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Survey Says…

Surveys are evidently a popular way to get a paper published. Put “complementary alternative medicine survey” into Pubmed and get 2,353 hits. I would have trouble coming up with a hundred groups about whom I would be interested in their use of SCAMs, but I tend to be a lumper rather than a splitter. But if you want to know about SCAM use in chronic pain patients in one Singapore hospital, the information is available.

I am a survey magnet and a remarkable number of people send me dead tree and electronic surveys which I generally ignore. So people like me, those who ignore surveys (but support public television), are underrepresented in surveys. But evidently there is no group whose attitudes about SCAM are not amenable to analysis including my medical brethren, Infectious Disease doctors.

So I was understandably curious when I was sent a link to “Infectious Diseases Physicians’ Attitudes and Practices Related to Complementary and Integrative Medicine: Results of a National Survey“. The abstract makes it sound like my colleagues are a bunch of ignorant rubes who just fell off the turnip truck:

ID physicians were most familiar with vitamin and mineral supplementation (83%), massage (80%), acupuncture (79%), chiropractic (77%), yoga (74%), and herbal medicine (72%). ID physicians most recommended vitamin and mineral supplementation (80%) and massage (62%). Yoga, meditation, and acupuncture were recommended by 52%, 45%, and 46%, respectively. Drug interactions, clinical research, and knowledge of CAM/IM modalities were factors that were considered a major influence. Almost 80% of respondents indicated an interest in IM versus 11% for CAM. Most respondents (75%) felt that IM modalities are useful, and more than 50% believed that they could directly affect the immune system or disease process. Conclusion. ID physicians expressed a markedly greater interest for IM versus CAM. They appear to be familiar and willing to recommend some CAM/IM modalities and see a role for these in the management of certain infectious diseases. Data regarding clinical efficacy and safety appear to be important factors.

Or are they? Abstracts can be misleading and the issue with many SCAM studies revolves around definitions as to what is a SCAM: it can vary from the wackaloon modalities like homeopathy and energy therapies to the potentially reasonable ones like minerals and herbs to interventions that are not alternative at all, like diet and exercise.

The first paragraph does not inspire confidence in what is to follow in the rest of paper.

In the United States of America (USA), as defined by the National Center for complementary and Alternative Medicine (NCCAM), complementary and alternative medicine (CAM) is a group of diverse medical and health care systems, practices, and products that are not presently considered part of conventional medicine and integrative medicine is medicine that combines treatments from conventional medicine and CAM for which there is some high-quality evidence of safety and effectiveness (1)

So I follow the reference to the NCCAM website where they do not give a definition for integrative medicine, instead saying:

There are various definitions for “integrative health care,

and instead give general examples and then state:

The scientific evidence is limited. In many instances, a lack of reliable data makes it difficult for people to make informed decisions about using integrative health care.

I do so love it when a reference does not reflect the claim. Of course, it may be a misplaced footnote, although it does come across as disingenuous.

Since Appeal to Popularity is perhaps the most common logical fallacy used to justify SCAM, a survey was done to see if three ID docs can make a tiger. So they surveyed 1,000 ID docs to:

…determine how ID practitioners in the USA view CAM and integrative medicine modalities by defining the following. (1) How familiar are ID practitioners with CAM and integrative medicine modalities and which ones do they recommend? (2) What are the perceived obstacles to the use of these modalities? (3) What are ID physicians’ beliefs and attitudes toward them and what role, if any, do they see for them in their patients?

311 replied. I didn’t receive the survey as it would have been one I would have filled out.

How you phrase a question determines the answer. CAM is defined as:

a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine.

and integrative medicine is defined as:

the practice of medicine that reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches, health care professionals, and disciplines to achieve optimal health and healing.

Wait. What? That is an interesting definition for the purpose of the survey, since it is an excellent definition not of integrative medicine but of medicine. It is what I aspire to do as a physician and what we teach our residents. However as a marketing ploy, it is excellent as it avoids the details as to what is being integrated.

Almost 80% of respondents indicated an interest in integrative medicine versus 11% for CAM. With those definitions it is no wonder there was interest in integrative medicine. If you are unaware that what is being integrated is fantasy (homeopathy, reiki, acupuncture etc.) with reality-based medicine… To quote me, when you integrate cow pie with apple pie, you do not make the cow pie better, you make the apple pie worse.

The abstract suggests that ID docs:

…appear to be familiar and willing to recommend some CAM/IM modalities and see a role for these in the management of certain infectious diseases.

Although the text would suggest that it depends on which SCAM. The truly wackaloon interventions are low with 8% in favor of homeopathy and 16% in favor or reiki and its ilk. Chiropractic gets a 33% “would recommend” rating and acupuncture a whopping 46%, not too surprising given the ubiquity of the former and the undeserved cachet of the latter.

I do not know whether to be proud or saddened by those numbers. I wonder how knowledgeable these physicians truly are, since it is a self-assessment. Would that embarrassing 8% offer hyperdilute duck liver as a treatment for the ‘flu? I hope not. I used to think that understanding the fantasy-based therapies would lead to their abandonment; that familiarity would breed contempt. Not so, yet again. The issues that influenced the use of SCAM were:

…drug interactions with botanicals and supplements (82%), clinical research showing clear benefit (80%), and knowledge of CAM and integrative medicine modalities (72%).

That 20% thought that clinical research was unimportant in using CAM is almost as sad as the embarrassing 8%. More information to suggest that knowledge of nonsense does not necessarily lead to wisdom with their application.

Or it could be more Dunning-Kruger than true knowledge, given that 75% felt that CAM and IM were useful for symptom relief. 50% thought the effects were due to placebo. Which is true. You are probably aware of my simple equivalency rule. SCAM effects are placebo. Placebo effects are nothing. Therefore SCAM effects are nothing.

What was really depressing was:

…more than 50% also believed that one or more CAM and integrative medicine modalities could directly affect the immune system or the disease process: mind-body modalities (n = 90), botanicals/supplements (n = 96), manipulative and body-based medicine (n = 63), energy medicine (n = 24), and whole medical systems (n = 35).

But then it is hard to say exactly what was going through the minds when filling out the survey, he says, desperately wanting to give his colleagues some benefit of the doubt. Maybe they were thinking about selenium and sepsis or treating vitamin D deficiency or, hell, please, I can’t do it. 35 thought Ayurveda or homeopathy could affect the immune system and 24 thought the same of reiki and therapeutic touch. I can’t make a silk purse out of this sow’s ear. Sorry. That is 24 to 35 too many.

And the madness continues, using SCAM for:

HIV and HIV-related complications (n = 191), recurrent bacterial infections (n = 138), autoimmune complications (n = 121), “chronic Lyme disease” (n = 116), hepatitis B, C (n = 74), acute bacterial infections (n = 35), and others (n = 43).

116 would treat the nonexistent chronic Lyme? Probably by boosting their immune system with the powerful placebo of homeopathy. Or acute bacterial infections? Or HIV? What are they thinking? Maybe I am missing some subtle thought process that would allow these modalities to be used, since the responders say that clinical research is only important 68% of the time. Or, maybe because 20% of the respondents are not Board Certified and 15% have an affiliation with a CAM center, perhaps the 311 who responded were not the best and brightest in the field.

Again, I love the flexible and inclusive way SCAM providers define their field. They call artemisinins, an extremely effective treatment for malaria, alternative. Like taxol. And aspirin. That 14% had insufficient knowledge of artemisinins and 6% thought them slightly beneficial and about half thought cranberries effective for UTI supports my thesis that the best-read in the field were not filling out the survey.

So what can you say about ID docs and SCAM? Given the broad response rates depending on the SCAM surveyed should I be happy or depressed with a statement like:

The practice of infectious diseases relies heavily on information and data; therefore it is not surprising that ID practitioners are data-driven in their clinical practice. The findings from this study support this, as 68% of respondents reported that data based on clinical research was the most important factor in determining treatment plan.

As if they expected surprise at the use of information and data. And what part of medicine does not rely on information and data? Oh, yeah. Evidently SCAM/IM practitioners.

This was a painful entry to write as it generated some cognitive dissonance. I tend towards strong loyalty to my various tribes, or perhaps my various granfalloons: SBM, ID, Trailblazers etc. And I had long considered that ID docs are without a doubt the smartest docs in the hospital and the best diagnosticians. We have to be, since ID crosses all specialties. I leave it to my readers to decide how much exaggeration I am making. But as a group we are evidently no better when it comes to thinking about SCAMs.

I went searching the Pubmeds. There are many articles on cognitive biases as they relate to diagnostic errors. There was a good reference in a recent CID. But there is very little I could find about the errors we make in deciding on a therapy. The only one that comes close is the classic “Observations on spiraling empiricism: its causes, allure, and perils, with particular reference to antibiotic therapy“.

There is nothing I can find that directly addresses the errors so routinely made in the research, evaluation, and specially application of SCAMs. The results of this survey should not come as a surprise. Most docs, even ID docs, are not given the tools to approach fantasy-based interventions.

My wife likes to sew and she has numerous tricks of the trade that she uses when putting a piece together. I am amazed when she watches Sewing with Nancy at all the shortcuts and techniques seamstresses have that allows them to make some amazing creations. She understands the subtleties that can make sewing easier. We need a similar collection of tips and tools for SCAMs.

Posted in: Acupuncture, Clinical Trials, Critical Thinking, Homeopathy, Science and Medicine

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