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The Bravewell Collaborative maps the state of “integrative medicine” in the U.S., or: Survey says, “Hop on the bandwagon of ‘integrative medicine’!” (2012 Edition)

Earlier today, Steve discussed a new report hot off the presses (metaphorically speaking, given that it’s been published online) from the Bravewell Collaborative. Naturally, given the importance of the issue, I couldn’t resist jumping in myself, but before you read the blather I have to lay down, you really should read what Steve wrote about it. It’s that good. (Also, he’s our fearless leader, and I wouldn’t want him to be…unhappy about my having muscled in on his usual day to post.) Have you read it? Good. Now we can begin…

One of the most common (and potent) strategies used by promoters of “complementary and alternative medicine” (CAM)–or, as its proponents like to call it these days, “integrative medicine” (IM)–to convince the public and physicians either to use it (or at least to remain a shruggie about it) is in essence an argumentum ad populum; i.e., an appeal to popularity. Specifically, CAM/IM apologists like to use the variant of argumentum ad populum known as the “bandwagon effect,” in which they try to persuade patients and physicians that they should get with the CAM/IM program because, in essence, everyone else is doing it and it’s sweeping the nation in much the same way New Coke did in the 1980s. (Admittedly, CAM/IM apologists are, unfortunately, much better at sales than Coca-Cola was.) Not coincidentally, this is one type of method of persuasion much favored by Madison Avenue when selling cars, clothing, music, movies, food, beer, and nearly every other product–like Coca-Cola. I say “not coincidentally” because what CAM proponents are doing, more than anything else, is selling a lifestyle, a brand, a belief system, and, of course, many, many products whose value reminds me, more than anything else, of the aforementioned New Coke. In using this appeal to popularity, CAM/IM proponents try to portray stodgy physicians (you know, like pretty much every one of us at this blog) who insist on plausibility, science, and evidence to support the use of drugs and treatments as hopelessly behind the times, dogmatic, out of touch, and in general no fun to be around at all, particularly at parties.
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The Cancer Cure Anecdote

Dr. Ian Gawler, a veterinarian, suffered from osteogenic sarcoma (a form of bone cancer) of the right leg when he was 24 in 1975. Treatment of the cancer required amputation of the right leg. After completing treatment he was found to have lumps in his groin. His oncologist at the time was confident this was local spread from the original cancer, which is highly aggressive. Gawler later developed lung and other lesions as well, and was given 6 months to live due to his metastatic disease.

Gawler decided to embark on an alternative treatment regimen, involving coffee enemas, a vegetarian diet, and meditation. Eventually he was completely cured of his terminal metastatic cancer. He has since become Australia’s most famous cancer survivor, promoting his alternative approach to cancer treatment, has published five books, and now runs the Gawler Foundation.

At least, that is the story he believes. There is one major problem with this medical tale, however – while the original cancer was confirmed by biopsy, the subsequent lesions were not. His oncologist at the time, Dr. John Doyle, assumed the new lesions were metastatic disease and never performed a biopsy. It was highly probable – the timing and the location of the new lumps following a highly aggressive cancer. But even a diagnosis that is 95% likely will be wrong in 1 patient out of 20 – which means a working physician will have patients with the 5% diagnosis about once a week. The standard of practice today would be to do a biopsy to get tissue confirmation of the diagnosis, and rule out the less likely alternatives.

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Defending CAM with Bad Logic and Bad Data

At SBM our mission is to promote the highest standards of science in medicine, and to explore exactly what that means, both in the specific and the general. We do spend a lot of space criticizing so-called CAM (complementary and alternative medicine) because it represents a semi-organized attempt to reduce or even eliminate the science-based standard of care, and to sow confusion rather than clarity as to how science works and what the findings of medical science are.

CAM proponents tend to use the same bad arguments over and over again. They have no choice (other than deciding not to be CAM proponents) – if a treatment were backed by solid logic and evidence it would not be CAM, it would just be medicine.  As SBM’s fourth year comes to a close I thought I would round up the most common bad arguments that CAM proponents put forward to defend their position. Like creationists, pointing out the errors in their facts and logic will not stop them from continuing to use these arguments. But this lack of imagination on their part makes it somewhat easy to counter their arguments, since the same ones will come up again and again.

The argument from antiquity

Our SBM colleagues in Australia have been critical of the incorporation of unscientific methods into academia. In defense of this practice:

Professor Iain Graham from Southern Cross University’s School of Health yesterday defended his university, saying the use of alternative therapies, such as homeopathy, can be traced as far back as ancient Greece.

This is a common claim – that some CAM modalities have been around for centuries, or even thousands of years, and so they must work. I am not sure if professor Graham intended to state that homeopathy can be traced back to ancient Greece, perhaps he just meant that some CAM therapies can, and chose homeopathy as a bad example. For the record, homeopathy was invented by Samuel Hahnemann about 200 years ago.

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Update on CPSOs Draft Policy

Four months ago David Gorski wrote about the  College of Physicians and Surgeons of Ontario’s (CPSO) draft policy on “non-allopathic” medicine. He pointed out:

It’s obvious from the wishy-washy approach to the scientific basis of medicine, the waffle words when it comes to whether an “allopathic” physician should support “non-allopathic” therapies, and the apparently inadvertent use of language favored by quacks that there were far too many “alternative” practitioners involved in drafting this policy.

I agree.  The proposed policy addresses the issue of so-called complementary and alternative medicine (CAM) and has drawn serious criticism from Canadian physicians (at least those who are paying attention and have the slightest clue about what is going on). The backlash is good to see, but it is not nearly vigorous enough.

There is now an update to this story as the CPSO has published a revised policy proposal. There are some improvements, based on the criticism, but still there are problems with the policy.

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Some Encouraging Backlash Against Nonsense

One of the themes of SBM is that modern health care should be based upon solid scientific ground. Interventions should be based on a risk vs benefit analysis using the best available scientific evidence (clinical and basic science).

As an extension of this, the standard of care needs to be a science-based standard. Science is (or at least should be) objective and transparent, and without such standards there is no way to have meaningful quality control. Without the filter of science there is no limit to the nonsense and magical thinking that can flow into the health care system. Increasingly we cannot afford the waste of fanciful and ineffective interventions, and even if limited resources were not an issue – individual patients deserve better.

It is for these reasons that we oppose the attempts by proponents of so-called complementary and alternative medicine (CAM) to erode or eliminate the science-based standard of care in medicine. Proponents differ mostly on how open they are about this goal, but there is no escaping the reality that at the heart of the very concept of CAM is at least a double standard – one in which the science-based bar for inclusion is lowered for some favored modalities.

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For Good Reason…

This one crept up on me by surprise. You see, I recorded an interview with D.J. Grothe, President of the James Randi Educational Foundation and host of the podcast For Good Reason back in November. I wasn’t sure when it would appear. Well, it turns out that it popped up on my iTunes podcast feeds sometime over the last few days. (It’s been really busy at work, and I haven’t really been paying attention to podcasts–at least, not until yesterday.)

So, here it is. I haven’t listened to it all yet, but hopefully I explained myself well enough and did credit to my fellow SBM bloggers. DJ is a good interviewer, which means he presses his subjects a bit and sometimes gets them out of their comfort zone.

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“Hard science” and medical school

One of the recurring themes of this blog, not surprisingly given its name, is the proper role of science in medicine. As Dr. Novella has made clear from the very beginning, we advocate science-based medicine (SBM), which is what evidence-based medicine (EBM) should be. SBM tries to overcome the shortcomings of EBM by taking into account all the evidence, both scientific and clinical, in deciding what therapies work, what therapies don’t work, and why. To recap, a major part of our thesis is that EBM, although a step forward over prior dogma-based medical models, ultimately falls short of making medicine as effective as it can be. As currently practiced, EBM appears to worship clinical trial evidence above all else and nearly completely ignores basic science considerations, relegating them to the lowest form of evidence, lower than even small case series. This blind spot has directly contributed to the infiltration of quackery into academic medicine and so-called EBM because in the cases of ridiculously improbable modalities like homeopathy and reiki, deficiencies in how clinical trials are conducted and analyzed can make it appear that these modalities might actually have efficacy.

Given this thesis, if there’s one aspect of medical education that I consider to be paramount, at least when it comes to understanding how to analyze and apply all the evidence, both basic science and clinical, it’s a firm grounding in the scientific method. Unfortunately, in medical school there is very little, if any, concentration on the scientific method. In fact, one thing that shocked me when I first entered what is one of the best medical schools in the U.S., the University of Michigan, was just how “practical” the science taught to us as students was. It was very much a “just the facts, ma’am,” sort of presentation, with little, if any, emphasis on how those scientific facts were discovered. Indeed, before I entered medical school, I had taken graduate level biochemistry courses for a whole year. This was some truly hard core stuff. Unfortunately, I couldn’t get out of taking medical school biochemistry my first year, but taking the course was illuminating. The contrast was marked in that in medical school there was very little in the way of mechanistic detail, but there was a whole lot of memorization. The same was true in nearly all the other classes we took in the first two years. True, for anatomy it’s pretty hard not to have to engage in a lot of rote memorization, but the same shouldn’t necessarily be true of physiology and pharmacology, for example. It was, though.

Over time, I came to realize that there was no easy answer to correcting this problem, because medical school is far more akin to a trade school than a science training school, and the question of how much science and in what form it should be taught are difficult questions that go to the heart of medical education and what it means to be a good physician. Clearly, I believe that, among other things, a good physician must use science-based practice, but how does medical education achieve that? That’s one reason why I’m both appalled and intrigued by a program at the Mt. Sinai School of Medicine for humanities majors to enter medical school without all the hard sciences. It’s a program that was written up in the New York Times last Wednesday in an article entitled Getting Into Med School Without Hard Sciences, and whose results were published in Medical Academia under the title Challenging Traditional Premedical Requirements as Predictors of Success in Medical School: The Mount Sinai School of Medicine Humanities and Medicine Program.

Let’s first take a look at how the NYT described the program:
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New CMS Chief Donald Berwick: a Trojan Horse for Quackery?

NB: I posted this on Health Care Renewal a couple of days ago, figuring that Dr. Gorski’s post would suffice for the SBM readership (he and I had discussed the topic while at TAM8 last week). But Managing Editor Gorski has asked me to repost it here, which I’m happy to do. I am especially pleased to demonstrate that I am capable of writing a shorter post than is Dr. Gorski. 😉

On July 7, President Obama appointed Dr. Donald Berwick as Administrator of the Centers for Medicare and Medicaid Services (CMS). Dr. Berwick, a pediatrician, is well known as the CEO of the non-profit Institute for Healthcare Improvement (IHI), which “exists to close the enormous gap between the health care we have and the health care we should have — a gap so large in the US that the Institute of Medicine (IOM) in 2001 called it a ‘quality chasm’.” Dr. Berwick was one of the authors of that IOM report. His IHI has been a major player in the patient safety movement, most notably with its “100,000 Lives Campaign” and, more recently, its “5 Million Lives Campaign.”

Berwick’s CMS gig is a “recess appointment”: it was made during the Senate’s July 4th recess period, without a formal confirmation hearing—although such a hearing must take place before the end of this Senate term, if he is to remain in the position. A recent story suggested that Obama had made the recess appointment in order to avoid a reprise of “last year’s divisive health care debate.” The president had originally nominated Berwick for the position in April, and Republicans have opposed “Berwick’s views on rationing of care,” claiming that he “would deny needed care based on cost.”

A “Patient-Centered Extremist”

If there is a problem with the appointment, it is likely to be roughly the opposite of what Republicans might suppose: Dr. Berwick is a self-described “Patient-Centered Extremist.” He favors letting patients have the last word in decisions about their care even if that means, for example, choosing to have unnecessary and expensive hi-tech studies. In an article for Health Affairs published about a year ago, he explicitly argued against the “professionally dominant view of quality of health care”:

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Talking Science With Patient Advocates

Laurie Edwards has a rare chronic disease called primary ciliary dyskinesia. Her symptoms are quite similar to those associated with cystic fibrosis, and her young life has been punctuated by numerous hospitalizations, physical limitations and the occasional near-death experience. She is a remarkably upbeat woman, and attributes her self confidence and optimistic outlook to her loving friends and family.

Laurie is part of the patient blogging community online. She reads physician blogs with interest, and wants to protect others like her from snake oil and misinformation. She recently interviewed me about my pro-science views for a new book that she’s writing. People like Laurie play a critical role in accurate health communication, and I welcome the chance to discuss science-based medicine with them. Here are some excerpts from our chat: (more…)

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All Medicines Are Poison!

That’s the title of a new book  by Melvin H. Kirschner, M.D. When I first saw the title, I expected a polemic against conventional medicine. The first line of the Preface reassured me: “Everything we do has a risk-benefit ratio.” Dr. Kirschner took the title from his first pharmacology lecture in medical school. The professor said “I am here to teach you how to poison people.” After a pause, he added, “without killing them, of course.” 

He meant that any medicine that has effects has side effects, that the poison is in the dose, and that we must weigh the benefits of any treatment against the risks. Dr. Kirschner has no beef with scientific medicine. He does have a lot of other beefs, mainly with the health insurance industry, the pharmaceutical industry, and alternative medicine. (more…)

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