With the way our dysfunctional federal government works, it's not uncommon for the end of a fiscal year to come and go without there being a budget for the next fiscal year in place. This phenomenon is particularly common during election years, and this year was no different. September 30 came and went, followed by the beginning of FY2015 on October 1 with no budget in place, just a continuing resolution. Finally, this week, Congress acted and passed a budget, but, as is often the case given that the President does not have line item veto power, the omnibus spending bill funding the government for the rest of the fiscal year was loaded down with unrelated clauses doing this or that for various interest groups.
Oddly enough, one of those bits of oddity larded onto the omnibus bill had something to do with a government institution (a Center at the National Institutes of Health, if you will) that is a frequent
target topic of this blog. I'm referring, of course, to the National Center for Complementary and Alternative Medicine, a.k.a. NCCAM. Actually, it's no longer NCCAM. Thanks to a clause in the omnibus spending bill, NCCAM has been reborn. Gone is the word "alternative" or any hint that this is a center that's funded a whole lot of pseudoscience. In its place is the National Center for Complementary and Integrative Health (NCCIH). Goodbye, NCCAM! Hello, NCCIH! Sadly, the term NCCIH doesn't have quite the je ne sais quoi that NCCAM did. Maybe it's because it's harder to say than NCCAM, which was often pronounced "n-cam."
Issues of pithy abbreviations being lost aside, though, what does this mean? You might remember that back in May I commented on NCCAM's desire to rename itself and how its director, Dr. Josephine Briggs, had asked for public comment. At the time, the new proposed name was the National Center for Research on Complementary and Integrative Health (NCRCIH), and I referred to the whole endeavor as "polishing a turd." Well, the turd has been polished. Or, at least, NCCIH has tried and failed to polish the turd. Interestingly, sometime between May and now, the "research" part was lost. One wonders why. Perhaps it's because, contrary to what its proponents said, NCCAM was never just about research; it was about promoting "complementary and alternative medicine" (CAM), now "integrative medicine" through educational grants to various universities and training programs.
So what does the NCCAM/NCCIH say about this name change? (Damn, I'm going to have to get used to stop typing "NCCAM" and to using the new name. I also might have to go back and tag all my NCCAM posts with the terms "National Center for Research on Complementary and Integrative Health" and "NCRCI." Whoa. That's a lot of posts.) Let's just say, it's more of the same from NCCIH:
Large population-based surveys have found that the use of alternative medicine — unproven practices used in place of conventional medicine — is rare. Integrative health care, defined as a comprehensive, often interdisciplinary approach to treatment, prevention and health promotion that brings together complementary and conventional therapies, is more common. The use of an integrative approach to health and wellness has grown within care settings across the United States, including hospitals, hospices, and military health facilities.
“Since its establishment 16 years ago, the center has funded thousands of important research projects. Without this work, the American public would lack vital information on the safety and effectiveness of many practices and products that are widely used and readily available,” said NIH Director Francis S. Collins, M.D., Ph.D. “This change by Congress reflects the importance of studying the approaches to health and wellness that the public is using, often without the benefit of rigorous scientific study.”
“The intent of an integrative approach is to enhance overall health status, prevent disease, and alleviate debilitating symptoms such as pain and chemotherapy-induced nausea, among others. However, the scientific foundation for many complementary approaches is still being built,” said Josephine P. Briggs, M.D., Director of NCCIH. “The mission of NCCIH will remain unchanged. We will continue to focus on the study of the usefulness and safety of complementary and integrative interventions, and provide the public with research-based information to guide health care decision making.”
The name change is in keeping with the center’s pre-existing congressional mandate and is aligned with the strategic plan guiding the center’s research priorities and public education activities. Public comments on a revised name were invited in May and June 2014 and indicated overall support for the change.
It's the same ol' same ol'. Note the trope that the use of alternative medicine (i.e., unproven medicine) alone is rare. That is, of course, true. No one is arguing with that—or has been—although we frequently feature stories of people who have actually chosen to rely on alternative medicine to deal with serious diseases, often with tragic results. Of course, when NCCAM started, it was first called the Office of Alternative Medicine before being raised to full Center status in 1998, thanks to Senator Tom Harkin (D-IA), NCCIH's patron and chief proponent in Congress since the early 1990s and the legislator most responsible for having created and maintained this bastion of pseudoscience in the NIH. One has to wonder if this name change is one last gift from Harkin before he retires. I don't know if that's what happened, but it's totally plausible that Harkin slipped this into the omnibus bill as a last act before he retired. Did he do it? Who knows?
Be that as it may, the objection to NCCIH does not depend on a small number of people using alternative medicine instead of scientific medicine. In fact, the threat of NCCIH and other government entities promoting dubious science is not so much that. Rather, it's how NCCIH facilitates the "integration" of quackery into conventional medicine by giving cover to alternative medicine modalities that are either so implausible as to be worth no further study (such as "energy healing") that are commonly lumped into the category of "integrative medicine." Similarly, it's how NCCIH facilitates the "rebranding" of modalities, such as nutrition and exercise/lifestyle, that are easily within the domain of science-based medicine and need no special "branding," the better for advocates of actual quackery to lump them together with nonsense like "energy healing" and traditional Chinese medicine, thus giving them the appearance of plausibility by association.
Also, there's the issue of spending our taxpayer money on studying and promoting pseudoscience. While it's true, as far as I can tell perusing NIH RePORTER, that NCCIH hasn't funded a study of homeopathy since 2008, it still funds lots of studies on acupuncture, which is only marginally less ridiculously implausible, and traditional Chinese medicine (TCM), a retconned version of old Chinese folk medicine. It also funds studies on healing touch, reiki's "Western" bastard child, as far as "energy medicine" goes. There's nothing in the name change that will likely change that, given that acupuncture and TCM are highly popular, arguably among the most popular bits of quackery frequently "integrated" into SBM. Similarly, naturopathy is a veritable cornucopia of quackery based on prescientific vitalism.
The press release basically concludes:
The center’s research priorities include the study of complementary approaches — such as spinal manipulation, meditation, and massage — to manage pain and other symptoms that are not always well-addressed by conventional treatments. The center’s research also encourages self-care methods that support healthier lifestyles and uncovers potential usefulness and safety issues of natural products. The practices and products studied by the center are prioritized by four guiding principles: scientific promise, amenability to be studied using the highest quality research methods, use by the American public, and the potential impact on public health.
Back when a name change for NCCAM was first proposed in May, there was a lot of joking about what the new name should be, because the proposed name (or the actual new name) don't truly describe what NCCAM did (and NCCIH will continue to do). I saw proposed names such as the National Center for Research on Supplements, Complementary and Alternative Medicines (SCAMs), the National Center for Research on Tooth Fairy Medicine (I liked this one), National Center for Research on Snake Oil and Science Denial, National Center for Unprovable Therapies, and National Center for More Research is Needed. (I suggested a slight alteration to this one to National Center for More Research Is Always Needed, No Matter How Implausible the Treatment or Negative the findings. Unfortunately, that name is too long and doesn't lend itself to a pithy abbreviation less than five letters.) Personally, I liked Harriet Hall’s suggestion, seen on the HealthFraud mailing list, of Center for Studying Things Scientists Wouldn’t Otherwise Bother Studying, which pretty much nailed it. Remember, NCCAM (now NCCIH) was not created due to an overwhelming demand in the scientific community to study acupuncture, reiki, and coffee enemas. After all, the seemingly plausible modalities that fall under the CAM/"integrative medicine" rubric could already be studied (and were already being studied) as conventional modalities. For instance, studying herbal medicine requires nothing more than pharmacognosy, or natural products pharmacology, and there is nothing "alternative" about studying the effects of nutrition and diet on disease.
In the end, it really doesn’t matter very much what NCCAM is called. NCCAM, NCCIH, whatever. Sure, removing “alternative” and adding “integrative” somewhere in the name might make it less offensive to its stakeholders, the alternative medicine practitioners whose purpose it serves, and make it somewhat more palatable for a different reason to science-based physicians, but unless the underlying mission and structure are changed radically, it’ll just be putting lipstick on a pig or polishing a turd, or whatever metaphor you like for trying to make something that is fundamentally flawed beyond redemption seem attractive or reasonable.
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N-cam? I've been calling it 'nick'em'.
Lipstick on a pig.
Somewhat off-topic, Mythbusters were able to polish a turd a couple seasons ago. https://www.youtube.com/watch?v=yiJ9fy1qSFI
The center formerly known as NCCAM recently posted a lecture by Dr. Richard Deyo which summarized the research on alternative methods like acupuncture on back pain.
Dr. Deyo explains a study he conducted that indicated that "real" acupuncture is no better than sham acupuncture for back pain (and other conditions).
He also concluded that chiropractic and physical therapy for low back pain had nearly identical outcomes but the outcomes were not clinically significant over usual care (which he also said was basically a "no treatment group".)
The lecture took place in April, with Josephine Briggs in attendance.
And yet that hasn't stopped Briggs and company from claiming acupuncture is effective for back pain.
Recently when my doctor moved I had to find another provider. One doctor, when he found out my disease, told me my best chances were acupuncture and alternative medicine. When I pointed out that acupuncture was a placebo, he pretty much acknowledged that it was, and then suggested counseling.
I do not want sham treatments to be the go-to answer for a patient without available treatment options. There are doctors out there who have so little respect for their patients that they will put them into the "occupy with placebos" chase rather than admit there are not good answers.
The placebo effect is a real effect, and if you have nothing better, might as well at least go with that.
Justthestats: except placebo generally requires deception and is unethical, as Mrs. Woo's story illustrates. And placebo isn't what you think- Mark Crislip calls it the beer googles of medicine
Depends on your definition of "real", I guess. Will placebo effects make a recipient perceive their condition has improved? Perhaps--but will it actually cause an improvement in their condition? No.
Consider a study conducted in asthma patients, involving 46 chronic asthma sufferers who were given one of four treatments: an inhaler with albuterol, a placebo inhaler, sham acupuncture or no treatment. Efficacy was measured in two ways following treatment.
First, by asking the patients to rate their symptom improvement on a scale of 0 to 10. Patients reported symptomatic relief with the albuterol treatment as expected, but reported also reported similar improvement when using the placebo inhaler or the sham acupuncture.
When the team looked at an objective measure of improvement in lung function, however–the maximum air volume that patients could exhale in one second following treatment–they found improvement only when patients received albuterol. There was no improvement in objective measurements with the other treatments. (see http://www.ncbi.nlm.nih.gov/pubmed/21751905)
Somewhere I read a paper about ethically invoking the placebo effect. Maybe someone her can track it down. One of the author's suggestions is to prescribe a very low dose of something harmless off label, saying that it's not approved for the patient's condition but that sometimes it can help patients like the patient.
I'm aware that there are very few conditions where placebos actually improve the underlying condition. That doesn't mean that they are useless. I don't know about you, but comparing having an untreatable condition and feeling bad, to having an untreatable condition and feeling less bad, I'd take the second.
In the absence of clinical evidence that using whatever harmless off-label something chosen represented an effective treatment for that patient's condition--i.e., can actually help patients like the patient--wouldn't falsely claiming that if could represent medical malpractice?
Very few? I'm aware of none--after all, a treatment which can cause physiologic changes that result in improvements in a medical condition by definition it isn't acting as a placebo.
justthestats @6 (my emphasis)
Not if one has to pay the provider of the placebo for the privilege.
The only example I remember off the top of my head is some obscure condition that gets exacerbated by cortisol. The placebo effect leads to lower cortisol levels by purely psychological means, which then leads to shorter duration of the condition. I'd still call that a placebo instead of treating the underlying condition, but if you want to instead say that it's a rare case where essentially arbitrary sham treatments cause physiologic improvements, I've no serious objections.
Dissent number 1
Words matter. Language IS an ever-changing social construction. Meaning, as Stuart Hall would say, "is a site of struggle." And Orac is throwing in the towel. 'Integrative' has no fixed reference. Mike #4 provides evidence that a struggle to define it in the meaning of 'NCCIH' is very much enjoined already. 'Alternative' is an almost unredeemable concept: framing woo as a viable substitute for sbm, and it should be cause for applause it's been removed.
At worst, yes, 'integrative' could possibly just polish the turd, but only if the alt-ies win the definition war in a rout. A more likely outcome: a bit o' woo is validated, but only as a 'complementary' measure where placebo effects are valuable to a patient's psychological support "to manage pain and other symptoms that are not always well-addressed by conventional treatments," AND only when sbm M.D.s remain in the driver's seat for care of physical illness. A possible third outcome: the woo studies demonstrate there's no there there, and "methods that support healthier lifestyles" with a positive "impact on public health" validated are limited exactly to "modalities, such as nutrition and exercise/lifestyle, that are easily within the domain of science-based medicine."
What Orac is doing here is conceding the definition to the worst-case scenario, imagining that 'integretive' must mean what the SCAMers want it to mean, now and going forward. By attacking the word because bad people use it a certain way just reproduces and spreads the 'false consciousness' embedded in that use of the term.
The notion that by virtue of being sbm-OK "nutrition and exercise/lifestyle need no special 'branding'." is face-palm clueless. Hello! How's sbm doing getting folks to eat better, get active, quit smoking? How's sbm doing getting resources that would bring effective programs for that stuff under the sbm institutional umbrella? Does anyone in sbm understand the concept of 'branding'?
The very premise of 'branding' is the product is what it is, and does what it does, and sales depend on how consumers think about it some other set of terms. Put it this way, if the budget multinationals spend yearly to brand bottled water was applied to medical research, Orac could spend a lot more time blogging and a lot less time chasing grants.
Thought experiment: poll J. Doe medical consumers and see how many think their PCP is the go-to source for help with diet/exercise/lifestyle. In that terrain, the sbm 'brand' is non-existent at best, and sh!t, at worst. Any marketing consultant with half-a brain would tell you the best (and maybe only) way to get sbm-legit practice to gain ground in the diet/exercise/lifestyle market is under a new and different brand name.
Wake up, brothers and sisters! Drink the coffee enema and clean out that colon with wheatgrass juice. The name change, and the language in the block quotes in the OP, are an opportunity to whack the quacks. That opportunity may never knock again. And you're blowing it off.
Look, we know what quacks want. They DON'T want to be 'complementary' restricted to stuff where they may supply some sort of moral support, but can do no physical harm. They want to be legitimated as 'alternative' physicians. They want what the naturopaths want in Maryland, the whole loaf, not just the crumbs. They want the right to prescribe homeopathic nothings as alternatives to vaccines. When the Feds replaced "Alternative" with "Integrative" they LOST a battle. Big time.
The war's not over of course, and the naturopaths have two obvious strategy choices: 1) Concede the ground of 'integrative' and try to carpet bomb it into rubble — 'Integrative Medicine, once so promising a concept, is just the co-optation of true healing modalities into a sham 'holistic' approach that's just more of the same Pharma Shill treat-the-symptom-not-the-illness profiteering with a little polish on the turd.' 2) Storm the hill to recapture the lost ground, which in this case would be politicking to squeeze the Dr. Deyos out of NCCIH and re-define 'integrative' as a functional equivalent of 'alternative'. So yeah, Go Naturopaths! You're the best of both worlds all rolled into one beautiful holistic integrative enchilada!
Even if uttered as lip-service, "rigorous scientific study... scientific promise... highest quality research methods... impact on public health" are significant obstacles to strategy #2.
Sbm can engage the struggle for 'integrative', build the obstacles higher, show it's approved methods can get over them, monitor the woo attempts to negotiate the course, and publicize its failures... Or it can shrug a purist shrug, and turn away while woo sneaks around the obstacles or get's cheaters hand-ups to get over them from gullible or corruptible politicians.
Stupid is as stupid does?
Me? I'd take Dr, Deyo's back.
Postscript: The Birth of Branding
The "seminal work" in the field now known as Public Relations was the book Propaganda by Edward Bernays, published in 1928. Bernays had come up with the 'PR' rubric some 10 years earlier, but it wasn't in common usage — 'propaganda' being the only generally accepted term that covered the practice. By publishing Propaganda, Bernays reached a wider audience of professionals, and as they absorbied its teachings, 'PR' soon became the operative brand name. To this day, however, works on 'PR' and 'propaganda' share the same call number in the Library of Congress catalog.
"The notion that by virtue of being sbm-OK “nutrition and exercise/lifestyle need no special ‘branding’.” is face-palm clueless. Hello! How’s sbm doing getting folks to eat better, get active, quit smoking? How’s sbm doing getting resources that would bring effective programs for that stuff under the sbm institutional umbrella? Does anyone in sbm understand the concept of ‘branding’?"
SBM Branding initiatives which have as part of them bringing in additional resources for patient self management.
We are studying PCMH practices and a lot of the transformation in these practices has been about increasing patient self-efficacy around things like nutrition and exercise as well as other self-management tools that lead to better patient outcomes (like reduce hospitalizations and ER visits).
Many of these practices have hired additional staff specifically to help patients eat better and move more and other such science-based things that reliably and repeatedly improve patient outcomes in multiples studies done by completely different people.
There is a reason they have a PCMH logo and practices that get this designation put the logo on their websites. What part of that isn't about branding?
That being said, it does take work to transform from the standard of care of the last couple of decades to PCMH and there are lots of issues in how we pay providers so that they can keep the practice fiscally sound while doing things that reduce costs but traditionally have not been something you can bill for or be reimbursed for.
As for getting the Science into the practices. http://www.ncats.nih.gov/research/cts/ctsa/ctsa.html a nation wide consortium of science places studying how you get stuff out of the lab and into the clinic.
You could call them the Office of Quackery, or OfQuack for short.
Thank me later.
"placebo generally requires deception and is unethical"
If engaging in any practice — hiking, acupuncture, karaoke, whatever — makes a patient with a untreatable condition feel better, that's not a sham. Mrs. Woo's doc seems to have erred with a possibly ambiguous utterance about 'her best chances." Chances for what? I'm guessing this is less an ethics lapse than just careless care. The doc does not seem to have taken the time to get to know Mrs. Woo well enough to gauge what sort of palliative treatment for her condition might suit her frame of mind, or to understand how to pitch it to her.
This isn't rocket science, folks. Maybe med students should be required to do an internship in speciality retail sales where they would learn how to "qualify the customer." A few quick questions, a few minutes tops, and he'd have known alt was the wrong thing for this patient and gone straight to counseling (or maybe yoga, too.).
BUT THE DISCUSSION IS MISSING THE MAIN ISSUE!
Or straw-manning it. The OP isn't about woo vs. sbm for curable disease. It isn't just about woo minus sbm as palliative placebo for chronic conditions that have no conventional treatment. It's also about 'complementary' treatments in an integrative approach: sbm plus woo. e.g. "alleviate debilitating symptoms such as pain and chemotherapy-induced nausea."
I entered 'Tuesday' in the location field in reference to Orac's discussion the Jess Ainscough's progressing cancer two days ago. In that thread, leukemia survivor and med student Nikhil Autar wrote (slight edits):
Autar received exactly two replies, both to the effect "all of the commenters have a deep sympathy for Jess and indeed anyone with cancer." Which completely miss his point. He's not talking about Jess Ainscough, who's woo slinging he thoroughly condemns. He's talking about a patient like the young Jess — faced with a devastating sbm treatment offered by a medical institution that does not present as caring, sympathetic, or personal, regardless of what feelings the staff may harbor in their hearts.
If you have no idea what he's talking about, lucky you. That means you haven't been taken to an emergency room at a typical modern hospital and admitted in the wake of a significant incident lacking a dead-obvious diagnosis. As I've noted before, I was, 4 years ago. Meat gets treated better than I did. I had aphasia, but my eyes and ears worked, and I could see and hear the many other patients undergoing similar experiences.
But let's get back to Ainscough. Orac wrote (slight edits):
Yes, good friends, when push came to shove, when the fate of a human being with a face and a name came before him, facing horrible suffering whatever she choses, he opted for 'integrative oncology' as he knows this is likely the only way she can stay alive. Orac did not b!tch about the fact Ainscough will be "allowed to do her woo alongside conventional medicine." Did Orac compromise his 'ethics' by giving the 'non-judgemental oncologist' a pass on what s/he's probably told Ainscough about her health food regime being able to help her through her amputation? If you think so, go f*ck your ethics, as Orac revealed it would be grossly immoral to push a deluded young woman toward death by insisting on the hard scientific Truth.
Do you think Jess Ainscough is an isolated case? The Wellness Warriors and Healing Hotties have I don't know how many thousands of 'Follow'ers. They're driving themselves to early graves with their dedication to diet cancer cures, and dragging their tribes along with them. I do not want any one of them to suffer and die. it's challenge enough to get them to a non-judgmental oncologist who'll let them keep their woo alongside the sbm. Do you really want the oncologist to insist that's all bunkum and demand they give it up? Do you have a god-damn pulse?
Read and re-read Nikhil Autar's words until you get the point. Your 'sympathy' for cancer patients is worthless unless you can put yourself in their shoes, in this case shoes that believe in a higher power and some force of spirit (you know, like the vast majority of Americans, whether we like it or not). You're 22 and they have to cut your arm off at the shoulder. You're 10 and the chemo has ravaged your system so thoroughly you're in the ICU, convinced you're on the verge of death, and ready to embrace the reaper to escape the pain. Do you want The Truth, or do you want to believe? If you're forced to give up one of the two, which one do you chose?
Now take off the patient's shoes and put on the shoes of the mom/spouse/child of a Wellness Warriorette. Look in the eyes of a loved one, and imagine that person has epithelioid sarcoma with a fungating tumour in the shoulder that has bled into their armpit for the last 10 months. Do you want them to abandon their faith to face the Truth of Science? Or do you want them to swing that faith into a crutch that helps them walk into the hospital, have it ready as psychological salve for the horrible physical effects of life-saving treatment? (I'm not 'JAQing'. I'm asking. I don't know what your answers will be. But you know how I'm likely to judge them.)
Tueday's gone (to quote a dead redneck), and today Orac's line is 'don't give an inch, because they'll take 100 miles'. Today, he's wrong on the politics. Worse, he's wrong on the morality. But today is just today. The question is always, 'what are we going to do tomorrow.' We're probably all pretty sure the Food Babe, NN, AoA, Mercola etc, are going to do the same BS tomorrow they did did today. We're probably all hoping Jess Ainscough does something tomorrow she hasn't done in years. I'm just one unusually-verbose non-minion ally of the blinking box, but I'll be hoping to see more Tuesday-Orac than Thursday-Orac in the dawn of the new day.
Were you perhaps thinking of the study by Ted Kaptchuk? He purported to show that you could tell people they were getting a placebo and still elicit a placebo response. Except that's not what he actually did. He still used deceit, even though he did not acknowledge the fact.
Ah, yes. Here's Orac's post on Kaptchuk's study.
Sure it is. If you tell someone "eating chicken soup will make your cold go away quicker", it's a sham - even if they decide they're not quite as miserable as they might have been.
Well, where are the data?
Is there any reason to believe that the general public has any recognition of this logo? Does it affect decisions regarding provider choice? What's the target demographic?
I think the kind of thing you are suggesting might possibly win a tactical battle, but sure as hell will lose the war. 'Branding' like much marketing stuff, involves a certain form of deception, sometimes passively, sometimes not so, but it remains the case that marketing exercises in all domains are intended to skip any rational evaluation of a situation - whether its shampoo choices or medical choices, and
predispose people to believe one particular thing. Maybe in this case it is somewhat justified in the short term, but I hardly see the place for this kind of thing in medicine or science in general - its the antithesis of what I imagine the ideal solution to be.
Consider 'managing expectations' - this is where you deliberately make choices via presentational methods to try to ensure that the targets perception is exactly what you want it to be.
Frankly this kind of thing gets right under my skin in any situation - I want the facts and to reach my conclusions from them, preferably with the ability to question someone I trust on the points I don't understand.
Unfortunately anyone who I detect 'managing my expectations' or indeed engaging in any other form of manipulative behaviour has immediately lost my trust. This goes double for doctors, (and I have detected a tendency in some younger doctors to assume this as their default attitude - possibly because they do indeed undergo various courses on this aspect of practise, and possibly because in some cases it may in fact be indicated.
Doctors have difficult choices to make on these matters -no doubt about that!).
What you seem to be suggesting is that the woo BS should be subverted by essentially embracing some of
its methodology. I would much rather see the woo excised, and the general population brought to a point where
they can cope with the raw, rational explanations. Your suggested 'marketing' approach is completely the wrong direction for a real solution.
I also happen to believe that incorporating such courses in the general medical curriculum is likely to put off some of the talent - who are perhaps likely to choose a research
path rather than a patient facing one simply because they either don't like learning marketing BS or are perhaps don't feel they can cut the 'bedside manner' or 'managing people' aspects.
In fact, now I think about it, I believe we have already given too much ground to these aspects.
I'm not saying for instance 'bedside manner' or 'consulting technique' isn't an important aspect of general medical practise,but I do feel that its weighting in judging doctors performance has become too much - I'm pretty sure its
the one aspect all these woomeisters score 10/10 on, whereas the grumpy genius (ie the one I actually want treating me) is perceived as being somehow deficient. In otherwords, we're already over-emphasing peripheral aspects of care and that in itself may be counterproductive.
Deliberately throwing in 'marketing' techniques into the mix can hardly be the right thing if we eventually want to
reach a point of objective rational science based analysis being the way the general population makes its medical choices.
I'll call myself out on overuse of 'aspect' before someone else does
And the hits to America's Doctor just keep on coming!
@ Michelle: Any day that starts out with an article about Dr. Oz and his TV medical advice, is bound to be a good day for science. :-)
@sadmar - the doctor was condescending and talked to me like I was a ten-year-old. He certainly didn't get to know me. If I were at the beginning of this journey vs. six years in, I would have been devastated by the way he treated me and talked to me.
My disease causes very severe pain that is comparable to stage IV cancer. Quality of life scores in most studies are worse than patients with end stage kidney failure. I understand what counseling is for, and the desired result of counseling. A less informed person, though, would have taken the entire visit as dismissive and even suggesting they were malingering or dealing with a psychological rather than physical problem.
Since I have been around awhile, I just got mad. When I told him I was interested in nerve ablation, he told me that was because I didn't understand it.
He was an arrogant jerk.
No, the one I'm thinking of had a sort of similar sounding title, iirc, but wasn't about any clinical trials. It was just someone proposing various ways to administer placebos and arguing the ethics of them. It was closer in spirit to this, although I don't think it was that one either.
It seems like most of Orac's ethical reservations about the study you linked could have been avoided had they just said that it makes you feel better instead of makes you self-heal.
The problems with Kaptchuk's study was that he didn't just describe the placebo as inert sugar pills that would have no physiological effect. No need to add anything else. As a result, Kaptchuk's results are in error because he biased the subjects.
In that link you provided, I'd argue that the examples they use still involve some measure of deception in that the patient is misled to believe that there will be some objective physiological effect, rather than simply a subjective emotional/cognitive effect. Whether or not deception in general is ethical is an entirely different question.
I think what you're missing is that if you were to take the average American off the street and ask whether dietary changes were "medicine" or "alternative medicine," alternative medicine would win by a large amount right now. You probably define alternative medicine as stuff that doesn't work, full stop, but most people's definition spans all the way from kooky stuff that couldn't possibly work all the way to stuff that actually is scientifically validated. That's where the real war is. And it absolutely is an issue of branding.
I don't think it's too hard to convince people that the brand of real medicine includes everything that really works, and that alternative medicine is everything that doesn't. After all, that's the definition you seem to already be using. But people don't currently perceive it that way.
Getting people to see the dietary stuff done by alties as not alternative medicine but real medicine attempted by incompetent hands would take a lot of wind out of their sails. Of course, the biggest benefit of that rebranding would be that people would be starting to ask why medical insurance doesn't cover actually competent people doing that real medicine a lot of the time.
The tl;dr is that the alties get a lot of their support from stuff that isn't woo, and if we can successfully pull that away from them they will lose most of their strength.
Mrs. Woo: I am sorry that you found a doctor who was so disrespectful to you. I have been talked down to on occasion as well, because I have a degree in Epi, I spend a lot of time in research of disease, and I absolutely hate to be lied to. I hope that your circumstances (insurance, location, etc.) will allow you to find another physician who will be helpful for your condition and not an enormous prick and I wish you the best of luck. Thankfully no one in the immediate family suffers a chronic condition at the moment, but it is sometimes challenging to find a GP whom we all like. And of course a pediatrician for the child. Best of luck in your search, and may you find some relief for your pain.
Branding is correct.
Pardon me if I wax philosophical but I just heard something awful on the computer....
As you know, the solstice draws close and the light fades, soon to be nearly extinguished- its last dying embers flickering away ominously framed by the megaliths of Stonehenge on the sunset of the shortest day ( across the circle from the place everyone gathers in June) thus I reach far back into the mists of time to consult our druidic past...
Now doesn't that sound a lot more romantic and profound than saying that we get depressed around this time of year?
-btw- it was the internet radio - PRN.fm - and the lunatic host and his guest ( Ms Phan-Le) mourned how modernity has been casting aside traditional healers and their ancient pharmocopaiea - oracles and shamans are threatened by the rise of EBM - their mode of investigation is ' artistic not mechanistic' thus they get closer to the source of problems says she, embracing the spiritual as well as the physical. And of course, she has a film.
OBVIOUSLY this stuff sells.
I tend to view most of their material as advertisement heavy with catch phrases. Rather than saying "eat less processed fattening foods" they'll say, "eat like a Paleolithic hunter-gatherer'.
The latest is the Viking Diet- berries, herring and roasted meat.
"The only example I remember off the top of my head is some obscure condition that gets exacerbated by cortisol."
I don't believe such conditions are obscure in the sense of extremely rare. If you the sense of obscure as difficult to and not well understood, then yes. I have had this experience myself, though at the time I did not understand the effect.
While one cannot think oneself into or out of a cancerous lump, I do think the comments here underestimate the interaction of state of mind and health. The brain lives in the rest of the body and is an organ as any other, it is connected directly and indirectly to functions throughout one's system. Even if we don't know the particular connections, it seems wise to consider it essential to the functioning of the system.
- btw, does anyone here know if the tale of Vance Vanders is true? Supposedly a dramatic example of the nocebo effect.
rrr still no edit function.
I have no way of knowing if the effect I experienced was due to cortisol. The experience about matches, but of course there was no tricorder around to suss out what caused it.
I was sent to a physical therapist recently for a neck injury by my orthopedist. On the first visit to him he started off trying to educate me on the benefits of some expensive homeopathic/natural pain controlling gel.
He also asked if I had considered getting a referral to an aucupuncturist or chiropractor since workmans comp apparently pays for such in Ca. I told him I had no desire to see either type of practitioner since there is no good evidence for said services. He then eagerly informed me that there was indeed a good study that showed an increase of the release of endorphins or something ( to be honest at this point of the conversation I was hearing something along the lines of ....... whaa whaaa whaa)
I told him that I could also smash my thumb with a hammer to get a good dose of endorphins but it wouldn't do a damn thing for my neck, nor for the new injury and heard crickets.
Never went back to that guy.
Sounds like you should get a new orthopedist.
Maybe you read a headline about that, but if you read the actual paper it's actually quite unimpressive and not really as reported.
All I can say is that the company I work for has marketers and testers, and both are essential to our success, but there is a reason that marketers aren't testers.
I said "untreatable condition" not a head cold, and "makes a patient feel better" =/= "go away" sooner or ever.
And congratulations at nitpicking a straw-man and ignoring the substantive issue: the moral judgment of cases where some accommodation of woo results in real human beings accepting sbm treatment and avoiding death.
By JCL's 'logic' we close all the hospital chapels, and when stage IV cancer patients fold their hands to pray the Dr, slaps them on the wrist and admonishes them to cope with the raw, rational expectations. Like that would ever work.
I'm an athiest, and the LAST person I want at MY bedside when I'm in the medical shits is any kind of spirituality slinger. (more on this in comment to follow). But how JCL imagines what get's under HIS skin, and what HE wants from a physician has any relevance whatsoever to general standards of care is beyond me.
Routine medicine, even in specialties, isn't rocket science.* The grumpy genius belongs in the research lab, or a House-type gig with a support team who can deal with people. The talent PCPs need most is people skills. Most patients do not have Mrs. Woo's experience-acquired wisdom.
Human interaction isn't peripheral to medical at all. It's where it starts. AFAIK, the medical term for "qualifying the customer" would be "working up an intake," — the primary source of information being a not-medically-literate human being (not a machine) whose responses will be affected by a complex set of emotions and subjective perceptions. I mentioned my ER horror story — I underwent 48 hours of physical misery and a serious threat to my long-term health because when my speech facility returned I told the Dr. exactly what my condition was, and he was only pretend-listening, blew me off completely, and put me on exactly the WRONG treatment program...
Less than 5 minutes of the right diagnostic questions would have established my history, and that I knew WTF I was talking about. That doc was dead stop incompetent, and should never have been let anywhere near patients. I have no doubt that had he properly diagnosed my problem, he would have known what to do to high standards of medical science. That knowledge was less than useless under the circumstances.
If any would-be PCP is put off by a people-skills curriculum or can't hack it, GOOD. See, this isn't a 'one bad egg' story at all. The problem was utterly systemic to the way the hospital was operated. I was there 3 days. At no point did I ever see a member of hospital medical staff more than once. Each time I got looked-in on, for anything, it was someone new I hadn't seen before and knew nothing about my case other than whatever scant notes might have been scribbled on my chart.
The people-skills problem for sbm is systemic well beyond the ass-f**ked care at L&M Hospital in New London, Connecticut (if you fall ill in that neck of the woods, DEMAND to be taken to Middlesex Hospital in Middlebury, and get out of the f**king ambulance and call a cab if they don't comply.) It's not just the woo-practioners are more psychology-savvy — though no doubt they are. It's that the system allows them to take more time with patients, give them more attention, establish relationships — options that are denied even the most sensitive sbm practitioners in most instances under the Taylorized ethos into which sbm is forced by insurance mandates. It won't do for sbm practitioners to be as good as woo-meisters in patient contact. They have to be better.
JCL probably means well. Anyone who calls out their own repetition of "aspect' strikes me as an unlikely candidate for possession of an arrogant jerk core. But knowing that, I still get the vibe of self-congratulatory, holier-than-thou stoicism in his post, and it feels like condescending wanking. And I see what I can only take as a face-palm worthy myopia. I'm guessing JCLs medical issues have only ever involved conditions that presented straightforward diagnoses. If you have fungus consuming your big toenail, it is what it is, and the bloodwork will tell the Dr. whether she can prescribe lamisil tabs or not. A dislocated finger is a dislocated finger. Etc. Lot's of us are not so lucky, especially as we get older. Methinks some folks could use a hubris check.
* I’ll call myself out on overuse of ‘rocket science’ before someone else does, and also that it's a way overused cliche and far more egregious than JCL's repetition of 'aspect', which didn't bother me at all.
I wrote (currently in moderation):
I ended up with a new primary care that took over my departing doctor's practice. Here in the U.S. chronic pain patients on pain medication have difficulty getting new doctors. It is pretty normal to be regarded with suspicion. I am an excellent patient in that regard, and more than intelligent enough to understand my body and what is normal vs abnormal.
@LurkeyLoo - I suspect the therapist was more susceptible to placebo affect and it made them believe it was more valuable than it really is. I live with a die-hard true believer. He has many good qualities. I often wonder how he can believe whole-heartedly in the implausible and tell you with a straight face that real medicine cannot be trusted or expected to work.
I keep praying that his health doesn't get any worse. I know if he gets cancer, it will be impossible to get him to take studied treatment. He will opt for laetrile or some other woo.
a neck injury by my orthopedist.
You expect that more from osteopaths.
OT but are teaser announcements by a woo-meister about to bravely share his secrets to SAVE THE WORLD!!11!!! ever TRULY OT @ RI?
I personally would think not.
It's nearly a new year and as usual, Mikey has promised ground-breaking, earth-shattering discoveries about to be unveiled in the next weeks.
It seems that in addition to his analytical lab work ( heh) he has been playing around with a 3D printer and INVENTING 'low tech' innovations that will enable all readers to break free from the chains of corporate food, supplement and pharmaceutical oligarchies/ mob rule and grow their own superfoods , supplements, medicines and ( probably) weed.
Yes sirree, it's all not-for-profit, openly sourced, freely shared and supported by his own private charity thus independent of grants and supervision by the powers-that-be. All you need is a lulzbot and some material. He will also sell you parts if you haven't a printer.
His monumental achievement will be detailed on Food Rising.org. ( see video)
Never again will you live in fear and subjugation to the supermarket, the vitamin dealer or the frankenfood you ingest in the fast food jungle.
Sadmar is all too correct.
Oh good. I've been being victimized by grocery stores for so long I don't even notice it.
Right that's what happens with addiction: you imagine your dealer to be your friend because they supply your habit- be it salmon Greek cappucino yougurt or granola bars.
Isn't 3D printing not natural?
Of course 3D printing is natural. How do you think God was able to make everything in 6 days? Just letting cells grow and divide and organisms to evolve takes a lot longer.
Until the Health Deranger figures out a way for me to grow my own coffee, I'm not interested.
Good article. I'll just dump in my gripe about the trend towards open access on the internet turning into a godsend for the quacks and chowerheads. Any crackpot can dive into the NIH repository, fish out a random paper, and resurface to wave it around screaming NIH SAYS REIKI CURES CANCER!!!!! Then you have to explain that the Journal of Irresponsible Speculation is not endorsed by the NIH, one article by itself doesn't prove anything, and that's not even what the article says in the first place. So tired, from swatting down the nonsense... come on people, get an education; at least know the fundamentals before claiming you have overthrown all existing knowledge.
I like National Center for the Study of Holistic and Integrative Therapeutics. Mostly for the acronym.
I take it that you haven't met any junkies.
Orac, how do you propose alternative therapies and treatments be dealt with? Should it just all be part of medicine in general and be given equal attention to any other potential treatment? In other words, given research attention until disproven? I mean, there is that adage "what do you call alternative medicine that has proven efficacy - medicine!" But how do you get from alternative to medicine or alternative to debunking? If not NCCAM or whatever, then regular research modes?
I hit submit too soon.
Because I think it is not respectful to patients to discount anything that is not already in the books as medicine. When treating disease, doesn't it sometimes pay to think outside the box? Isn't that occasionally how new treatments and ideas are discovered? I would hate for research institutions to be so conceited in their viewpoint that they refuse to entertain any other modalities at all. At least try to research the alternatives even if all you do is prove them wrong or placebo. Personally, there is nothing worse than being sick and having a stuck up, egotistical doctor tell you your idea is bunk but then have nothing to back up that claim. I want to know the treatments being offered to me are sound. Similarly, if I ask about another treatment, I want research-based evidence to back up why it will or will not work for me.
Kathy: "In other words, given research attention until disproven?"
What alternative medicine do thing has the possibility of being proven to work? Homeopathy, reiki, acupuncture, chiropracty, what?
And tell why those things have a chance of being proven effective.
"When treating disease, doesn’t it sometimes pay to think outside the box? Isn’t that occasionally how new treatments and ideas are discovered?"
There is this prior possibility thing. And sometimes they do think out of the box, but the method had a scientific reason it could work. For instance this story that was in the morning paper:
Home for the holiday: Last-gasp drug saves Seattle baby’s life
"Personally, there is nothing worse than being sick and having a stuck up, egotistical doctor tell you your idea is bunk but then have nothing to back up that claim."
This blog and the ScienceBasedMedicine blog have several articles detailing the reasons many of those treatments cannot and do not work.
For actual medical stories where real medical researchers "thought outside the box" I suggest you read these books:
The Emperor of All Maladies: A Biography of Cancer Paperback by Siddhartha Mukherjee
Rabid: A Cultural History of the World's Most Diabolical Virus by Bill Wasik and Monica Murphy (you should also read the classic 1920s Microbe Hunters by Paul De Kruif)
and the book I am reading now: Dr. Mutter's Marvels: A True Tale of Intrigue and Innovation at the Dawn of Modern Medicine by Cristin O'Keefe Aptowicz
So, the idea is that you get to pull things out of your tokhes and the burden thus shifts to the physician to turn into a walking review article on whatever has caught your fancy?
Kathy @54 and 55:
Be sure you let the alternative providers know that. And that means going beyond testimonials to blinded trials.
Many of these alternative treatments – say, naturopathy (in the sense of herb-based folk medicine), homeopathy, “traditional” Chinese medicine, or chiropractic – well, they’ve been around long enough now that they’ve build their own boxes around themselves.
"What alternative medicine do thing has the possibility of being proven to work? Homeopathy, reiki, acupuncture, chiropracty, what?
And tell why those things have a chance of being proven effective."
Accupuncture, chiro, and homeopathy have been studied and proven ineffective.
Case and point.
I would expect all orthopedic surgeons to know why chiro is not a good idea and I would expect all pain specialist MDs to be knowledgeable about accupuncture and why it doesn't alleviate pain. I would expect all medical doctors to know that homeopathy is just sugar pills and fancy water, has been researched, and has been proven bunk. I would expect them all to be able to have a conversation with their patients about why energy healing principles are not scientific.
I don't know much about Reiki.
"So, the idea is that you get to pull things out of your tokhes and the burden thus shifts to the physician to turn into a walking review article on whatever has caught your fancy?"
Yes, if I ask my doctor about a popular treatment such as accupuncture for pain, for example, I expect him or her to be able to tell my why that will or will not work. What is so hard about that? There is nothing wrong with asking about options. No patient should sit and blindly take medical advice of any sort without asking questions about treatment options, side effects, etc.
Narad, Chris, and Chemmomo,
You are presuming I am a practitioner of alternative medicines and treating me like an idiot. You did not really do anything to answer my questions. Luckily, I lately have some great MDs such as an oustanding ENT and wonderful family doctor who are willing to talk to me about a variety of treatment options, including pros and cons, instead of dismissing my questions like you have done. For example, years ago, no MDs recommended sinus lavage for treatment of chronic sinus infections and now most ENTs do. At some point, it was just something yogis did but somehow it got researched and shown to be beneficial in preventing sinus infections and treating chronic sinus issues. Somebody thought outside the scientific box to try a new idea and now it has been proven efficacious.
I wish all medical doctors could be respectful with their patients. I certainly have encountered medical doctors who are egotistical jerks like you three. I left their practices.
Kathy: "Accupuncture, chiro, and homeopathy have been studied and proven ineffective."
Prove it for homeopathy. A naturopath by the name of Andre Saine claims homeopathy works better for rabies than the modern vaccine. Now that is something that could be easily test on animals, like rodents.
So just provide the PubMed indexed animal studies by non-homoepaths that show homeopathy works better for rabies than the modern vaccine.
I would also suggest you use the little search box at the upper right hand bit of this page and see what has been written here about acupuncture, chiro, reiki and homeopathy.
"You are presuming I am a practitioner of alternative medicines and treating me like an idiot."
Excuse me, where did I give the notion that you a practitioner? I just assumed you were someone who thinks it works for you, but has not really thought that about how or if it should work. It is all about that "prior plausibility" bit, like how does something work with it is diluted past reality or is just random hand waving.
And I did not call you an idiot, I asked you questions. The second one being "And tell why those things have a chance of being proven effective." You did not provide any evidence of why they would work. Hence, I have asked you about rabies.
I also you gave you many interesting readings on how modern medicine has "thought outside the box." I know you have not had time to read the books, but did you read the news article about the baby?
By the way I am not a medical care provider. I was an engineer until giving birth to a child with many medical issues. Trust I am very tired of someone telling to try a therapy the involves just literally waving their hands above his head to cure the damage to his brain due to seizures.
Some words escaped: 'Trust me I am very tired of someone telling me to try a therapy.."
You are quite correct. My point was that you should ask those questions (i.e., is the treatment effective? ) of those who are selling the answers: the purveyors of the alternative medicine.
As for your other questions? I suggest re-reading the blogpost with comprehension, and perhaps following the links back to earlier posts.
Going back to Kathy's question of
I am not Orac, nor do I play him on TV. However...
Any treatment that a doctor prescribes should be backed up with science that says it is safe and effective (remembering that both words are relative terms, not absolutes). The data that supports the treatment must be gathered in a way that maximizes the likelihood that the data is correct and observes actual results. In particular, the data should not be affected by the biases of either the subjects or the investigators. Right now, the best studies are randomized, placebo controlled, double blinded clinical trials with a significant number of subjects, particularly if the study results have been replicated by other, independent teams. Naturally, there are other types of studies that can provide good data, but this would be the best.
In an ideal world there would be resources available for any well designed trial to proceed for any proposed treatment. Everyone studies whatever they feel might do some good, the results are published, and the chips fall where they may. However, we do not live in that world. Research resources are limited and not everything that could be studied are funded or staffed. In determining what to study, then, there should be a "prior plausibility" test. If the best current knowledge says that a treatment has no chance of working, that particular treatment would require a substantial amount of new information to make it worth studying.
As an example: if homeopathy had never existed and someone were to develop it today, in its present form, then it would be perfectly reasonable to examine its precepts, determine that they aren't backed by the sum of biology, chemistry, and physics, and conclude that any work on it would be a waste of time. It would require a substantial amount of evidence to change that opinion.
Alternatively, were someone to claim that, say, cannabis could be used to reduce tumor size for lung cancer it could not be immediately discounted as totally implausible. Some evidence would be needed before starting work, as there is an entire universe of things that are not totally implausible as lung cancer treatments.
As to the comment that
The only reasonable standard in science is that the person claiming something works has the burden of proving that it does, rather than the people having to prove that it doesn't. Trying to prove that something doesn't work is much harder and inevitably leads to continual excuses from proponents. Were a test of, say, reiki to show no effect then invariably someone would claim that the practitioner was not properly trained, or that the subjects were sabotaging the results, or that the phase of the moon was incorrect, or that the control group was also affected because reiki is so darned powerful.
Now, were you to present a doctor with good evidence for a particular course of treatment and be told it was bunk with no discussion, then you might well have a beef.
Fecal transplants for Clostridium difficile colitis.
When I used to ask my doctor about testing for something I had heard about in the altie-sphere he would just ask me to bring him some evidence that test was useful before he would order it. I would take a closer look at the evidence on the internet and realize it was so bad I would be embarrassed to present it. What a jerk of a doctor eh.
Have you seen the NCCAM website? A large range of alternative treatments have been researched, but there is very remarkably little of substance there, apart from some alarming findings about adverse effects of some CAM treatment, such as aloe vera gel inhibiting healing of deep surgical wounds, and its leaf being carcinogenic and possibly causing liver damage when ingested.
This is despite NCCAM spending over $120 million of US taxpayers' money every year to fund research into CAM including support for clinical trials; that's $1.3 billion between 2000-2011. OCCAM spends a similar amount on alternative treatment for cancer and is equally disappointing. There is plenty of evidence against the efficacy of the great majority of alternative medicine, but it remains in common use. That's the depressing thing about it, that reason seems to have been abandoned in this area to a worryingly large degree by people who should know better.
I'm not sure that is a good use of the time spent educating doctors. We have bodies of experts who spend their time looking at research to assess what the best treatment modalities are for various conditions. I do expect my doctor to be up to date on the relevant portions of that, but CME takes up an enormous amount of time, and I don't think it's fair for me to demand that she also keeps up to date on the vast literature on things that don't work, or that have insufficient evidence to know if they work or not.
@sadmar #18, Orac applauded Ainscough's decision to go with modern medicine, at the same time understanding that she needs a large dose of fantasy to help her face the grim reality. Orac criticized the U.S. government for squandering money studying, re-studying, and re-re-studying "treatment" modalities that can't work (e.g., homeopathy and reiki) or have been shown not to work (e.g., acupuncture) or could be and have been studied in genuine research settings (various plants), when that same money could be used for real research that might really lead to fewer people facing the grim reality that Ainscough faces. You see a contradiction there? I don't.
Nothing, except that it's not what you originally said, i.e., what I was responding to.
^ Let me know if I need to fix that blockquote fail for it to be intelligible.
I still wonder about flossing the entire GI tract in this way. The idea tickles me, for some reason.
Kathy: “Accupuncture, chiro, and homeopathy have been studied and proven ineffective.”
Woo hoo, Kathy! I am still waiting for you to support that statement, especially homeopathy, with real evidence.
Also, have you started on the books I suggested? Or did you just leave us. That is so sad that you will not come back and educate us on how to think.
Loath as I am to correct you, I fear you have misread what Kathy wrote i.e. "ineffective", not "effective".
AAArgh! You are so right. I am now blushing.
We've seen those claims a thousand times before, so your mistake is quite understandable. I am wondering what alternatives Kathy thinks we might be wrongly dismissing. Looking at NCCAM, there doesn't seem to be much left that hasn't been examined.
I think a lot more research into chocolate theropy should be done.
I prefer Supplemental, Complementary, and Alternative Medicine aka (SCAM).