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More Dialogs

There is no alternative medicine. There is only scientifically proven, evidence-based medicine supported by solid data or unproven medicine, for which scientific evidence is lacking. JAMA

Just just because there are flaws in aircraft design that doesn’t mean flying carpets exist. Ben Goldacre

Wiser heads than I have commented on “Invitation to a Dialogue: Alternative Therapies” in The New York Times. So why add my two cents? Partly because The New York Times wanted brief responses and I don’t do brief. Partly because I write for me; nothing focuses the mind like putting electrons to LCD, except, perhaps, a hanging. Partly we do need a dialog, just not of the kind suggested by the writer. And partly, life has been so busy of late I needed a topic that required no research.

The letter starts:

…the Affordable Care Act will likely reinforce current practice, which dictates surgical and pharmacological interventions that can be expensive, inappropriate, burdened by side effects and, often, ineffective.

Yep. Medicine has issues. And the solution? Using therapies based on fantasy and magic? Most alternative therapies cost money, have no good indications, have known side effects and are always ineffective beyond the wishful thinking of its practitioners. Those are the defining characteristics of alternative medicine. But what are alternative therapies? Even the NCCAM, given millions to study it, has no idea. One of the many ways the NCCAM inspires confidence.

But that gets to terminology. I am used to thinking of using a specific intervention for specific problem. Cephalexin for cellulitis. Proponents of alternative medicine rarely specify a specific treatment for a specific disease, since so many of their interventions are recommended for everything. Except, as I have noted before, birth control. To suggest we should have a dialog about the use of alternative medicine without being specific is to like suggesting we should discuss antibiotics not only for the treatment of infections but all of medicine. They remain vague, an ill-defined target.

Forty years ago, as a researcher at the National Institute of Mental Health, I began to study inexpensive self-care strategies — then called “alternative therapies” — that might address the underlying biological and psychological imbalances that contribute to chronic conditions. These included nutrition, exercise and “mind-body” techniques like meditation, guided mental imagery and biofeedback.

So it is hard to discuss the utility of SCAMs when the terms are so loose. I tend to think of SCAMs as coming in four varieties:

Type 1: Total nonsense with zero prior plausibility. These are SCAMs based on ideas divorced from reality as I understand it, cannot have efficacy and do not have efficacy. It includes, but is not limited to, homeopathy, acupuncture, chiropractic, ayurveda, reiki and other energy therapies, iridology, applied kinesiology, craniosacral therapy, water therapy, and on and on and on.

People who inflict these modalities on others may be well intentioned, but as we all know “the road to Hell is paved with frozen alternative care providers. On weekends, many of the younger demons go ice skating down it.”

All type 1 SCAMs are useless, non-reality-based magic. I would think anyone who proposes this type of SCAM for diagnosis and treatment should be kept as far from providing medical care as is feasible.

Type 2: Those SCAMs that may or may not have efficacy. These are mostly various herbs, whose reasons for use are often historical or related to aggressive marketing.

The prior plausibility that a given herb will actually have efficacy for a given disease is small, but not zero, and occasionally an herb or supplement, like red yeast rice, is discovered to have actual active ingredients and effect.

Type 3: Those SCAMs where a little efficacy in the test tube or in a small, poorly-done study that is blown out of all proportion to its real effect. The effects are perhaps real, often small, and usually not clinically relevant. Green coffee beans are a recent example, thank you very much Dr. Oz.

Type 4: SCAMs that are not SCAMs at all. For example, diet and exercise. Diet and exercise are often part of the marketing of SCAM, and there is nothing alternative about diet and exercise.

Often interventions that are not SCAMs are labeled as such in inflate popularity or used as a Trojan rabbit for more fantasy-based therapies.

This is what the author is suggesting as ‘alternative’: diet, exercise and relaxation techniques. I practice in teaching hospitals and to suggest diet and exercise are ‘alternative’ is laughable. Diet and exercise are major parts of the interventions used by and taught to our residents. Getting them implemented, especially in a clinic serving the underprivileged, is a challenge. I have a shtick that there are 4 things in medicine that are 100% sensitive and specific. I think I will add a fifth. Anyone who thinks diet and exercise are alternative is a shill for Big Alternative and is using advertising, not information.

The author does limit his definition of alternative to that which isn’t alternative, but I suspect a physician who writes:

homeopathic remedies are effective for common conditions such as asthma, arthritis and allergies

and recommends a book on homeopathy for his patients probably lives in a different reality than I do and has wider hopes for the application of pseudomedicines than just diet and exercise.

We spend about twice as much as many other industrialized nations on health care, often with inferior outcomes. Three-quarters of that spending is on chronic conditions, including heart disease, diabetes, cancer, arthritis, depression and chronic pain — exactly the ones for which self-care is best suited. Comprehensive programs that offer self-care in a supportive group are even more promising, for both treatment and prevention. This approach is also proving effective for psychological trauma.

Absolutely. A “comprehensive programs that offer self-care in a supportive group.” A fabulous idea. The problem is not a lack of alternative therapies in health care, but a lack of organization and coherence in the application of reality-based medicine to patients. In my system we call them Medical Homes. It is difficult to apply the concept in a country where medical insurance and organization is fractured and FUBAR, but it can be done.

So Dr. Gordon has it half right when he finishes:

If we are going to reduce our ruinous costs and improve our declining national health, we must make self-care and group support central to all care.

But with reality-based medicine, not the fantasy-based interventions that define so much of alternative medicine

We do not need a dialog on the need for SCAMs in healthcare. That would be ignoring more fundamental issues in US healthcare.

There are two dialogs we need: one is on the structure of health care in the US. Ain’t gonna happen in my lifetime as best I can tell.

The other dialog in medicine is what standards we are going to use in deciding care for patients – what constitutes valid research and how it will be applied to patient care.

Reality-based practice has important issues with inadequate or biased data, as “How evidence-based medicine is failing due to biased trials and selective publication” nicely reviews. Those problems are increased many fold in the world of alternative medicine research.

Is the standard going to be reality-based interventions with high quality studies free of financial and other bias? I suspect not. For alternative medicine, the standard is badly designed, badly controlled and ineptly reviewed clinical trials with negative or equivocal results to justify the use of interventions with no basis in known reality. The alternative medicine studies are haunted by poor methodology and a bias far more insidious and difficult to recognize than the bias from money.

Conflicts of interest are very common in biomedical research , and typically they are inadequately and sparsely reported. Prejudice may not necessarily have financial roots. Scientists in a given field may be prejudiced purely because of their belief in a scientific theory or commitment to their own findings. Many otherwise seemingly independent, university-based studies may be conducted for no other reason than to give physicians and researchers qualifications for promotion or tenure. Such non financial conflicts may also lead to distorted reported results and interpretations.

Although it matters not a whit if quality studies show that highly implausible therapies such as homeopathy, reiki or acupuncture do nothing beyond placebo. There has never, ever, been an alternative therapy that has changed or been abandoned as a result of quality biomedical trials. Instead those discredited interventions become part of the core curriculum at naturopathic, chiropractic, acupuncture and other schools of pseudo-medicine. And has there ever been a published study of alternative medical practice whose goal is to improve practice and patent safety? Not that I can find. One would think acupuncture, with its puncturing of the skin, would be a low-hanging fruit for quality improvement. Guess not as no one has seen fit to improve:

The current situation is that acupuncturists have understanding insufficiency in hospital infection management, lack the sterile concepts and consciousness of disinfection and isolation. Aseptic technic principles aren’t strictly followed; disinfection and isolation systems are unsound; sanitary condition of hand of medical staff is unsatisfied; and there is shortness in traditional long filiform needle manipulation.

or the situation of naturopaths:

Concerning the hygiene control visits, a concept for hygiene was lacking in 79% of 109 practices, while in 49% a concept for cleaning and disinfection was also missing. In 60% of the practices, a dispenser for hand disinfection was lacking.

Somehow substituting or including the eternal and unchanging ‘truths’ of alternative medicine with no ability or interest in quality improvement, change or efficacy does not seem to me to be in the patients’ best interest. What has made medicine more effective and safer in my career is the ability for self-evaluation and subsequent change, a feature completely lacking in alternative medicine. There is no All Trials equivalent in the world of alternative medicine, much less a push for basic quality improvements like proper hand hygiene.

Judging from the continued expansion of magic into medical care, I suspect an interest in standards is lacking. The vast majority of docs don’t care, as mentioned by yet another shruggie:

If you get benefit from complementary therapies, who are we to argue? Those therapies might be able to meet your emotional and spiritual needs in a way that a blister-pack of Ibuprofen and ten minutes of weary scepticism just can’t manage.

Integrative Medicine Programs will continue to grow, with:

Services available in Flemington by appointment include acupuncture, massage therapy, nutrition counseling, herbal medicine consultations, and Reiki

in academic centers and the community hospitals. Those with the cash will get their alternative therapies, whether it is effective or even ethical to provide. It is a good thing I learned a long time ago that it is the journey, not the destination, that can be important.

Every day I see huge gaps and barriers to providing effective and quality care due to a deeply flawed health care system. People paying with their lives, health and financial wellbeing, due to lack of access to affordable science-based medicine, not a lack of access to alternative medicine, however it may be defined. That is the dialog that is lacking.

Posted in: Basic Science, Clinical Trials, Critical Thinking, Science and Medicine

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