairly recently (and to the extent that I thought about it at all), that’s what I assumed NCCAM was doing–playing some long shots in a search for safe, cheap and effective therapies, trying to find reliable, reproducible scientific underpinnings for alternative stuff, and by extension, separating the wheat from the chaff.

    I had no idea they were actively promoting chaff.

    The thing is, I bet I’m not the only one with this impression. You know who else probably thinks the same thing? My congressman.

    Also, Student X’s congress member. You don’t say if he goes to a public or private med school, but in either case, it probably gets public money. After Student X puts together–per your excellent advice–the assorted documents about this problem, he (possibly with some like-minded colleagues) may wish to make an appointment at his representative’s office. He’ll have two things to make clear there: (1) CAM is not doing anything fruitful or in the public interest, it’s just dicking around, often on the public dime (remember, politicians aren’t scientists, so he may have to show them what good research looks like in comparison); and (2) his school is contributing to this. (And (3), the Rep’s office needs to be discreet about his identity.)

    Having suggested this, I can see two possible problems: (1) Student X’s rep (or more likely, his aide or ombudsman) takes the “shruggie” position and won’t help; and (2) the rep or his/her office decides to help but in doing so, tips the dean off about Student X’s identity. That said, if anything can make an entity that relies on public money shape up, it’s the wrath of the feds. Which your congressional representative can do for you, if so inclined.

  29. ImperfectlyInformed says:

    Some surprisingly violent reactions to my comment, which I thought was neutrally-worded. Apparently people aren’t happy to see evidence which contests — even slightly — their preconceived opinions.

    Peter Lipson:

    Perhaps I should have reworded my comment on antibiotics of ear infections. The study found “seven to eight children aged 6 to 24 months with acute otitis media needed to be treated with antibiotics to improve symptomatic outcome at day four in one child”. So perhaps less effective than generally thought? I know I got lots of antibiotics when I was a kid, followed by tubes, followed by more ear infections. Maybe they aren’t as effective now due to antibiotic resistance, although I’m not that old. As far as “any other idea” of osteopathic therapy as absurd, well, there’s a large literature supporting the fact that spinal manipulation temporarily reduces back pain.

    I had to look up the word “concern troll”. I found that it was a term oft thrown around extremist forums like Democratic Underground, DailyKos, probably The Free Republic, ect. to describe those who question the faith and try to some reason. I get that reaction fairly often from both sides. In this case, I’m not sure it applies to me for the simple reason that I’m not a part of your group, and if I’ve pretended to, I apologize. I’m not secretly an antivaccinationist homeopath, either. Since you seem to have a black and white view of the world, I suppose that may be hard to understand. I’ll admit I get some pleasure out of insolently questioning dogma, but who doesn’t?

    It’s not surprising that you reduced yourself to ad hominem attacks, since your behavior both here and at your circumcision post show that you’re as pigheaded as they come.

    wertys and Harry:

    Interesting how you have opposite reactions to technique — wertys says it’s “common sense”, Harry says “it has no foundation in anatomy”. wertys, it’s not clear that the “Galbreath” technique is equivalent to popping one’s ears. Harry cites zero sources, and it seems as if he missed the trial.

  30. Dr Benway says:

    Imperfect, you’re as much fun as a rash. Now piss off. We’re trying to save the world.

    Ok, here’s my idea:

    We make a blog in the genre of “Pimp My Ride.” The lead at the top of the page:

    This is not your daddy’s med school. Ain’t no kids with epiglottitis dropping dead in the ER. No, today iz all ’bout de chronic. Even heart disease, cancer, and AIDS have become chronic at this medical school. And you know what that means: THE PLACE IS FRIGGIN’ BORING!

    Well we got the remedy for that malady. Y’all get ready for the freaky and the funky when you shout out: QUACK MY MED SCHOOL!

    Blog entries will describe questionable ideas promoted at particular med schools –e.g., Chopra-like talk on campus about quantum healing. The tone will be that of a critic awarding style points for quacktastic features of the talk, event, or practice.

    Students, faculty, or others can send us scanned flyers, handouts, pics, vids –anything that documents the woo.

    If the site is funny, current, and true, it might create a buzz. And it might shame faculty out of their coma.

  31. sowellfan says:

    If a site like that were to be made, I’d definitely make it part of my daily rotation.

  32. Dr. Skeptizmo says:

    Hey Imperfect- If you go back and read Harry’s post he does cite sources, at the beginning and the end. I guess that you were to busy trying to be snarky that you forgot to actually read the post….

  33. David Gorski says:

    Dr. Benway, that’s even better than when Dr. R.W. coined the term “quackademic medicine.”

  34. Dr Benway says:

    I assumed NCCAM was doing–playing some long shots in a search for safe, cheap and effective therapies, trying to find reliable, reproducible scientific underpinnings for alternative stuff, and by extension, separating the wheat from the chaff.

    Molly, you know why you thought that? Because the CAM folks talk in vague generalities –e.g., wellness, holism, prevention. Their writing is like cold reading: you unconsciously fill in the confusion with what you imagine they are trying to say.

    “Mind-body medicine” sounds nice if you don’t think deeply about it. But what does it mean? I see two options: something banal like how to keep a positive attitude when you feel like crap, or something silly like mind-over-matter Christian science.

    Ambiguous language is convenient for the CAM advocate, who can pretend a more reality-based meaning around scientists and a more mystical meaning around the credulous public.

    Real scientists remove ambiguous terms from their lexicon. The NCCAM gang has had a decade to operationally define “wellness,” “holism,” etc., so I say we stop giving them the benefit of the doubt when they’re overly vague.

    The other trick: the non-definition definition, e.g., “CAM modalities, such as yoga, guided imagery, biofeedback, meditation, and accupuncture.” Creates the impression that there’s a vast array of CAM stuff under study when in fact the “such as” gets nearly all the non-drug, non-crazy bits.

    Yes we spent a billion dollars on accupuncture, basically. We found out that it works best in poorly controlled studies and not so well in well controlled studies.

    Here’s how we study guided imagery: patients visualize a good thing. Then we check to see if the good thing happened.

    IMHO all future guided imagery studies ought to focus on whether visualizing a less credulous brain helps a person to wise up.

  35. Harry says:

    @ImperfectlyInformed
    Harry cites zero sources, and it seems as if he missed the trial.

    Luckly for me, the burden of proof lies with the person making the claim… and that’s you.

    And no, I did not miss the trial. I did not miss it’s small size, nor that it hasn’t been independently reproduced. Speaking of missing things, tell me, what did Pichichero have to say about it on page 852?

    As for your other citation, Hayes and Bezilla, in JAOA was only a retrospective review from two sites. It looks like it was just little research project they did while they were residents or students at PCOM. Hardly a convincing paper. It should be a prospective study with multiple clinical sites

    Searching PubMed for Galbreath only brings up the Pratt-Harrington’s 2000 review in JAOA… which is also the only thing Pratt-Harrington seems to have written. Hardly a convincing authority.

    As I said, the burden of proof lies with you, not me. I quoted from the Foundations of Osteopathic Medicine as an example of the “Gish Gallop” that the Osteopaths throw out. The AOA makes so many unsubstantiated claims, it is nearly impossible to go through and shoot them all down individually.

    Ball is in your court for evidence.

    -Harry

  36. ImperfectlyInformed says:

    Hey Dr. Skeptizmo:

    The evidence Harry cited was from the osteopaths, promoting their work. So not sure how that supports his argument. Thanks for reading though.

    I’m not an expert on osteopathy, nor do I plan to be. I just don’t dismiss things I don’t know much about unless I’ve got the evidence.

  37. tmac57 says:

    Dr Gorski RE “Indeed, he should go beyond that and find out if there are other faculty members in the department to which that outpatient clinic belongs who are concerned about the woo being taught to the medical students alongside scientific medicine.”
    What about the possibility of someone penning an open letter of position against CAM that asks concerned faculty throughout the nation to sign, to show where they stand on this growing concern.
    The letter being made public would give students a chance to see who their allies are without making a hazardous guess.
    Further it could be presented to political office holders, students willing to go public, and any other people of influence to take a stand publicly.
    It’s time for all ‘shruggies’ and SBM proponents to come out of the closet.

  38. Dr. Skeptizmo says:

    Imperfect- I am an osteopathic medical student so I know a bit more than the average bear when it comes to this, I dismiss the claims with much evidence under my belt. Next- You said nothing about having non osteopathic citations in your post,just that he didn’t have citations. No fair moving the goal post when someone calls your foul. Be a bit more specific with your mud hucking.

  39. Harry says:

    @ImperfectlyInformed
    I just don’t dismiss things I don’t know much about unless I’ve got the evidence.

    You bring up a critical point. I DO dismiss thing that lack evidence whereas you are saying that you do not. That is a very important distinction. I believe that if someone is making a claim, such as rubbing your ear in a defined manner will treat your ear ache, or that someone can can tell your future by analyzing the lines in your hand, that they should have evidence to support their claims. The farther their claims are from the norm the more robust the evidence needed. “Extraordinary claims require extraordinary evidence” Carl Sagan.

  40. Dacks says:

    How about a website that functions as a “Buyer’s Guide to Med Schools”? It could document courses, lectures, opinions, rotations, etc. that are being offered (or required) at each med school. Then a “woo rating” could be assigned to each school, a la Quackometer.

  41. sowellfan says:

    I’m an HVAC design engineer, not a medical student, but I’d imagine that there are already things out there that function as guides to picking medical schools. Trying to start from scratch to do something along those lines would seem to be a massive duplication of effort – but perhaps in addition to some of the things already discussed, one of the existing ‘guides’ might like the idea of incorporating some information regarding wacky CAM stuff into an existing guide…

  42. Dr Benway says:

    Imperfect: We’re under no obligation to take any claim seriously until that claim has been proven. And the burden of proof always rests upon the person asserting the claim.

    If we’re not allowed to dismiss claims until we gather evidence against them, we’re going to be very, very busy for a very long time. The the set of dodgy claims is nearly infinite.

    Dacks: A school’s woo quotient won’t sway students applying to med school. There are too many other, more important factors driving that decision.

    Faculty have egos. Simply drawing their attention to embarassing ideas being promoted at their schools ought to have an impact.

    The convincer will be in provoking a sense of personal responsibility for the evidential standards at their school. They must appreciate that no one else will take care of the problem on their behalf.

  43. Versus says:

    Student X: I’d like to add alumni as a possible resource for your problems, if you know any, or know anyone who knows an alum. I don’t know how long your med school has been around, but I imagine that the vast majority of alums would be appalled at what is going on and it could generate some nasty calls to the dean. Your only problem here is remaining anonymous, but I’ll bet they’d be willing to help. Of course, the school doesn’t want to make alums mad because they give money.
    That said, please be very careful in gathering your evidence — you don’t want them to crucify you with HIPPA or other patient confidentiality issues when you finally get to make your case.

    To those of you who get bashed for speaking out against sCAM, please don’t stop. I get the same reaction and it’s hard, but we must press ahead. I like to point out that CAM violates the patient’s right to autonomy because the patient is not being given all the facts (e.g., no basis in science, it doesn’t work). It’s hard for anyone to argue against the patient’s right to know exactly what it is that’s being done to him. I wonder if someone would accept a chiropractic treatment with the preface that it was invented in 1895 by a “magnetic healer,” that its diagnostic methods have never been vaildated, and that the treatment would address a non-existant spinal pathology with methods of no demonstrated clinical efficacy. Oh, and applied to the neck it might cause a stroke.

  44. The problem is pervasive and deeply entrenched. Over 3 years ago I began blogging about the problem at http://doctorrw.blogspot.com/

    Since that time about 20% of my blog content has been devoted to exposing the quackery infiltrating mainstream medicine, especially academic medicine. Orac at Respectful Insolence reaches a wider audience and devotes a greater portion of his blog to such exposure. http://scienceblogs.com/insolence/

    The Science-Based Medicine blog has since added to the chorus. There are a number of academics who read these blogs who would claim to support science based medicine. For a time I naively believed that the exposure of quackademic medicine in our blogs would move academic leaders to effective action. Now I know it’s too entrenched and has too much money behind it for them to be able to snuff it out.

    Student X is not in good company. The largest and most powerful organization of med students, the AMSA, promotes quackery. http://www.amsa.org/ Medical schools increasingly invite student participation in curriculum development and AMSA has been more than happy to fill that role.

    Even worse, it has recently become clear that two of the most revered organizations in all of medicine, the Institute of Medicine and the Institute for Healthcare Improvement, support the infusion of pseudoscience as I have documented here.

    http://doctorrw.blogspot.com/2009/03/institute-of-medicines-summit-on_16.html

    And while we’re at it, let’s not forget the AAMC!

    We should take some lessons from pharma critics who with their documentaries and books have done a very effective job at exposing the corrupting influence of the pharmaceutical industry. People, it’s time for a book!

  45. Joe says:

    @Dr. Benway

    That link is, shall I say, cryptic …

  46. Dr Benway says:

    I require examples. Send ‘em to me and I’ll funny ‘em up.

  47. mhuben says:

    My doctor is a Tufts University School of Medicine Associate Professor, and pretty much at every visit there are medical students rotating through his office to take histories and otherwise get patient practice under his supervision.

    When they offer me CAM and I declare that it’s fraudulent, they are invariably shocked because the doctor also offers it. I do wonder what they’re teaching about CAM there.

  48. mhuben:

    Please tell us what ‘CAM’ those students and that doctor are offering.

  49. nikwit says:

    Very interesting blog. I appreciate the high level of discourse. I think it’s a mistake, however, to completely discount the positive impact of more “spiritual” practices, or “woo” as some so disparagingly call them. I can understand your frustration, as a biologist I have frequently been angered by creationist “science.” But I don’t think all spiritual aspects should be discounted as useless, and I don’t think it should be compared to creationism, which after all is pretty much an argument as to facts, not spirituality per se.

    Would you call chiropractic “woo” as well? Just curious. My personal experience with chiropractic has been quite positive.

    Some effects cannot be completely explained by our current level of science.
    thanks.

  50. Phledge says:

    Dr Gorsky,

    THANK YOU. It means a lot to me, knowing that I’m not the only one currently steeped in woo. I will be taking the steps that you recommended to Student X, as my current rotation has me participating in homeopathic injections, meridian regulatory acupuncture, multi-level marketing supplements, bioimpedance analysis for weight loss programs, and detoxification programs. Oh, and OMM. (But I have to expect that–I’m in a DO school.) I’m politely nodding my head but refusing to outright agree when my preceptor says, “People might not think much of [particular flavor of woo] but you can’t argue with results!” Yeah, well, when your “results” cost $250 a month, and I sit with a crying patient who can’t afford your supplements, I can argue A LOT.

  51. Harriet Hall says:

    nikwit asked if we would call chiropractic “woo.”
    If it is based on the idea that they are correcting mythical subluxations, restoring the flow of nerve impulses and allowing Innate to heal the body, it is woo, especially if it is used for somatovisceral conditions. If it is limited to appropriate short-term spinal manipulation and associated treatments (like exercise, heat, and massage) for mechanical back pain, it’s not woo – but in that case it is hard to differentiate from what physical therapists do.

  52. Dr Benway says:

    <blockquoteSome effects cannot be completely explained by our current level of science. This begs the question: are the results observed more than we would see with a placebo or sham treatment?

    Please define “spiritual.”

  53. Dr Benway says:

    Some effects cannot be completely explained by our current level of science.

    This begs the question: are the results observed more than we would see with a placebo or sham treatment?

    Please define “spiritual.”

    Chiropractic “subluxations” have not been reliably proven to exist. That part is woo.

    The massage part is nice and seems to produce benefits similar to what physical therapists and massage therapists achieve.

  54. Lindsay Waterman says:

    I’ve been following this blog for several years and I’m heading to med school in the fall. Debates with sCAMmers is something I (naively, probably) look forward to. And actually already enjoy on a pretty regular basis, because almost everybody here in B.C. worships some sort of woo. Hopefully one day soon I will have the CAM-shattering critical thinking skills that bloggers here demonstrate.
    Until then, it’ll be the Germans that bombed pearl harbour.

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