Alternative medicine by definition is medicine that has not been shown to work any better than placebo. Patients think they are helped by alternative medicine. Placebos, by definition, do “please” patients. We would all like to please our patients, but we don’t want to lie to them. Is there a compromise? Is there a way we can ethically elicit the same placebo response that alternative theorists elicit by telling their patients fairy tales about qi, subluxations, or the memory of water?
Psychiatrist Morgan Levy has written a book entitled Placebo Medicine. It’s available free online. In it, he makes an intriguing case for incorporating the best alternative medicine placebo treatments into mainstream medicine.
In a light, entertaining style, he covers the placebo effect, suggestibility, and the foibles of the human thought processes that allow us to believe a treatment works when it doesn’t.
“Thinking like a human” is not a logical way to think but it is not a stupid way to think either. You could say that our thinking is intelligently illogical. Millions of years of evolution did not result in humans that think like a computer. It is precisely because we think in an intelligently illogical way that our predecessors were able to survive… [by acting on quick assumptions rather than waiting for comprehensive, definitive data]… We have evolved to survive, not to play chess.
He offers evidence from scientific studies indicating that belief in a treatment and the power of suggestion can have actual physiologic consequences such as production of endorphins or changes on brain imaging studies. He spices his narrative with colorful stories, including anecdotes from his own sex life and an impassioned plea (tongue in cheek?) for everyone to drink coffee for its proven benefits. (more…)
In discussions of that bastion of what Harriet Hall likes to call “tooth fairy science,” where sometimes rigorous science, sometimes not, is applied to the study of hypotheses that are utterly implausible and incredible from a basic science standpoint (such as homeopathy or reiki), the National Center of Complementary and Alternative Medicine (NCCAM), I’ve often taken Senator Tom Harkin (D-IA) to task, as have Drs. Novella, Lipson, and Atwood. That’s because Senator Harkin is undeniably the father of that misbegotten beast that has sucked down over $2.5 billion of taxpayer money with nothing to show for it. NCCAM is the brainchild of Senator Harkin, who foisted it upon the National Institutes of Health not because there was a scientific need for it or because scientists and physicians cried out for it but rather because Senator Harkin, who believed that alternative medicine had healed a friend of his, wanted it, and he used his powerful position to make it happen, first as the Office of Unconventional Therapies, then as the Office of Alternative Medicine, and finally as the behemoth of woo that we know today as NCCAM. The result has included a $30 million trial of chelation therapy in which convicted felons were listed among the investigators and a totally unethical trial of the Gonzalez therapy for pancreatic cancer. It’s not for naught that Wally Sampson called for the defunding of NCCAM, as have I and others. Not surprisingly, alternative medicine practitioners are appalled at this idea.
Most recently, Harkin has been most disturbed by the observation that NCCAM’s trials have all been negative, going so far as to complain that NCCAM hasn’t produced any positive results showing that various alternative therapies actually work. This is, of course, not a surprise, given that vast majority of the grab bag of unrelated (and sometimes theoretically mutually exclusive) therapies are based on pseudoscience. One of the only exceptions is the study of herbal remedies, which is a perfectly respectable branch of pharmacology known as pharmacognosy. Unfortunately, as David Kroll showed, in NCCAM the legitimate science of pharmacognosy has been hijacked for purposes of woo. Meanwhile, earlier this year, Senator Harkin hosted a hearing in which Drs. Dean Ornish, Andrew Weil, Mehment Oz, and Mark Hyman (he of “functional medicine“) were invited to testify in front of the Senate. Add to that other powerful legislators, such as Representative Dan Burton (R-IN), trying to craft legislation in line with his anti-vaccine views and pressure the NIH to study various discredited hypotheses about vaccines and autism. Clearly, when it comes to quackery, there are powerful legislative forces promoting pseudoscience and studies driven by ideology rather than science.
A neglected skeptic
Near the end of my series* on ‘Acupuncture Anesthesia’, I wrote this:
Most Westerners—Michael DeBakey and John Bonica being exceptions—who observed ‘acupuncture anesthesia’ in China during the Cultural Revolution seem to have failed to recognize what was going on right under their noses.
I should have added—and I now have—Arthur Taub’s name to that tiny, exceptional group. Taub, a neurologist and neurophysiologist at Yale, was a member of a delegation of Americans sent to China to observe ‘acupuncture anesthesia’ in May of 1974, about a year after Dr. Bonica‘s visit. The delegation included several prominent anesthesiologists. Their report, Acupuncture Anesthesia in the People’s Republic of China: A Trip Report of the American Acupuncture Anesthesia Study Group, was published in 1976 and is available in its entirety here. Excerpts follow (emphasis added):
Pain is a subjective experience. Judging whether an individual is in a state of pain depends on observations of the subject’s behavior, including verbal reports to the observer…When there is no evidence of pain, the observer can adopt one of three positions: (more…)
Alternative medicine practitioners love to coin magic words, but really, how can you blame them? Real medicine has a Clarkeian quality to it*; it’s so successful, it seems like magic. But real doctors know that there is nothing magic about it. The “magic” is based on hard work, sound scientific principles, and years of study.
Magic words are great. Terms like mindfulness, functional medicine, or endocrine disruptors take a complicated problem and create a simple but false answer with no real data to back it up. More often than not, the magic word is the invention of a single person who had a really interesting idea, but lacked the intellectual capacity or honesty to flesh it out. Magic is, ultimately, a lie of sorts. As TAM 7 demonstrates, many magicians are skeptics, and vice versa. In interviews, magicians will often say that they came to skepticism when the learned just how easy it is to deceive people. Magic words in alternative medicine aren’t sleight-of-hand, but sleight-of-mind, playing on people’s hopes and fears.
In searching for just what FM is, one has to in a way read between lines. Claiming to treat the “underlying cause” of a condition raises the usual straw man argument that modern medicine does not, which of course is untrue. It also implies that there are underlying causes known to them and not to straights. FM claims to treat chronic disease which FM claims is inadequately treated by medicine. FM claims to be a more advanced approach both in conceptual thinking and in practical management. Such claims are on the face doubtful, but hard to disprove. The way to find out would be to analyze cases they manage and critique them.
I tried to see specific examples of treatments but the web page text book links were not working at the time. I understand others have seen the contents and perhaps can add some information. I sense a difference between “CAM” and FM – at least among the MDs and DOs – is that FMers tend to use methods and substances with some degree of scientific or biochemical rationale, even if not proved, moreso than many of the CAMers. Many seem to practice both systems or do not distinguish between the two systems. In order to get a sense of the degree to which FM is known, I requested from the web page the names of practitioners in a 50 mile radius of my home (near Palo Alto, Calif.). The names ranged from Santa Cruz (40 miles) to Berkeley (50) and San Francosco (40) and Marin County (Sausalito – 50 miles) The population of that area is about 5 million. They sent 46 names: MD/DO 31 – (including a nephrologist formerly on the staff of my teaching hospital) PhD 1 DC 8 Lac 3 ND 2 RN 1 Because I had become aware of FM only 1-2 years ago, I thought 46 was a relatively large number. The Web page lists four text books published in the past few years. A manuscript of the first one is available on line for downloading (not functioning when I tried.) . 21st Century Medicine: A New Model for Medical Education and PracticeMonograph Set – Functional Medicine Clinical Monograph Set – CME Available Textbook of Functional Medicine Clinical Nutrition: A Functional ApproachAs mentioned, I could not activate the links to those books, and did not have time to get to them individually. No authors were listed.
Have you ever been surprised and confused by what seem to be conflicting results from scientific research? Have you ever secretly wondered if the medical profession is comprised of neurotic individuals who change their mind more frequently than you change your clothes? Well, I can understand why you’d feel that way because the public is constantly barraged with mixed health messages. But why is this happening?
The answer is complex, and I’d like to take a closer look at a few of the reasons in a series of blog posts. First, the human body is so incredibly complicated that we are constantly learning new things about it – how medicines, foods, and the environment impact it from the chemical to cellular to organ system level. There will always be new information, some of which may contradict previous thinking, and some that furthers it or ads a new facet to what we have already learned. Because human behavior is also so intricate, it’s far more difficult to prove a clear cause and effect relationship with certain treatments and interventions, due to the power of the human mind to perceive benefit when there is none (placebo effect).
Second, the media, by its very nature, seeks to present data with less ambiguity than is warranted. R. Barker Bausell, PhD, explains this tendency:
A new study suggests that it may not be uncommon for patients who are in a minimally conscious state to be misdiagnosed as being in a persistent vegetative state. The study underscores the necessity of using standardized and objective diagnostic criteria in diagnosing coma. However, it also leaves some important questions unanswered.
As background it is essential to understand a bit about consciousness and coma, for not all comas are created equally. In order to be conscious a person requires at least one hemisphere of the brain be mostly functioning and they require a functioning brainstem. The cortical hemispheres contain the gray matter – that part of the brain that thinks. So it makes sense that a certain minimal amount of gray matter is necessary to generate consciousness. As gray matter is damaged or inhibited from functioning one’s level of consciousness decreases until it descends beyond that fuzzy boundary into unconsciousness. When such unconsciousness is persistent we call that coma.
But interestingly the cortex by itself cannot generate consciousness. It requires constant prodding by a diffuse region in the brainstem (that primitive part at the base of the brain that connects the brain and the spinal cord) called the brainstem activating system. This region sends a constant barrage of electrical signals through the thalamus (the relay center of the brain) and then onto the cortex. Without this constant stimulation the cortex will lapse into sleep and coma.
Tylenol (acetaminophen, also known as paracetamol outside the US) has been in the news recently. Most of the stories I’ve seen have been accurate, but I’ve run across a couple of people who misunderstood what they read. I thought I’d try to put the record straight.
An FDA advisory panel has recommended reducing the maximum allowed single dose from 1000 mg to 650 mg in over-the-counter acetaminophen products. The 1000 mg dose would be available by prescription only. They also recommended eliminating painkillers like Percocet and Vicodin that contain a combination of a narcotic and acetaminophen. They did not recommend removing acetaminophen from over-the-counter cold remedies, cough medicines and similar products that combine acetaminophen with other drugs. Advisory panel recommendations are not binding, but the FDA usually follows them.
Some people got the impression that the FDA had just discovered that acetaminophen can be dangerous. No, we always knew that. The danger is when you take too much: it can damage the liver. The “new” information is just that acetaminophen overdose is now the leading cause of liver damage, causing an estimated 1600 cases of liver failure each year. (more…)
In 1994, Congress enacted the Dietary Supplement Health and Education Act (DSHEA). This act allows for the marketing and sales of “dietary supplements” with little or no regulation. This act is the work of folks like Tom Harkin (who took large contributions from Herbalife) and Orrin Hatch, whose state of Utah is home to many supplement companies.
DSHEA has a couple of very important consequences (aside from filling the pockets of supplement makers). (more…)
Screening for disease is a real pain. I was reminded of this by the publication of a study in BMJ the very day of the Science-Based Medicine Conference a week and a half ago. Unfortunately, between The Amaz!ng Meeting and other activities, I was too busy to give this study the attention it deserved last Monday. Given the media coverage of the study, which in essence tried to paint mammography screening for breast cancer as being either useless or doing more harm than good, I thought it was imperative for me still to write about it. Better late than never, and I was further prodded by an article that was published late last week in the New York Times about screening for cancer.
If there’s one aspect of medicine that causes more confusion among the public and even among physicians, I’d be hard-pressed to come up with one more contentious than screening for disease, be it cancer, heart disease, or whatever. The reason is that any screening test is by definition looking for disease in an asymptomatic population, which is very different from looking for a cause of a patient’s symptoms. In the latter case, the patient is already being troubled by something that is bothering him. There may or may not be a cause in the form of a disease or syndrome that is responsible for the symptoms, but the very existence of the symptoms clues the physician in that there may be something going on that requires treatment. The doctor can then narrow down range of possibilities for what may be the cause of the patient’s symptoms by taking a careful history and physical examination (which will by themselves most often lead to the diagnosis). Diagnostic tests, be they blood tests, X-rays, or other tests, then tend to be more confirmatory of the suspected diagnosis than the main evidence supporting a diagnosis.