Perpetual Motion: More on the Bravewell Report

I’m not here to convince people that we are right, although it would be nice if it turned out that way. I’m here to tell the truth and let readers decide for themselves.

— Kimball Atwood, Science Based Medicine, Bravewell Bimbo Eruptions

I had been too inarticulate to formulate what is essentially my approach to this blog: to tell the truth. That would appear to be simple enough. Of course it gets down to what constitutes the truth, and whether you can handle the truth.

What is truth, small ’t’? Truth with a big ’T’ is provided by belief systems that originate in a personal epiphany and you suddenly understand the meaning of life, the universe and everything. Or conjure up reiki or chiropractic. I suspect I was either born without the part of the brain that allows me to appreciate the mystical/spiritual aspects of human existence, or perhaps it was my upbringing. Probably a bit of both, although having raised two kids in the eternal nurture/nature debate has swayed me heavily towards the nature side of the fence. I bet I was born that way. But I am totally tone deaf to issues of spirituality and the surrounding issues of big ’T’ Truths, so I am going to stick to the little ’t’ truths.

Little ’t’ truths’, or as I like to call them, facts, consists of the approximate understanding of the reality provided by the scientific method. Note the word approximate. I have always liked Richard Dawkins metaphor of science as climbing a series of peaks (at least that is how I remember it, having read the book years ago). Get to the top of one peak, and it provides a vista of understanding, but there is always another peak to climb to offer an even more comprehensive view of the topic. Every year our understanding of reality is refined and extended. Understanding something as ostensibly simple as influenza vaccination gets more sophisticated and subtle every year. It is not as simple as give an antigen, develop an antibody and become immune to that strain of flu. It is the continuing increased understanding of the multiple facets of infectious diseases is in part what makes ID the most endlessly fascinating specialty in medicine.

There are still lots of unexplained phenomena in the universe, but mostly at the extremes of scale: the quantum level and the universe. At the approximation of the human scale, the scaffolding upon which we hang our understanding is quite well worked out. The basic sciences (physics, chemistry, biochemistry, anatomy, physiology, pharmacology, evolution, etc.) that inform our understanding of medicine do not leave any space for ‘new’ concepts. The existing concepts that underlie medicine do not support much of what passes for the underlying mechanisms that are the alleged basis of supplements, complementary and alternative medicine (SCAM’s). If is more to human existence, wondrous strange, I have yet to see it demonstrated.

O day and night, but this is wondrous strange!

And therefore as a stranger give it welcome.
There are more things in heaven and earth, Horatio,
Than are dreamt of in your philosophy.

If there are phenomena at the human scale that exist outside our understanding of the basic sciences, it has never been demonstrated over and above the ability for humans to convince themselves that magic exists. My philosophy seems pretty comprehensive

At some level I am not a ‘true’ skeptic, since given the current understanding for the reality, the following not only do not exist, but cannot exist. Their prior probability is zero. A true skeptic would give credence to the possibility, however small, that a counterexample could be produced to confirm the reality of some bit of pseudoscience. The following incomplete list do not and cannot be true, small ‘t’, and are fictions:

  • Telepathy
  • Astrology
  • Psychics
  • Talking to the dead (or at least the dead talking back)
  • Homeopathy
  • Chiropractic subluxations and all interventions that derive from that idea
  • Meridians and chi, and all interventions that derive from the idea
  • Energy medicine
  • Reiki
  • Therapeutic touch
  • Iridology
  • Reflexology
  • Craniosacral therapy
  • Large swaths of naturopathic training,

It reinforces the idea that science based medicine is reality based medicine. SBM is based on facts and small ’t’ truths. While SCAM’s use the tools of science, much of the underling conceptual framework is imaginary. Dr. Hall’s idea of Tooth Fairy Science conceptualizes the idea perfectly.

There is a lot of uncertainty in medicine, both diagnostically and therapeutically. What does the patient have and how best to treat it can be very complex and the often the most reliable diagnostic intervention, the autopsy, is refused by the patient. The uncertainty in medicine is still within the framework of the sciences and the difficulty in the sorting through the great variability of disease presentation and treatments requires no understanding of CSF tides, energy blockages or Laws of Similars.

Chronic Fatigue Syndrome, CFS, is perhaps a good example where medicine fails. There are still no diagnostic or therapeutic interventions that shed light on the disease or improve the quality of life for the patients. I remain reasonably convinced that a subset of CFS patients have an infectious trigger, and that someday we will have an understanding of the pathophysiology of these patients. I do not think it is ‘all in their head’, although as Takotsubo cardiomyopathy demonstrates, there is a mind-body connection, just not the mystical connections promulgated by many SCAM providers. There are no features about CFS to suggest its etiology will not eventually be amenable to understanding. As I have mentioned before, humans operate within very narrow physiologic parameters and have a limited repertoire with which to respond to the environment and CFS appears to be variations on a theme.

In medicine we have an understanding of truth, of reality, an expanding collection of facts and their interrelationship, provided by the basic sciences. At the center of medicine is applying that reality as best as is possible to ill, frightened people. The ill are vulnerable. When you are sick you often do not have the luxury to search for the best product available, like finding a TV on consumer reports. And even if you have the time, the complexity of medicine may preclude a good understanding of what the diagnosis and therapy. Hell, when I had my lipids checked, my primary said they were bad. She started to talk about LDL and HDL and ratio’s and risks and I stopped her. I didn’t care. I have better things to occupy my neurons with than lipids; I have blogs to write. What did I need to do? Lose weight. So I did. Now my lipids are fine. Just do not ask me what my numbers are or what they mean. I don’t care to learn the ins and outs of lipids; I trust my doctor.

There was a time when medicine was less standardized and reality based. At the beginning of the 20th century there were multiple competing forms of medicine and no standardization of medical education. Becoming a doctor could be as easy as hanging up you shingle, declaring that since you cured deafness with a pop of the spine, you were a doctor and a healer. Because of the hodgepodge of disparate medical practices and the lack of an organized medical education, the Carnegie Foundation financed a review of medical education in the United States. Authored by Abraham Flexner,  for some unknown reason it became known as the Flexner Report, and it became the foundation for the standardization of medical education.

The Flexner Report resulted in a reorganization of medical schools and gave rise to the system of medical training in use today. Among the many changes was a clear delineation between those aspects of medicine that were science/reality based and those that were not: chiropractic, homeopathy, and naturopathy.

When Flexner researched his report, “modern” medicine faced vigorous competition from several quarters, including osteopathic medicine, chiropractic medicine, eclectic medicine, naturopathy and homeopathy. Flexner clearly doubted the scientific validity of all forms of medicine other than that based on scientific research, deeming any approach to medicine that did not advocate the use of treatments such as vaccines to prevent and cure illness as tantamount to quackery and charlatanism. Medical schools that offered training in various disciplines including eclectic medicine, physiomedicalism, naturopathy, and homeopathy, were told either to drop these courses from their curriculum or lose their accreditation and underwriting support.

The last 100 years has seen the proliferation of reality based biomedical sciences and there has been a similar proliferation of fantasy based SCAM’s that, one would think, would have no reason to be included in modern medicine. The Flexner report had put medicine firmly on the path of reality/science based medicine, which I would argue is the ethically based medicine as well. Diagnosis and therapies based upon what is, well, made up shit, should have no utility in medicine. Ill, vulnerable people should not, one would think, have their lives, their health, and their finances put at risk on the basis of fictions. This is the point in the essay where someone will mention Vioxx. Thank you. Vioxx bad. Got it. Vioxx gone. SCAMs persist. That is the important difference.

Fast forward 100 years to the Bravewell report. Many of the issues of the Bravewell report have already been discussed by Dr’s Gorski, Novella and Atwood; I might as well pile on. What is striking about the report is how many of what I would have thought of as premier medical institutions in the US have repudiated science and reality in favor of fantasy based medicine. These are what I would have thought of as top notch medical centers: UCSF, Scripps, Vanderbilt, Duke, Cleveland Clinic and MD Anderson are on the list.

As always with proponents of SCAM’s there is a spectrum from legitimate therapists and therapies to the completely wackaloon. I am going to limit myself to the 100% fantasy based wackaloon SCAMs offered by institutions who really should have known better. But that’s me. I do not think popularly and profit should trump truth and integrity. Shame, I guess, is not a concept embraced by our ‘top’ medical centers.  I am using quotes; I worry that soon I will be typing in caps and using multiple exclamation marks, the sure sign on the web that the writer is unhinged.

70% of these institutions employ an acupuncturist, 62% a TCM practitioner, 38% a chiropractor, 28% a naturopath, 17% an ayurvedic practitioner, 17 % a homeopathy practitioner. Almost one in 5 think it is legitimate medical practice to offer water to treat their patients. The mind boggles. If your medical institution has so little grasp of reality that they hire homeopaths and their fellow travelers, the naturopath, time to seek care elsewhere. 38% have hired a holistic nurse, what ever that is.  Probably who is doing the reiki and therapeutic touch. Other fantasy based therapists employed included energy psychologist, Feldenkrais practitioner, Qi Gong practitioner, and a reflexologist.

Of the 29 centers 15 used healing touch or reiki for cancer or chronic pain. Legitimate medical centers waving hands over patients to treat cancer. Really, there is no shame. None. Evidently they are proud of the fact; I am sure the Board of Directors is pleased. For asthma, 9 used healing touch, 4 used chiropractic, 3 used homeopathy. For cancer, 15 used reiki, 15 used healing touch, 4 used homeopathy. For diabetes, 7 used reiki, 5 healing touch, 2 homeopathy.  These are real diseases with well known pathophysiologies and complications for which they offer magic.

Interestingly, for diabetes,  only 24 of 29 used “food/nutrition” and 18 of 29 used “exercise/fitness” in their therapies And here I thought diet and exercise were the mainstay of diabetes treatment. Same with heart disease with 24 of 29 used “food/nutrition” and 20 of 29 used “exercise/fitness” and for obesity with 25 of 29 used “food/nutrition” and 24 of 29 used “exercise/fitness.”  I wonder, rather than diet and exercise, how they treated diabetes, obesity and heart disease; the lists suggests probiotics, therapeutic touch, reiki or homeopathy.

And post operative care? 3 of 29 used endurance training or Pilates.  Doesn’t seem, off hand, to be the best time for endurance training. They are probably not getting the patient ready for an iron man after their hip replacement. Or I would hope. Given the approach to diabetes, obesity and heart disease, I am not so sure.

It gets worse: 38% have on site retail sales of homeopathy, 21% from their website, and 7% from pharmacy or gift shop. They are selling water and are happy to proclaim it to the world. Similarly 48% gave on site retail of TCM or Ayurvedic, 21% from their website, and 3% from pharmacy or gift shop, and 38% have on site retail of AROMATHERAPY (!!!!!!!!!) , 17% from their website, and 7% from pharmacy or gift shop.

It is a serious question: Why not have a psychic on staff to predict the patients course? Or have John Edwards visit after a patient dies so that the family can talk to their dead? Does anyone see any difference between those interventions and the ones already offered? I can’t. Major medical institutions are offering fiction to their patients.

It would be nice, or at least easier, to practice in one of those institutions. Where I work I have to justify adding new drugs to the formulary. We review the costs and benefits of new interventions and decide, based on the available data, if an antibiotic should be added to the formulary. We have to follow standards and review the literature. If I were to practice at Duke or Scripts, I could do whatever I damn well pleased. They evidently have no  standards of care since and any institution that sells homeopathy should have no institutional credibility to control their pharmacy.

Flexner was a fool for thinking

Such exploitation of medical education … is strangely inconsistent with the social aspects of medical practice. The overwhelming importance of preventive medicine, sanitation, and public health indicates that in modern life the medical profession is an organ differentiated by society for its highest purposes, not a business to be exploited.

A scientific basis of medical care and medicine have a higher purpose. I love humor. As the Bravewell report says “cash remains the most frequent form of payment.” When the choice is between reality and an exchange of fantasy for money, as Las Vegas demonstrates, fantasy wins.

The humor continues in the Bravewell report. They report that clinical success is based in part on “Using an evidence-informed approach to care.” I presume for those institutions that offer the fantasy based therapies, the evidence is from billing and collections, not Pubmed.

While most of the institutions measure patient satisfaction, the results of those measurements are not mentioned. I would bet that patient satisfaction is high. Unfortunately,

higher patient satisfaction was associated with less emergency department use but with greater inpatient use, higher overall health care and prescription drug expenditures, and increased mortality.

That may be why they do report outcomes. I would postulate that high satisfaction with your alternative care would be associated with increased mortality.

My bias is that medicine should be based on the best approximation of reality that the scientific method can provide. Science based medicine is reality based medicine. The forms of therapy offered by what used to be considered top notch medical institutions are neither based on science nor reality, but I understand that popularity and profit are more important than honesty and integrity. That’s the wave of the future. I was always under the impression that you can judge of person by the company they keep.

One of the most striking, though perhaps predictable, conclusions of this study is that integrative medicine is, in fact, integrative. It integrates conventional care with non- conventional or non-Western therapies; ancient healing wisdom with modern science; and the whole person—mind, body, and spirit in the context of community.

If you integrate fantasy with reality, you do not instantiate reality. If you mix cow pie with apple pie, it does not make the cow pie taste better; it makes the apple pie worse.

I had long thought that the laws of thermodynamics prohibited perpetual motion machines. No longer. If we can some how harness the kinetic energy of Flexners corpse, we would no longer have to import oil. At the rate it must be spinning, it is probably going to rotate forever.

Posted in: Health Fraud, Medical Academia, Medical Ethics

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