Consider these statements:
…there is an evidence base for biofield therapies. (citing the Cochrane Review of Touch Therapies)
The larger issue is what constitutes “pseudoscience” and what information is worthy of dissemination to the public. Should the data from our well conducted, rigorous, randomized controlled trial [of ‘biofield healing’] be dismissed because the mechanisms are unknown or because some scientists do not believe in the specific therapy?…Premature rejection of findings from rigorous randomized controlled trials are as big a threat to science as the continuation of falsehoods based on belief. Thus, as clinicians and scientists, our highest duty to patients should be to investigate promising solutions with high benefit/risk ratios, not to act as gatekeepers of information based on personal opinion.
–Jain et al, quoted here
Touch therapies may have a modest effect in pain relief. More studies on HT and Reiki in relieving pain are needed. More studies including children are also required to evaluate the effect of touch on children.
Touch Therapies are so-called as it is believed that the practitioners have touched the clients’ energy ﬁeld.
It is believed this effect occurs by exerting energy to restore, energize, and balance the energy ﬁeld disturbances using hands-on or hands-off techniques (Eden 1993). The underlying concept is that sickness and disease arise from imbalances in the vital energy ﬁeld. However, the existence of the energy ﬁeld of the human body has not been proven scientiﬁcally and thus the effect of such therapies, which are believed to exert an effect on one’s energy ﬁeld, is controversial and lies in doubt.
—Cochrane Review of Touch Therapies, quoted here
Science is advanced by an open mind that seeks knowledge, while acknowledging its current limits. Science does not make assertions about what cannot be true, simply because evidence that it is true has not yet been generated. Science does not mistake absence of evidence for evidence of absence. Science itself is fluid.
When people became interested in alternative medicines, they asked me to help out at Harvard Medical School. I realized that in order to survive there, one had to become a scientist. So I became a scientist.
—Ted Kaptchuk, quoted here.
…It seems that the decision concerning acceptance of evidence (either in medicine or religion) ultimately reflects the beliefs of the person that exist before all arguments and observation.
—Ted Kaptchuk, quoted here.
Together they betray a misunderstanding of science that is common not only to “CAM” apologists, but to many academic medical researchers. Let me explain. (more…)
My co-bloggers and I have spent considerable time and effort over the last four years writing posts for this blog (and I for my not-so-super-secret other blog) bemoaning the infiltration of quackademic medicine into what once were bastions of evidence- and science-based medicine. We’ve discussed at considerable length reasons for why this steady infiltration of pseudoscience into medical academia has been occurring. Among other potential explanations, these reasons range from the ascendence of postmodernism in areas where it really doesn’t belong; to a change in our medical culture to a more “consumer”-oriented, “keep the customer satisfied”-sort of model in which patients are often referred to as “clients” or “customers”; to the corrosive influences of moneyed groups (such as the Bravewell Collaborative) and government agencies (such as the National Center for Complementary and Alternative medicine, a.k.a. NCCAM); to the equally corrosive influences of powerful woo-friendly legislators who use their position and influence to create such agencies (such as Senator Tom Harkin and Representative Dan Burton) and otherwise champion “complementary and alternative medicine” (CAM) and “integrative medicine” because they are true believers in quackery; to cynical legislators, like Senator Orrin Hatch, who champions such government programs supporting pseudoscience because he represents a state that is home to the largest concentration of supplement manufacturers in the United States and is consequently a master at bringing any initiative to regulate the supplement industry more tightly to a screeching halt.
As a result of our efforts and the need for a counterweight to the quackery that has infiltrated so much of academia, SBM has become fairly prominent in the medical blogosphere. Our traffic is good, and we have a number of “thought leaders” who regularly read what we write. We’ve even caught the attention of Dr. Josephine Briggs, director of NCCAM, and our founder Steve Novella was even invited to appear on The Dr. Oz Show for “balance.” All of this is something that we are justly proud of. On the other hand, I can’t help but keep things in perspective. While our traffic as a blog is quite respectable and we have become prominent in the skeptical and medical blogosphere and even, to some extent, in academia—we’re particularly gratified at the number of medical students who are regular readers—compared to the forces arrayed against SBM in academia and the media, we have to face facts: We are truly a tiny voice in the wilderness. For instance, we average around 9,000 to 16,000 visits a day. Compare that traffic to the many millions who used to watch Oprah Winfrey and still watch her protégé Dr. Oz or to health media and product empires of people like Andrew Weil and Deepak Chopra, and you get the idea.
All of this is why I started looking for opportunities to respond more directly to incursions of pseudoscience into medical academia. Occasional SBM contributor Peter Lipson provided me with just such an opportunity last summer when he sent me a link to a brain-meltingly bad study about the use of CAM in cancer that shows just how bad a study can be and still be published in what I used to consider a reasonably good cancer journal. I say “used to consider,” because the fact that this journal accepted a study this ludicrous indicates to me that its peer review is so broken that I now wonder about what else I’ve read in that journal that I should now discount as being too unreliable to take seriously. Maybe everything. I don’t know. What I do know is that seldom have I seen such a bad study in such a good cancer journal. Studies like the one about Tai Chi in fibromyalgia or placebo acupuncture applied to asthma don’t even come close.
Soon after this study appeared online ahead of print, James Coyne contacted me and asked me if I wanted to be co-author on a letter to the editor of the journal. Honored by Dr. Coyne’s request, I immediately said yes (of course), and together with Dr. Christoffer Johansen at the Survivorship Unit of the Danish Cancer Society, we submitted our letter to the editor. To my surprise, given the utter failure of past efforts to publish letters to the editor about studies of this sort, our letter was accepted for publication. Last week, the study in question saw print, and our letter was published online ahead of print, along with the response of the authors. All are instructive and, to me, show just what we are up against in trying to prevent pseudoscience from creeping into academia.
I’ve subscribed to Nature for many years now, even though I don’t always read it. Nature is one of the oldest and most respected scientific journals around. It’s been around since 1869 and is said to be the world’s most cited journal. What makes Nature unusual these days is that it’s one of the last of the remaining general science journals and one of the two that still publish original peer-reviewed research in a wide variety of scientific fields. Astronomy, physics, chemistry, medicine, biology, Nature publishes it all. The only other journal of its type that I can think of is Science, which also has a similar high impact factor. In any case, getting published in Nature is a big deal, one that can make a career. Believe it or not, I actually have a Nature publication. True, it’s from the 1990s, and, true, I’m only the fourth author, but it is a Nature publication. Ever since then, I keep telling myself that, one of these days, I’ll manage to find a way to be published again in Nature, although I realize that it’s looking increasingly unlikely that that will happen. Such is the power and cachet of Nature. It’s a name that has provided prestige to some of its spinoff journals, such as Nature Medicine, although of late Nature appears to have diluted the brand name beyond belief.
Nature sells out
All of the above is why I’m very, very disappointed in Nature for having dropped a huge lump of coal into the stockings of supporters of science-based medicine a mere three days before Christmas. Maybe its editors thought that it wouldn’t be noticed right before the holiday season. I don’t know. I do know that I noticed. Basically, Nature sold out to a Japanese pharmaceutical company, which, along with a research institute, bought a supplement in Nature that is in essence an advertorial for its point of view. Don’t believe me? Check out this acknowledgment of the sponsors published in the advertorial:
Every so often, I come across studies that leave me scratching my head. Sometimes, these studies are legitimate scientific studies that have huge flaws or come from an assumption that is very off-base. Other times, they involve what Harriet Hall has termed “tooth fairy science,” wherein the tools of science are used to study a phenomenon that is fantastical, whose very existence hasn’t been demonstrated. Many such studies, not surprisingly, are studies of “complementary and alternative medicine” (CAM) or “integrative medicine” (IM). Modalities like reiki (which is faith healing that substitutes Eastern mysticism for Christian beliefs) and homeopathy (which is, when you boil it down to its essence, sympathetic magic) fall into the category of therapeutic modalities that are based on fantasy but are studied as with the latest tools of science, producing no end to confusing noise. This “tooth fairy science” has, over the last few years, reached its epitome in the application of the latest genomics technology to, in essence, magic, and I’ve recently come across an incredible example of just such a thing. But, first, let’s take a step back to what is going on in medical science now before I introduce a concept that I’ve dubbed “woo-omics.”
A prelude to woo-omics: Genomics, proteomics, everywhere an “omics”
One of the most difficult problems in science-based medicine is how to do a better job identifying which patients will respond to which treatments. Clinical trials, by their very design, have to look at average responses in populations. In essence, a treatment is compared to either placebo or standard-of-care, a choice mainly driven by ethics and whether effective treatments exist for the condition being studied. It is then determined using statistics whether a significant difference exists between the two groups. The difficulty, as any clinician knows, is applying the results of clinical trials to individual patients. In any population, there is, after all, a range of responses to any drug or treatment, and it would be desirable to be able to predict which patients will fall at the end of the bell-shaped curve where the treatment is most effective and which will fall at the end of the curve where the treatment works poorly or not at all.
Last Thursday, I had the distinct privilege and honor to be invited to speak at Grand Rounds at the Florida State University College of Medicine in Tallahassee. Ray Bellamy, who is on the faculty there and is also the husband of our very own Jann Bellamy (who is herself is the founder of the Campaign for Science-based Health Care), invited me down to give a talk on “complementary and alternative medicine” (CAM) and “integrative medicine” (IM). Although I’ve spoken to skeptics’ groups, such as local groups or even to workshops at The Amazing Meeting, and to medical students’ groups, this represented the first time I had been invited to speak in front of a large group of medical professionals, not all of whom necessarily agreed with our viewpoint here at SBM. So it was with some trepidation that last Wednesday I braved the trip to Tallahassee, with the unfortunately requisite connection in Atlanta that necessitated my practically running from one end of that massive airport to the other in order to make my connection to the little puddle jumper of a jet that took me to Tallahassee. Whether or not my talk was a success or not, readers can judge for themselves, as it’s been posted online on the FSU Grand Rounds page. (Just scroll down to November 10 and then hit the link. Unfortunately, it appears that you’ll need Microsoft Silverlight to get the video to work.) I haven’t watched the whole thing yet, but I encourage you to do so and tell me how good (or bad) I was and why. I want to get better, and I won’t rest until I’m as good at communicating medicine as Neil deGrasse Tyson or Richard Wiseman, for instance, is at communicating science.
A Loose End
In the last post I wondered if Ted Kaptchuk, when he wrote the article titled “Effect of interpretive bias on clinical research,” had understood this implication of Bayes’s Theorem: that interpretations of most scientific investigations are exercises in inverse probability, and thus cannot logically be done without consideration of knowledge external to the investigation in question. I argued that if Kaptchuk had
…understood the point when he wrote his treatise, he was dishonest in not explaining it and in not citing at least one pertinent article, such as Steven Goodman’s (which I’m willing to bet he had read). If he didn’t understand the point he should have withheld his paper.
In researching more of Kaptchuk’s opinions I’ve discovered that he had certainly read Goodman’s article, but that he either didn’t understand it or preferred to obscure its implications in deference to his ongoing project in belittling scientific knowledge. In a letter to the editor of the Annals of Internal Medicine in 2001, Kaptchuk opined that even if “more trials of distant healing with increased methodologic rigor” were positive, it still would not “be persuasive for the medical community”:
The situation resembles the predicament with homeopathy trials, another seemingly implausible intervention, where the evidence of multiple positive randomized, controlled trials will not convince the medical community of its validity. Additional positive trials of distant healing are only likely to further expose the fact that the underpinning of modern medicine is an unstable balance between British empiricism (in the tradition of Hume) and continental rationalism (in the tradition of Kant).
…It seems that the decision concerning acceptance of evidence (either in medicine or religion) ultimately reflects the beliefs of the person that exist before all arguments and observation. [Kaptchuk cites the second of the two Goodman articles that I referred to above, discussed here]
Since I have a master’s and doctoral degree in health education and since I’m a professor in a department of public health with an undergraduate curriculum that includes substantial attention to health education, I participate in the email discussion group of HEDIR, the Health Education Directory. On August 16th, I received a message to the discussion group from the American Association for Health Education inviting participants to complete an online survey from the Joint Committee on Health Education and Promotion Terminology with results to be analyzed at the Committee’s meeting in September 2011.
The survey items include various terms used by health educators, the currently approved terminology, and three choices followed by a type-in box:
- This term should remain as defined
- This term should remain in the report but modified in definition
- This term is no longer commonly used in health education/health promotion literature
If modify, please provide the suggested wording and reference for that definition if you are citing it from a specific source.
For one of the terms, my preferred response would have be have been a fourth choice that was not offered: The term is commonly used in health education/health promotion and elsewhere, but it should not be used because its use only serves to distort our thought processes and promote quackery.
Here is the term along with the definition presented in the survey:
Complementary and Alternative Health Practices: These practices generally include natural substances, physical manipulations, and self-care modalities. These approaches often incorporate aspects of interventions derived from traditional practices. The approach in Western societies has been to select specific approaches from these systems and apply them to health maintenance, health enhancement, or disease management. Such approaches can be used to compliment[sic] conventional allopathic care (complementary therapy), or as an alternative to conventional approaches (alternative therapy). Many of these complementary and alternative approaches have not been validated through experiential research, but those that have, such as acupuncture for pain, are being integrated into conventional health practices (integrative medicine).
And here are my objections to the term and to the definition given:
“Strong Medicine”: Ted Kaptchuk and the Powerful Placebo
At the beginning of the first edition of The Web that has no Weaver, published in 1983, author Ted Kaptchuk portended his eventual academic interest in the placebo:
A story is told in China about a peasant who had worked as a maintenance man in a newly established Western missionary hospital. When he retired to his remote home village, he took with him some hypodermic needles and lots of antibiotics. He put up a shingle, and whenever someone came to him with a fever, he injected the patient with the wonder drugs. A remarkable percentage of these people got well, despite the fact that this practitioner of Western medicine knew next to nothing about what he was doing. In the West today, much of what passes for Chinese medicine is not very different from the so-called Western medicine practiced by this Chinese peasant. Out of a complex medical system, only the bare essentials of acupuncture technique have reached the West. Patients often get well from such treatment because acupuncture, like Western antibiotics, is strong medicine.
Other than to wonder if Kaptchuk had watched too many cowboy ‘n’ Native American movies as a kid, when I first read that passage I barely blinked. Although the Chinese peasant may have occasionally treated someone infected with a bacterium susceptible to his antibiotic, most people will get well no matter what you do, because most illnesses are self-limited. Most people feel better even sooner if they think that someone with special expertise is taking care of them. If you want to call those phenomena the “placebo effect,” in the colloquial sense of the term, fine. That, I supposed, was what Kaptchuk meant by “strong medicine.”
Turns out I was mistaken. Let’s briefly follow Kaptchuk’s career path after 1983. In the 2000 edition of The Web, he wrote:
A board certification in woo?
I’ve been harshly critical of the entire concept of “integrative medicine” (IM), which has over the last few years nearly supplanted the former term used for non-science-based medicine or medicine based on prescientific ideas represented as though it were scientific medicine, “complementary and alternative medicine” (CAM). Indeed, just last week I pointed out how IM is far more about marketing than it is about science or medicine, and over the last three years I’ve been particularly harsh on the concept of “integrative oncology,” which is actually being represented as a “subspecialty” of IM. Despite the utter lack of a rationale based on science or the scientific basis of medicine, IM has still been making inroads into academic medical centers, where I tend to refer to it with the unapologetically disparaging term “quackademic medicine.” Even worse, now, increasingly, such woo has been insinuating its way into community medical centers as well.
Arguably, the man who has done more than any individual to promote the quackification of science-based medicine is Dr. Andrew Weil. (At least, I can’t think of any single person who’s done more during his lifetime to promote the infiltration of quackery into medicine. Readers are free to chime in if they know of someone who could challenge Weil for the title of King of Quackademic Medicine.) As I pointed out the last time I discussed him, Dr. Weil doesn’t really like science-based medicine. Oh, no, he doesn’t like it at all. Unfortunately, he’s been very successful in promoting quackademic medicine. He’s also arguably been the single most successful person at legitimizing what used to be viewed as quackery. Master of the domain of “integrative medicine,” having formed a model of an “integrative medicine in residency” that’s spread like kudzu through quackademia, all from his redoubt at the University of Arizona, Dr. Weil has now announced his intention for the next phase of his “integrating” pseudoscience with SBM. I learn this from The Integrator Blog, which has as a recent headline from last week Special Report: “Strategic Change in Direction” as Weil’s Arizona Center Commits to Creation of American Board of Integrative Medicine:
In a major strategic shift, the University of Arizona Center for Integrative Medicine (ACIM) has announced that it will lead the creation of a formal specialty for medical doctors in integrative medicine. ACIM, founded by Andrew Weil, MD and directed by Victoria Maizes, MD, is in dialogue with the American Board of Physician Specialties toward establishing an American Board of Integrative Medicine. They are collaborating with leaders of the American Board of Integrative and Holistic Medicine (ABIHM). Here is the ACIM announcement, a statement from two ABIHM leaders, a brief interview with Maizes and the list of 18 founding Board members. Is this the right strategic choice? What impact will this have on integrative medicine and the broader integrative healthcare movement?
A Brief Clinical Vignette
In researching this post, I found an article published nearly two years ago in The Hospitalist entitled Growth Spurt: Complementary and alternative medicine use doubles, which began with this anecdote:
Despite intravenous medication, a young boy in status epilepticus had the pediatric ICU team at the University of Wisconsin School of Medicine and Public Health in Madison stumped. The team called for a consult with the Integrative Medicine Program, which works with licensed acupuncturists and has been affiliated with the department of family medicine since 2001. Acupuncture’s efficacy in this setting has not been validated, but it has been shown to ease chemotherapy-induced nausea and vomiting, as well as radiation-induced xerostomia.
Following several treatments by a licensed acupuncturist and continued conventional care, the boy’s seizures subsided and he was transitioned to the medical floor. Did the acupuncture contribute to bringing the seizures under control? “I can’t say that it was the acupuncture — it was probably a function of all the therapies working together,” says David P. Rakel, MD, assistant professor and director of UW’s Integrative Medicine Program.
The UW case illustrates both current trends and the constant conundrum that surrounds hospital-based complementary medicine: Complementary and alternative medicine’s use is increasing in some U.S. hospitals, yet the existing research evidence for the efficacy of its multiple modalities is decidedly mixed.
My jaw dropped in horror when I read this story. Acupuncture for status epilepticus? There’s no evidence that it works and no scientific plausibility suggesting that it might work. And what does the questionable research suggesting that acupuncture might ease chemotherapy-induced nausea and vomiting or radiation-induced xerostomia (which, if you look more closely at the studies, it almost certainly does not, but that’s a post for another time) have to do with this case, anyway? Nothing. Worse, Dr. Rakel fell for the classic post hoc ergo propter hoc fallacy; i.e., despite his disclaimer, he appears to be implying that, because the child recovered, acupuncture must have contributed to his recovery. He also repeats the classic fallacy that I’ve written about time and time again in the context of cancer therapy, namely that if a patient is using quackery as well as science-based medicine, then either it was the quackery that cured him or the quackery somehow made the conventional medical care work better.
I expect better from an academic medical center like the University of Wisconsin. Unfortunately, increasingly I’m not getting it. Quackademic medicine is infiltrating such medical centers like kudzu.