Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Friday, August 10, 2007

More on "CAM"

Not unexpectedly, my previous post generated a measured and considered response from a true believer. [Intended to be read as respectful and not sarcastic.] That's what I get, in part, from having a clear idea of my thesis but rushing to publish its execution. Allow me to clarify, beginning with a quote from Orac*:
I reject the distinction between evidence-based medicine and "alternative medicine" as a false dichotomy. To me, the only dichotomy that matters is between medicine that has high quality scientific evidence showing that it works and medicine that does not, a category that includes plausible treatments that might work but have not yet been shown to work, implausible treatments with little or no evidence of efficacy (a category that includes the vast majority of what is lumped together as "alternative medicine"), and treatments for which the preponderance of evidence shows that they do not work.
Modalities such as homeopathy, Reiki, acupuncture, etc. have not been shown to work. Over and over, mainstream researchers have tried to prove their efficacy. Hey, who wouldn't be excited about new treatments? The problem is that over and over, those experiments -- when well-designed -- have failed. Testimonials, even from initial unbelievers ("I didn't believe it would work, but I tried it and it did") do not constitute evidence.

My problem is when these "alternative" practitioners reject the idea that their modality can be subjected to scientific study. "You have to believe," or it doesn't work. That's what disqualifies it -- right there -- from being considered "medicine" at all. It's trying to claim the rights and privileges of medicine without accepting the responsibility of proving itself objectively, or at least the willingness to try.

Do they make people feel better? No doubt about it.

Many women I know claim that a trip to the beauty parlor is rejuvenating. Getting their hair washed (perhaps with a nice scalp massage), cut, styled and blown dry; maybe get a mani-pedi; it feels great! They can forget their troubles while they're there and allow themselves to be pampered. But no one would dream of calling it medicine, despite its undisputed contribution to well-being.

Perhaps that's where we can forge a compromise: If alternative therapies help, make patients feel better, enhance wellness and well-being, fine. Physicians should feel free to refer away. (In a sense, I do it all the time when I recommend chicken soup.) I'm sure there would be much greater openness from physicians to "other things that may help" as long as they're not misrepresented as "medicine." Practitioners can set themselves up in business all day long, as long as they don't call themselves "doctors." Hell, maybe I should "integrate" a hairdresser into my office. Plenty of women would surely be thrilled with the convenience!

It is by putting on airs, overreaching, and running the risk of steering their customers (not "patients") away from needed medical attention that alternative practitioners alienate doctors.

Let's reserve the term "medicine" for interventions that have either objective evidence of efficacy, scientific plausibility, or the willingness to be studied objectively (which of course runs the risk of not demonstrating efficacy, in which case includes the willingness to be discarded.)


*Actually, this entire post from Respectful Insolence about double standards says some of this more clearly.

14 Comments:

At Fri Aug 10, 08:16:00 AM, Anonymous difficultpt said...

Great post . . . and Lynn's comment on the other post was great as well. I love discussions like this on blogs.

As a patient, I would like a doc who has a lot of knowledge regarding alternative medicine/therapies because it is hard to do the research as a patient when you don't have the background to question some of the claims. Some are obvious, but others aren't.

One example I can think of is the use of candles to remove ear wax. I know people who claim this works well and others who say the build up you see in the candle will appear if you us the candle on a Coke can as well . . . clearly the Coke can has no ear wax.

If you aren't familiar with the practice, here is some info:

http://healthpsych.psy.vanderbilt.edu/earwaxcandle.htm

http://altmedicine.about.com/cs/govtregulation/a/EarCandle.htm

Anyhow, I'm sure there are other examples as well. I mention the ear candling because it certainly sounds like a less expensive way to remove ear wax, but perhaps (like other alternative remedies) it might not be a good idea.

 
At Fri Aug 10, 02:15:00 PM, Blogger Lynn Price said...

Testimonials, even from initial unbelievers ("I didn't believe it would work, but I tried it and it did") do not constitute evidence.

Why? I find it arrogant that the patient’s condition has no validity. Case in point: I had two maladies; ADD for which I took Ritalin, and a complete hysterectomy for which I took hormones for ten years. During the course of my book research, I bumped into Reiki. Skeptical as ever, as you indicate above, I nonetheless decided if I was going to possibly write about it, I needed to know its benefits, or lack thereof. After several treatments, I found that I couldn’t tolerate the Ritalin or my hormones. I gradually began reducing the doses until I wasn’t taking anything. After I quit taking them, I felt better than I had in years.

My ob/gyn checked me out and gave me the, “all’s well, don’t change a thing” bit. When I told him I’d been off my hormones for six months, he nearly fell flat on his face. After giving him my story, all he could do is shrug. After four years, my doc still gives me a clean bill of health and scratches his head. So, yes, I did try it, and, yes, it worked – even though I never went into Reiki with the intent of having anything “fixed.”

The main concern here is that no one should ever believe that what worked for one person is an across the board guarantee that it’ll work for everyone. That notion is as bogus as being able to guarantee that chemo will affect every patient in the same manner.


My problem is when these "alternative" practitioners reject the idea that their modality can be subjected to scientific study. "You have to believe," or it doesn't work.

I agree with you here, with a caveat. The integrative therapists with whom I’ve researched say is that ‘before’ and ‘after’ tests should be run to insure the patient is medically safe and sound. If those ‘after’ tests reveal the condition has been alleviated or eradicated without any known (medical) reason, they’d like their therapies’ interaction to at least be considered rather than being laughed out of the zip code. Docs call these head-scratcher cases “spontaneous remission,” which is doctor-ese for “beats the shit out of me.”

The notion of “you have to believe or it won’t work” is crap.

Docs get their backs up against the wall over anything that uses the term “medicine” but is nonscientific. I don’t have a problem with this, per se. But it’s nitpicky. What is meant by using the term “alternative medicine” is to indicate that these modalities are being utilized in a medical application, such as relieving the side effects of chemo or stress in heart patients.

Conversely, a pedicure or shampoo and set may have side effects that are seemingly medically beneficial, but that isn’t their primary purpose. Their primary purpose is cosmetic. Reiki or biofeedback, on the other hand, have a very specific purpose that has medical foundations.

I'm sure there would be much greater openness from physicians to "other things that may help" as long as they're not misrepresented as "medicine."

This is a case of semantics. I think the term “alternative medicine” clarifies things pretty well. From the very name, it’s clear that it’s not scientifically based.

Practitioners can set themselves up in business all day long, as long as they don't call themselves "doctors."

They don’t. I have yet to find a single alternative care therapist who did this. If they do, they should be shot at dawn.

It is by putting on airs, overreaching, and running the risk of steering their customers (not "patients") away from needed medical attention that alternative practitioners alienate doctors.

I’ll agree with this observation only to a point, because most docs I’ve interviewed readily admit their bias doesn’t originate from any research on their part, but the stereotype of the alties.

However, the idea that alternative healers overreach their bounds with their clients is the center of my concern as well. No one should ever leave their docs. Ever. This is why I’m such a proponent of integrating alternatives. It’s not my intent that alternatives play the lead role in medicine, but a supporting position whereby the patient has the best of all worlds, science, body, and mind. I think what docs tend to forget is the importance of the mind and how that marvelous hard drive plays a key role in our health.

Plato got it right when he said, “In order to heal the body, you must first heal the mind.” Cardiologists know that stress kills. How many oncologists have I heard mutter, “Cancer, the angry disease.” Many alternative healers understand this and align their therapy around this reality. It’s a marvelous concept that I think marries very nicely with allopathic medicine.

Difficultpt:
As a patient, I would like a doc who has a lot of knowledge regarding alternative medicine/therapies because it is hard to do the research as a patient when you don't have the background to question some of the claims. Some are obvious, but others aren't.

This is the exactly what integrative medicine is all about. It’s about marrying docs and alternative modalities together so the patient stays safe at all times. The Continuum Center for Health and Healing
in NYC does this, as does GW Center for Integrative Medicine . In both cases, docs and alternative therapists practice together under one roof.

 
At Fri Aug 10, 04:58:00 PM, Blogger Sid Schwab said...

In my community the local hospital just opened a very impressive multi-disciplinary cancer center. In addition to the latest radiation therapies and a well-reasoned approach to bringing all cancer care under one roof, they have included "complementary medicine," under the guidance of a former partner of mind, a pediatrician, who has studied with Andrew Weil, among others. They offer acupuncture, yoga, mediation, etc. I was surprised. I haven't fully decided what I think: I'm sure such things provide comfort and distraction and a sense of control. But I'm also fairly sure they don't make a "real" difference in treatment outcomes. So should it be taking up space in this place? In my mind, it's not entirely clear either way. But it's a consumer-driven, feel-good marketing tool at its heart. Or so I think.

 
At Fri Aug 10, 05:02:00 PM, Blogger MedStudentGod (MSG) said...

So long as the patient is not undergoing something that's harmful, I say let the placebo effect do it's magic! Just make sure you document the hell out of it.

 
At Fri Aug 10, 05:05:00 PM, Blogger Sid Schwab said...

I should have added that I really liked that Orac post when I read it, and fully agree with your take on it: we ought not be distinguishing between evidence-based medicine and -- "other," at least to the extent that such "alternative" medicine is even mentioned in the same breath, or allowed to have the word "medicine" attached to it. Medicine, as we understand it, is science as applied to treating disease. It's subject to study and proof, or it isn't. The stuff that is unproven and disproved should be labelled as such: whatever it is, it aint' medicine. "Woo" is as good a term as any.

 
At Fri Aug 10, 05:54:00 PM, Blogger GeorgeH said...

Alternative treatment is much like creationism. Even if we stipulate that creationism is true, it still isn't science, it's theology.

Science is the study of what happens if there is no mystical/miraculous intervention. If there is mystical/miraculous intervention, it's theology.

Medicine is the application of science to human health

 
At Fri Aug 10, 05:57:00 PM, Blogger GeorgeH said...

That doesn't mean that if I have a crick in my neck that I can't get out that I woon't go to a Chiropractor.

I just won't go to one who claims he is more than a type of physical therapist.

 
At Fri Aug 10, 07:25:00 PM, Blogger Lynn Price said...

Sid, I’ll give you kudos for at least not throwing the entire idea out the window, but I can’t help but feel that stating alternatives is feel-good marketing and do little more than provide a distraction diminishes and belittles verifiable results.

I followed the treatments of three patients suffering reoccurrences with cancer after they ended up in the office of the doc I was shadowing for my research. Two patients chose biofeedback and the other one chose Reiki, and none of them suffered the usual side effects from chemo and radiation; vomiting, lethargy, dry tongue, prone to infection and illness due to low white blood cells, etc. They came in very skeptical about integrative medicine and came out supporters because they had been given relief that no doc had been able to offer since they first began fighting cancer.

I think what’s most frustrating is the continued snub by the general medical community to acknowledge the possibility that integrative medicine may have a place in medicine. Opinions aren’t formed based on research, but bias. It’s like how I used to say that I hated spinach. Said that for years until I actually tried it and liked it. I let the smell and appearance of spinach turn me off. And that’s what many docs are doing. I’ll concede that much of the bias has been earned by a lot of lunatic fringe. After all, how are docs supposed to parse the nut jobs from the ones who have legitimacy? It wasn’t all that long ago that chiropractors were deemed the smelly dog in the room, yet my doc pays homage to one twice a month.

Anyway, I know I won’t change any minds here, and that’s not my intent. My intent is to spur discussion in hopes of an exchange of ideas. I remember when a woman who’d a honcho in the integrative care community and works with docs on a full time basis contacted me about my book. I told her that the story mirrors the controversy that’s going on in medicine today. She decided against buying my book because she said, “Oh, I’d feel uncomfortable reading this because I never see docs who don’t agree with the importance of integrative medicine.” I could only laugh and wonder what planet she was living on.

 
At Fri Aug 10, 07:31:00 PM, Blogger #1 Dinosaur said...

Lynn: *IF* all alternative practitioners lived in your ideal world (recognition of their limitations and respect for medicine) then I agree there wouldn't be as much of an issue with CAM. Unfortunately, they are not.

It's like me saying, "If all docs were as smart as Dr. Bob, as skilled as Sid and as compassionate as I am, there wouldn't be as many problems with patient care." But they aren't, so there are.

There are plenty of "ND"s out there who know full well people think it's just a typo for "MD", and many if not most chiropractors are openly anti-vax as well as anti-doc. Both call themselves "doctor," so if we're going to drag them out and shoot them all, I'll meet you at sunrise. You bring the blindfolds and I'll bring the cigarettes. It'll be a long day, though.

Oh, and both of the clinics you mention are cash only, putting them pretty much out of reach for most of the working families in my practice who depend on insurance to cover their medical care. Do you know any alternative therapists who do charity care?

DP: Ear candling has been studied and has been found to be both ineffective and potentially dangerous. (Reference here. A second reference that needs a subscription to access is called "Ear Candles: A Triumph of Ignorance Over Science" and is actually from "Natural Standard: the Authority on Integrative Medicine.")

GeorgeH: Well said! (x2)

 
At Fri Aug 10, 07:59:00 PM, Blogger Lynn Price said...

Yes, Dino, the lunatic fringe is what makes a mockery of the whole integrative movement. But that's why I give such credence to The Continuum Center for Health and Healing, GW Center for Integrative Medicine, the huge integrative fellowship program by Andrew Weil at ASU in Tucson. These are the directions we need to be taking. We'll agree to leave those who chant around avocado pies and don't shave their armpits up against the executioner's wall. You did say you were bringing the cigarettes, right? Note to self: Learn to smoke.

 
At Fri Aug 10, 08:07:00 PM, Blogger #1 Dinosaur said...

Cigarettes for the condemned, silly; not us. Don't you know smoking is bad for you?

You still haven't addressed the financial issue, you know. If Integrative Medicine is so important, why is it only available to those who can afford it?

 
At Sat Aug 11, 12:24:00 PM, Blogger Lynn Price said...

Cigarettes for the condemned, silly; not us.
Yeah, okay, I thought that sounded weird.

If Integrative Medicine is so important, why is it only available to those who can afford it?
It's not covered by insurance. Insurance creates artificially low prices to the insured. Time was chiropractic care was only affordable to those with bucks. Now that most insurance companies include chiro care in their benefits, everyone can afford to see one because, like docs, they've agreed to accept a negotiated fee that's far below what they deserve.

Meanwhile, Reiki practitioners, acupuncturists, biofeedback techs are still commanding top dollar. If insurance ever decides to include them into their fold, the story will be much the same as it is for docs and chiros.

 
At Sat Aug 11, 11:31:00 PM, Blogger Sid Schwab said...

Opinions aren’t formed based on research, but bias.

Exactly.

 
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