Medicare is paying for chronic care management! Here’s what you need to know.

The Medscape Physician Compensation Report puts primary care physicians at the bottom of the heap, with a median earning of less than $200,000 per year in 2014. What if the largest insurer of older Americans took those numbers to heart and decided to give primary care a pay raise of 25 percent, in recognition of […]

via Medicine Joint Channels

Can a surgeon operate while sitting down?

A loyal reader alerted me to news of a lawsuit brought by an obstetrician in South Carolina who is suing a hospital for suspending his privileges. He had performed a cesarean section while sitting on a stool because he had a foot fracture secondary to diabetes. Several witnesses said that the doctor “had been unable […]

via Medicine Joint Channels

So you want to change doctors. Here’s how to do it right.

Question from a reader: “What are your feelings about when a patient breaks up with you? I love love my doc, but …” Patients “break up” with me all the time. Well, not all the time, but it’s not uncommon. There are many reasons, some of which are under the patient’s control, and some which […]

via Medicine Joint Channels

We have built a sickness care system rather than a health system

A version of this speech was delivered May 14, 2015 to the graduating class at the University of Manitoba. I’m not a doctor. I never will be. I’m a lowly journalist. I tell stories.  For almost 30 years, I’ve tried to help Canadians understand their health system and their medical care. In that time, I’ve seen […]

via Medicine Joint Channels

A psychiatrist is burnt out and depressed. Here’s what she did about it.

I noticed that my writing and conversations with others convey far less emotion than usual.  My reserve for tolerating stress had reached maximum capacity, which I realized upon my first day back at work from vacation three weeks ago as exhaustion immediately erased any sense of relaxation from my trip.  Perhaps I should have requested two weeks […]

via Medicine Joint Channels

The best places for a doctor to practice: It’s more than money

I would think that when physicians decide where to set up practice, there are things that they would want to think about other than how much money they’ll make.  Yet if one reads Medscape’s current list of the best and worst places to practice, it would appear that money trumps everything else (although Medscape said […]

via Medicine Joint Channels

Heart surgery in Silicon Valley: The future is already here

Here is a behind-the-scenes peek into an operating room in the midst of Silicon Valley. Here, routinely there is a groundbreaking intersection of technology and medicine that’s blurring the lines between what’s possible today and what you’ll come to expect as routine in the future. Imagine two experienced surgeons working side by side to replace […]

via Medicine Joint Channels

Conflicts of interest aren’t only about financial incentives

Everyone has an angle. Everyone. Your doctor? Sure. But, he or she isn’t the only one. The pharmaceutical company? Of course. The medical device company? The hospital? The insurance company? You get the point. Everyone has an angle. Everyone has a conflict of interest. Know it. Get over it. It’s time to focus on something else. […]

via Medicine Joint Channels

Doctor saves patient from harm after her insurer tries save money

The insurance company insisted that they would be saving money in the end.  So they sent the PA (physician assistant) to my patient’s house.  They didn’t take into consideration that I was just there a week before.  Or that I made home visits on a regular basis.  In fact, they didn’t even inform me about […]

via Medicine Joint Channels

NCCIH and the true evolution of integrative medicine

There can be no doubt that, when it comes to medicine, The Atlantic has an enormous blind spot. Under the guise of being seemingly “skeptical,” the magazine has, over the last few years, published some truly atrocious articles about medicine. I first noticed this during the H1N1 pandemic, when The Atlantic published an article lionizing flu vaccine “skeptic” Tom Jefferson, who, unfortunately, happens to be head of the Vaccines Field at the Cochrane Collaboration, entitled “Does the Vaccine Matter?” It was so bad that Mark Crislip did a paragraph-by-paragraph fisking of the article, while Revere also explained just where the article went so very, very wrong. Over at a blog known to many here, the question was asked whether The Atlantic (among other things) matters. It didn’t take The Atlantic long to cement its lack of judgment over medical stories by publishing, for example, a misguided defense of chelation therapy, a rather poor article by Megan McArdle on the relationship between health insurance status and mortality, and an article in which John Ioannidis’ work was represented as meaning we can’t believe anything in science-based medicine. Topping it all off was the most notorious article of all, the most blatant apologetics for alternative medicine in general and quackademic medicine in particular that Steve Novella or I have seen in a long time. The article was even entitled “The Triumph of New Age Medicine.”

Now The Atlantic has published an article that is, in essence, The Triumph of New Age Medicine, Part Deux. In this case, the article is by Jennie Rothenberg Gritz, a senior editor at The Atlantic, and entitled “The Evolution of Alternative Medicine.” It is, in essence, pure propaganda for the paired phenomena of “integrative” medicine and quackademic medicine, without which integrative medicine would likely not exist. The central message? It’s the same central (and false) message that advocates of quackademic medicine have been promoting for at least 25 years: “Hey, this stuff isn’t quackery any more! We’re scientific, ma-an!” You can even tell that’s going to be the central message from the tag line under the title:

When it comes to treating pain and chronic disease, many doctors are turning to treatments like acupuncture and meditation—but using them as part of a larger, integrative approach to health.

No, that’s what they say they are doing (and—who knows?—maybe they even believe it), but what that “integrative” approach to health actually involves is “integrating” quackery like acupuncture with scientific medicine. Elsewhere, in her introduction to the article in which she explains why she did the story, Rothenberg Gritz describes a visit to the National Center Complementary and Integrative Health (NCCIH), which is how the National Center for Complementary and Alternative Medicine (NCCAM) was renamed last December:

After visiting the NIH center and talking to leading integrative physicians, I can say pretty definitively that integrative health is not just another name for alternative medicine. There are 50 institutions around the country that have integrative in their name, at places like Harvard, Stanford, Duke, and the Mayo Clinic. Most of them offer treatments like acupuncture, massage, and nutrition counseling, along with conventional drugs and surgery.

One notes that the renaming of NCCAM to eliminate the word “alternative” was a longstanding goal of NCCAM, its supporters, and “integrative medicine” advocates. The reason is obvious: “Alternative” implies outside the mainstream in medicine, and that’s not the message that proponents of integrating quackery into medicine want to promote. One can’t help but wonder if it was a retirement present for Senator Tom Harkin (D-IA), the legislator most responsible for the creation and growth of NCCAM who retired at the end of the last Congressional term. Whatever the case, the name change was, as I put it, nothing more than polishing a turd.

Be that as it may, no one, least of all here at SBM, argues that “integrative” medicine is “just another name for alternative medicine.” It isn’t, as most integrative MDs use conventional, science-based medicine as well. The problem with “integrative” medicine is that, to paraphrase Mark Crislip, mixing cow pie with apple pie does not make the apple pie taste better; i.e., mixing unscientific, pseudoscientific, and mystical quackery like acupuncture and much of traditional Chinese medicine does not make science-based medicine better. Rather, it contaminates it with quackery, just as the cow pie contaminates the apple pie.

Basically, integrative medicine is a strategy for mainstreaming alternative medicine, even though the vast majority of alternative medicine has either not been proven scientifically to be efficacious and safe, has been proven not to be efficacious, or is based on physical principles that violate laws of physics (such as homeopathy or “energy healing). Indeed, if the term “integrative medicine” were not thus, it would be a completely unnecessary moniker. The reason is, to paraphrase Tim Minchin, Richard Dawkins, John Diamond, Dara Ó Briain, and any number of skeptics, there is no such thing as “alternative” medicine because “alternative” medicine that is shown through science to work becomes simply medicine. Thus, newly validated medical treatments have no need to be called “integrative” because medicine will integrate them just fine on its own. That’s what medicine does, although admittedly the process is often messier and takes longer than we would like. Integrative medicine, like alternative medicine before it, is a marketing term that is based on a false dichotomy. Only unproven or disproven medicine needs the crutch of being “integrative,” a double standard that asks us to “integrate” unproven treatments as co-equal with science-based medicine even though they have not earned that status.

Unfortunately, this is a false dichotomy that Rothenberg Gritz promotes wholeheartedly. The only hint of skepticism is a brief passage near the beginning in which she refers to Paul Offit’s 2013 book, Do You Believe in Magic? The Sense and Nonsense of Alternative Medicine and briefly quotes him saying what I’ve been saying all along, that “integrative medicine” is a brand, a marketing term, rather than a specialty. She also noted his criticism in his book of what is now NCCIH, and includes a quote by Dr. Offit about Josephine Briggs (the current director of NCCIH) that she “certainly was very nice” and assured him that they “weren’t doing things like that any more” (referring to “things” NCCCIH studied in the past, like distance healing, and magnets for arthritis). This is, of course, hardly even a criticism at all, but rather getting Dr. Offit to state for her Dr. Briggs’ frequent claim that NCCIH doesn’t study pseudoscience any more. It’s a claim she made when Steve Novella, Kimball Atwood, and I met with her five years ago, and, yes, back then Dr. Briggs was also very nice to us, although she did rapidly turn around and, in a painful fit of false balance, use that meeting as evidence of her even-handedness in meeting with both critics and homeopaths. It’s a claim embedded in the 2011-2015 NCCAM strategic plan, which I now like to characterize in talks as “Hey, let’s do some real science for a change!” In any case, Rothenberg Gritz’s account isn’t false balance. It’s no balance at all, with the token skeptic role taken by Dr. Offit.

The Integrative Medicine Wheel — A good example of the branding of integrative medicine.

Revisionist history about NCCIH

Advocates for “integrative medicine” have used a variety of talking points over the years, and Rothenberg Gritz hits most of them in her article quite credulously. Indeed, it is very clear from her introduction that she was predisposed to believe. Early in the article, she tells the tale by looking back to the early 1990s, when she was in high school and her father was a family physician who was clearly into some woo, including Transcendental Meditation, Ayurveda, and the like, even going so far as to incorporate them into his practice. The inescapable implication is that she considers her father a trailblazer for what is now integrative medicine.

Unfortunately, it is very clear that her knowledge of history in this area, particularly how NCCAM/NCCIH came to be, is sorely lacking, which leads her to parrot the version of history that integrative practitioners want you to believe:

Back in the 1990s, the word “alternative” was a synonym for hip and forward-thinking. There was alternative music and alternative energy; there were even high-profile alternative presidential candidates like Ross Perot and Ralph Nader. That was the decade when doctors started to realize just how many Americans were using alternative medicine, starting with a 1993 paper published in The New England Journal of Medicine. The paper reported that one in three Americans were using some kind of “unconventional therapy.” Only 28 percent of them were telling their primary-care doctors about it.

And:

Enough Americans had similar interests that, in the early 1990s, Congress established an Office of Alternative Medicine within the National Institutes of Health. Seven years later, that office expanded into the National Center for Complementary and Alternative Medicine (NCCAM), with a $50 million budget dedicated to studying just about every treatment that didn’t involve pharmaceuticals or surgery—traditional systems like Ayurveda and acupuncture along with more esoteric things like homeopathy and energy healing.

Now there’s some revisionist history! The word “alternative” was just popular because there was so much other “alternative” stuff (alternastuff?) going on in the early 1990s! But it’s not the 1990s any more; so “alternative” isn’t as cool as it used to be. Of course, the word “alternative” as applied to quackery dates back at least to the 1960s.

Longtime readers know how NCCAM really came about. One wonders if Rothenberg Gritz ever came across Wally Sampson’s classic 2002 article, “Why the National Center for Complementary and Alternative Medicine (NCCAM) Should Be Defunded” or Kimball Atwood’s “The Ongoing Problem with the National Center for Complementary and Alternative Medicine“. Even if you buy into the false notion that NCCIH (née NCCAM) has completely reformed itself and doesn’t study or promote quackery any more, a history lesson is important. What really happened matters.

Basically, Sen. Tom Harkin was a believer in a lot of alternative medicine. Thus, in 1991 he used his power as the chair of the Senate Appropriations Committee to create the precursor to the NCCIH. His committee declared itself “not satisfied that the conventional medical community as symbolized at the NIH has fully explored the potential that exists in unconventional medical practices” and, to “more adequately explore these unconventional medical practices,” ordered the NIH to create “an advisory panel to screen and select the procedures for investigation and to recommend a research program to fully test the most promising unconventional medical practices.” This advisory panel became the first incarnation of NCCIH, the Office of Unconventional Medicine, which was quickly renamed the Office of Alternative Medicine (OAM).

This next part is very important. NIH didn’t request this new office. There were no scientists and physicians in the NIH leadership clamoring for such an office. Congress didn’t respond to a “groundswell” of support to establish this office. The NEJM article cited by Rothenberg Gritz wasn’t even published until nearly two years after Harkin had already started the wheels rolling and a year after the founding of OAM. No, a single powerful senator with a proclivity for quackery used his power to get this enterprise off the ground, and he continued to nurture it over his remaining two decades in the Senate. The OAM was, in essence, imposed on a correctly-unwilling NIH, and has been ever since. Indeed, after she left as NIH director, Bernardine Healy revealed that she had considered the project to link research scientists with true believers in therapies like homeopathy to conduct experiments as foreshadowing nothing but disaster, but conceded that the NIH had “had no choice” because it couldn’t refuse to carry out a mandate from Congress.

And, make no mistake, Harkin was big into quackery, not to mention being in the pockets of quacks:

Harkin had been urged to take this legislative step by two constituents, Berkley Bedell and Frank Wiewel. Bedell, a former member of the House, believed that two crises in his own health had benefited from the use of unconventional medicine: colostrum derived from the milk of a Minnesota cow, he held, had cured his Lyme disease; and 714-X, derived from camphor in Quebec by Gaston Naessens, had prevented recurrence of his prostate cancer after surgery. Bedell, giving evidence of his Lyme disease recovery at a Senate committee hearing, observed: “Unfortunately, Little Miss Muffet is not available to testify that the curds and whey which she was eating are safe.” Wiewel had long been a vigorous champion of immunoaugmentative therapy for cancer, scorned by orthodox specialists; made in the Bahamas, this mixture of blood sera was finally barred from import by the Food and Drug Administration. Wiewel then began operating from his home in Otho, Iowa, an agency called People Against Cancer, a referral service for cancer treatments that orthodox medicine considered questionable.

Harkin, having lost two sisters to cancer, was susceptible to an interest in alternative therapies. Soon after sponsoring the law that launched the Office of Alternative Medicine, Harkin himself became a true believer in an unorthodox “cure.” On Capitol Hill, Bedell introduced the senator to Royden Brown of Arizona, promoter of High Desert bee pollen capsules. Harkin suffered from allergies; persuaded by Brown to take 250 bee pollen capsules within five days, he rejoiced that his allergies had disappeared. The senator did not know at the time that Brown had recently paid a $200,000 settlement under a consent agreement with the Federal Trade Commission, promising to cease disguising television infomercials as objective information programs and to stop including in his scripts dozens of false therapeutic claims for his capsules. These promotions also averred that “the risen Jesus Christ, when he came back to Earth,” had consumed bee pollen; a more recent customer, Brown’s infomercial declared, was Ronald Reagan. Brown later wrote Hillary Clinton, warning that her husband should begin dosing with bee pollen lest he develop fatal throat cancer.

So NCCIH started out at the urging of two quack constituents of Harkin; then Harkin became a believer himself. Not surprisingly, it soon became clear that the OAM was not intended to rigorously study alternative medicine, but rather to provide a seemingly scientific rationale to promote it. The office was initially set up with an acting director and an ad hoc panel of twenty members, many of whom Harkin hand-picked, including advocates of acupuncture, energy medicine, homeopathy, Ayurvedic medicine, and several varieties of alternative cancer treatments. Deepak Chopra and Bernard Siegel were also included. Critics of quackery were consulted and considered for panel membership but—surprise, surprise!—were not selected. These pro-alt med panel members became known in the OAM as “Harkinites.”

Against this background, the first director of the OAM, Joseph M. Jacobs, almost immediately ran afoul of Harkin by insisting on rigorous scientific methodology to study alternative medicine. To get an idea of what Jacobs was up against, consider that in 1995 the inaugural issue of Alternative Therapies in Health and Medicine featured not just one, but two, commentaries by Senator Harkin, “The Third Approach” and “A Journal and a Journey“. In these two articles, Harkin basically introduced the new journal as a “journey—an exploration into what has been called ‘left-out medicine,’ therapies that show promise but that have not yet been accepted into the mainstream of modern medicine.” and explicitly stated that “mainstreaming alternative practices that work is our next step.” Unfortunately, he had a bit of a problem with the way medical science goes about determining whether a health practice—any health practice—works and railed against what he characterized as the “unbendable rules of randomized clinical trials.” Citing his use of bee pollen to treat his allergies, went on to assert, “It is not necessary for the scientific community to understand the process before the American public can benefit from these therapies.” It is an attitude that did not change. In 2009, Harkin famously criticized NCCAM thusly:

One of the purposes of this center was to investigate and validate alternative approaches. Quite frankly, I must say publicly that it has fallen short. It think quite frankly that in this center and in the office previously before it, most of its focus has been on disproving things rather than seeking out and approving.

Truly, this was a profound misunderstanding of how science works. Also, the reason NCCAM had failed to “validate alternative approaches” is because they were, largely, pseudoscientific quackery that, as expected, failed scientific testing.

Ultimately Jacobs resigned under pressure from Harkin, who repeatedly sided with the quacks. It also didn’t help that Jacobs complained about various “Harkinites” on the advisory panel who represented cancer scams such as Laetrile and Tijuana cancer clinics. That Jacobs became tired of fighting and finally resigned is especially noteworthy given that Jacobs himself had been picked to run OAM precisely because of his openness to the idea that there were gems to be found in the muck of alternative therapies. Meddling by Harkin was a theme that kept repeating itself. Later, in 1998 after the then-NIH director had tried to impose more scientific rigor on the OAM, Harkin sponsored legislation to elevate the OAM to a full center, and thus was the NCCAM born. Not coincidentally, the NIH director has much less control over full centers than over offices.

Bad science and revisionist history about how alternative medicine evolved into “integrative” medicine

The key message promoters of unscientific medicine hammer home again and again is that they’re not quacks. Oh, no. They’re real scientists and don’t use medicine that’s not scientifically proven. Rothenberg Gritz drives that point home thusly:

But I was intrigued by the NIH center’s name change and what it says about a larger shift that’s been going on for years. The idea of alternative medicine—an outsider movement challenging the medical status quo—has fallen out of favor since my youth. Plenty of people still identify strongly with the label, but these days, they’re often the most extreme advocates, the ones who believe in using homeopathy instead of vaccines, “liver flushes” instead of HIV drugs, and garlic instead of chemotherapy.

In contrast, integrative doctors see themselves as part of the medical establishment. “I don’t like the term ‘alternative medicine,'” says Mimi Guarneri, a longtime cardiologist and researcher who founded the Academy of Integrative Health and Medicine as well as the integrative center at Scripps. “Because it implies, ‘I’m diagnosed with cancer and I’m going to not do any chemo, radiation, or any conventional medicine, I’m going to do juicing.'”

As I characterized it, “We’re not quacks! We’re not quacks!” Later Rothenberg asserts:

The actual treatments they use vary, but what ties integrative doctors together is their focus on chronic disease and their effort to create an abstract condition called wellness. In the process, they’re scrutinizing many therapies that were once considered alternative, subjecting them to the scientific method and then using them the same way they’d incorporate any other evidence-based medicine.

Except that that’s not the case. Here are a couple of examples that I like to use to show why this characterization of integrative medicine is a delusion.

First, I like to cite a certain medical society that I’ve butted heads with on more than one occasion and whose leadership really, really doesn’t like me, namely the Society for Integrative Oncology, declaring that it has “consistently encouraged rigorous scientific evaluation of both pre-clinical and clinical science, while advocating for the transformation of oncology care to integrate evidence-based complementary approaches. The vision of SIO is to have research inform the true integration of complementary modalities into oncology care, so that evidence-based complementary care is accessible and part of standard cancer care for all patients across the cancer continuum.” Would that this were true! If that truly is the case, then how does SIO reconcile itself with the fact that its current president, Suzanna Zick, and immediate past president, Heather Greenlee, are both naturopaths, one of whom authored official SIO guidelines for the integrative care of breast cancer patients? (Even more depressingly, Zick is a naturopath working in the Department of Family Medicine at my old alma mater the University of Michigan Medical School.) That alone puts the lie to any claims SIO has of being scientific, given that naturopathy is a cornucopia of quackery and pseudoscience. In particular, homeopathy—or, as I like to call it, The One Quackery To Rule Them All—is an integral part of naturopathy as a major component of the curricula of schools of naturopathy and is a required component of the naturopathic licensing examination (NPLEX). If you don’t believe just how quacky naturopathy is, read what they say to each other when they think no one is watching; learn about how full of pseudoscience their education and practice are, as related by a self-described “apostate“; and how unethical their research can be.

Despite all this, it’s not just integrative oncology that’s embracing naturopathy. (There’s even a specialty now known as naturopathic oncology that’s advertised by places like the Cancer Treatment Centers of America.) Meanwhile a whole host of integrative medicine programs offer the services of naturopaths, including Kansas University, UC Irvine, Beaumont Hospital (in my neck of the woods!), the University of Maryland, and, of course, the Cleveland Clinic, where a naturopath runs a traditional Chinese medicine clinic, just to name a few.

Now, here’s where the second point comes in. It goes way beyond naturopathy, whose tendrils have become firmly entwined with those of “integrative oncology,” perhaps more so than with other specialties. If, as its advocates claimed ad nauseam to Rothenberg Gritz, integrative medicine is all about the science, then its approach is all wrong. Let’s put it this way. They themselves admit that many of the modalities they are using are unproven. If they truly accept that, then for them to offer such services outside of the context of a clinical trial would be as unethical as offering a non-approved drug or unproven surgical treatment to patients. Yet, as I’ve described more times than I can remember, there are quite a few academic institutions out there offering reiki, which is just as quacky, if not more so, than homeopathy, given that it postulates the existence of a “healing energy” that has never been detected and in its particulars is no different than faith healing, except that it substitutes Eastern mystical beliefs for Christian beliefs. Under the banner of “integrative medicine,” academic medical centers are offering high dose vitamin C for cancer, anthroposophic medicine, and functional medicine. Indeed, there are academic medical centers out there that offer everything from acupuncture to chiropractic to craniosacral therapy to naturopathy. Heck, the University of Maryland offers reflexology, reiki, and rolfing, none of which have any good evidence to support them, while more integrative medicine programs than I can keep track of offer acupuncture and various other bits taken from traditional Chinese medicine, even though acupuncture is nothing more than a theatrical placebo.

In other words, integrative medicine puts the cart before the horse. Hilariously, Rothenberg Gritz inadvertently undermines her own praise of the science of integrative medicine by relating that Dr. Guarneri, whom she just represented as a paragon of science who only wants to use scientifically validated treatments, offers onsite massage therapy, herbal baths, craniosacral therapy, and acupuncture, the latter two of which are pure quackery. (Oh, and she teams with naturopaths, as well.) Indeed, craniosacral therapy is such ridiculous quackery that Guarneri’s offering it pretty much eliminates any chance I’ll buy her claim of adhering to science in her practice of “integrative medicine.”

My amusement at this aside, especially irritating is Rothenberg Gritz’s description of acupuncture. After noting that chronic pain is one reason why people seek out alternative medicine, she writes:

One reason pain is so hard to treat is that it isn’t just physical. It can carry on long after the initial illness or injury is over, and it can shift throughout the body in baffling ways, even lodging in phantom limbs. Two different people can have the same physical condition and experience the pain in dramatically different ways. As the Institute of Medicine report put it, pain flouts “the long-standing belief regarding the strict separation between mind and body, often attributed to the early 17th-century French philosopher René Descartes.”

This may be why so many chronic pain sufferers are drawn to traditional medicine: The Cartesian idea of mind-body duality never found its way into these ancient systems. Acupuncture, for instance, has been shown to help with problems like back, neck, and knee pain. But it’s very hard for science to figure out how it works, since it involves so many components that are mental as well as physical. The technique of inserting the needles, the attitude of the practitioner, the patient’s own attention—all of these are built into the treatment itself. In Acupuncture Research: Strategies for Developing an Evidence Base, researchers note that ancient Chinese physicians saw the mind and body as “necessarily connected and inseparable.”

Note that the study to which Rothenberg Gritz links is the acupuncture meta-analysis by Vickers et al., which so failed to show what it claimed to show that one SBM post wasn’t enough to explain why. It required discussion by Steve Novella, Mark Crislip, and myself, much to Vickers’ dismay.

The funny thing is, mind-body dualism is not a part of modern medicine, making it odd that the IOM would get it so very, very wrong 11 years ago. Remember, the concept of dualism posits that consciousness (the mind) is, in part or whole, something separate from the brain; i.e., not (entirely) caused by the brain. Now, if there’s anything modern neuroscience has taught us, it’s that dualism is untenable as a scientific hypothesis, that the “mind” is wholly a manifestation of the function and activity of the brain—or, as it’s sometimes stated, the brain causes the mind. In other words, science-based medicine rejected mind-body dualism a long time ago. Of course, as we’ve discussed here more times than I can remember, when rigorously studied acupuncture has never been convincingly shown to do anything more than placebo. Indeed, the reason why acupuncture “outcomes” (such as they are) are so dependent on practitioner and patient is because acupuncture is placebo.

In fact, my retort to Rothenberg Gritz’s outright silly argument about mind-body dualism is that it’s the integrative practitioners who emphasize mind-body dualism, whether they realize it or not. After all, they have a whole category of therapies known as “mind-body” medicine, an implicit acceptance, at least on some level, of dualism. Nor does their overblown appropriation of epigenetic studies as evidence that the “mind heals the body” (or, as I like to refer to it, wishing makes it so), which infuses so many alternative medicine practices, help. In actuality, given that the vast majority of alternative medicine practices, when rigorously studied, do no better than placebo, this new emphasis is basically integrative medicine rebranding the pseudoscientific practices it “integrates” as “harnessing the power of placebo.” Since placebo effects require that physicians in essence lie to their patients (albeit with good intent), it’s not for nothing that Kimball Atwood and I have dubbed the placebo medicine as practiced by integrative medicine practitioners as a rebirth of paternalism in medicine due to the lure of being the shaman-healer.

The rest of the article is full of the same old pro-integrative medicine tropes that I’ve seen over and over and over again. For example, Mark Hyman, the “functional medicine guru” now trusted by Bill and Hillary Clinton who regularly mangles science about autism and cancer while advocating anecdote-based medicine, opines that we have “an acute-disease system for a chronic-disease population,” that the “whole approach is to suppress and inhibit the manifestations of disease,” and that “the goal should be to enhance and optimize the body’s natural function,” whatever that means—and whatever “functional medicine” is. (For a reminder, look at Wally Sampson’s multi-part analysis of what functional medicine is claimed to be here, here, here, here, and here.)

Rothenberg Gritz also relies on the ever-annoying “science has been wrong before” canard, listing all sorts of areas where medicine got it wrong before getting it right, as though that justifies integrating alternative medicine into science-based medicine because, I suppose, science could be wrong about that too. It does not; it’s a fallacy. She also parrots the charge that doctors haven’t thought enough about prevention, a claim that has always irritated me. After all, what are vaccines, but prevention? What are diet and drugs to treat elevated blood sugar but prevention of diabetic complications? What are antihypertensive drugs but a means to prevent the complications of hypertension, such as heart attacks and strokes? What are smoking cessation programs but a means of preventing cancer, heart disease, and chronic obstructive pulmonary disease, the three most deadly consequences of smoking? (Note how integrative medicine only defines “prevention” as non-pharmacologic, or “natural,” approaches.) Yes, it’s difficult to practice some forms of prevention because making lifestyle changes, such as losing weight, drinking less, smoking less, and exercising are hard. Patients don’t want to do them and have a hard time achieving them. I’ve yet to see much evidence that “integrative” medicine will do any better after having appropriated lifestyle interventions and rebranding them as somehow being “integrative.”

What is integrative medicine, anyway?

Perhaps the most inadvertently telling passage in Rothenberg Gritz’s article comes near the end:

After months of speaking to leading integrative doctors and researchers, I found that I was still having trouble summing up exactly what integrative health was all about. It’s not a specialty like obstetrics or endocrinology. There are integrative training programs and certifications out there, but none of them has been universally recognized throughout the medical profession. “At this point it’s really a self-declaration,” Nancy Sudak, the chair of the Academy of Integrative Health and Medicine, told me. “And nobody has a tool kit that includes absolutely everything. It largely depends on who you are as a practitioner.”

In other words, integrative medicine is, as I said, a brand, not a specialty. Pretty much every other specialty has a definition of what it encompasses that is clear. Integrative medicine is this fuzzy entity about which I can’t help but recall the words of Humpty Dumpty in Lewis Carroll’s Through the Looking Glass, who said scornfully, “When I use a word, it means just what I choose it to mean—neither more nor less.” So it is with integrative medicine, which is why last week integrative medicine could be defended on using a fallacious argument that science-based medicine is “nonsense” or that “Western medicine” has lost its soul, while this week I can sit back and grit my teeth reading an article regurgitating the advocate line that integrative medicine is just as scientific as science-based medicine.

Rothenberg Gritz is correct that integrative medicine has evolved, but it hasn’t evolved in the way she thinks it has. In her final paragraph, she wonders whether the rise of integrative medicine is a result of cultural shifts (which is possible) but comes to an untenable conclusion that it may be the only way to treat chronic disease. In actuality, it is only the language that has evolved. I was half-tempted to recycle the introduction to my post on how integrative medicine is a brand not a specialty, where I describe the evolution of integrative medicine, but instead I’ll just give you the CliffsNotes version instead and you can read the original in all its snarky glory if you like. In fact, you should. You won’t regret it.

Basically, starting around the late 1960s and early 1970s, in a bid to gain respectability for what was then called quackery or health fraud, the term “alternative medicine” was coined, which didn’t have all the harsh connotations of the usual language. Around that same time, James Reston, a New York Times editor, wrote about his experience undergoing an emergency appendectomy while visiting China in 1971. His story was represented as successful “acupuncture anesthesia,” when it was anything but, stimulating popular interest in “alternative” medical approaches. However, the word “alternative” implied that this was not “real” medicine, that it still was somehow unrespectable (which it was and still is, for good reason). Consequently, in the 1990s, around about the time Rothenberg Gritz was in high school admiring her dad’s woo-filled medical practice, a new term was born: complementary and alternative medicine (CAM). The idea was that you need not fear these quack medical practices because they would be used in addition to medicine, not instead of it. This term contributed greatly to the increasing embrace of CAM by medical academia, but it was still not good enough for its advocates. After all, the word “complementary” implies a subsidiary status, that CAM is not the main medicine but just icing on the cake, so to speak.

That did not sit well with advocates, who wanted their woo to be fully part of medicine, even though they didn’t have the evidence for that to happen naturally. Thus was born the current term “integrative medicine.” No longer did CAM practitioners have to settle for having their quackery be merely “complementary” to real medicine. They could use this term to claim co-equal status with practitioners of real medicine. The implication—the very, very, very intentional implication—was that alternative medicine was co-equal to science- and evidence-based medicine, an equal partner in the “integration.” Thus was further advanced the false dichotomy that has been used to justify alternative medicine from the very beginning, that a physician can’t be truly “holistic” unless he embraces pseudoscience.

The true evolution of integrative medicine is not that it has become more scientific. Rather, it is that its advocates have gotten much, much better at branding quackery as being medicine under the guise of being “holistic” and “patient-centered.” It’s a false dichotomy that I reject and that Rothenberg Gritz clearly doesn’t understand.

 

 

via Medicine Joint Channels

Chiropractic and Stroke: The question is not answered

Extreme rotation of the atlas on the axis (at the atlantoaxial joint) stretches the vertebral artery. In layman’s terms, 40% of a hanging.

I am off to Chicago for 5 days to wow the SMACC crowd with my ID/SBM acumen. I hope. Given that most of my multiple-personalities do not seem to be able to get any work done, I am forced to write a brief post this week, limited by the battery life on my MacBook Air. Whatever I get down on paper? pixels? RAM? before the battery dies as I fly over the Rockies will be the post. It is times like this I wish I had Gorskian typing skills.

SBM has discussed the many limitations of chiropractic: the low grades for entry into chiropractic school, the inadequate training, their reason d’être, subluxations and their adjustments being divorced from reality, the lack of efficacy of chiropractic for any process beyond low back pain (and even that is no better than safer interventions), the fondness of chiropractors for other useless pseudo-medicines, and their opposition to vaccines.

Hm. When I put it like that chiropractic does appear a little sketchy. But is chiropractic safe? It is a hands-on intervention, for a brief period of time applying the same force to the neck as about 40% of hanging from the neck until dead. So there is certainly the potential for chiropractic to cause harm.

30-plus years in medicine have only reinforced the concept that under the right conditions, a perfect storm, even the most benign of interventions can kill. As an intern I had a patient whose IV, placed for an acute heart attack, became infected with S. aureus that went to her aortic valve that rapidly blew out and she died. There is always the potential of medical equivalent of Because a Little Bug Went Ka-Choo!

Can chiropractic care cause a stroke? No, because chiropractic care covers a lot of interventions, from the realigning nonexistent subluxations to the über-silliness of applied kinesiology and more.

Does neck manipulation, the high velocity, low frequency, amplitude (got the science-y terminology wrong the first time.  Got to make sure the lipstick is correctly applied to the pig) neck snap of a brief hanging, lead to occasional stroke? Now that is the question.

Chiropractors love to point to the Cassidy study as the be-all and end-all evidence that neck manipulation does not cause stoke. It is the poster child for chiropractic motivated reasoning.

A careful reading, such I as did previously, suggests that the Cassidy study points to an increase risk for stroke following chiropractic, especially in the young. It was a flawed study, but if you are a chiropractor who doesn’t read carefully or beyond the abstract, you might think the paper supports the safety of chiropractic.

The authors of “Chiropractic care and the risk of vertebrobasilar stroke: results of a case–control study in U.S. commercial and Medicare Advantage populations” also admire the Cassidy study:

The work by Cassidy, et al. [32] has been qualitatively appraised as one of the most robustly designed investigations of the association between chiropractic manipulative treatment and VBA stroke

Which says something about the quality of the chiropractic literature and the safety of neck manipulation. But the study was done in Canada. What we really need is to reproduce the same lousy study in the US.

The paper looked at stoke 30 days following a PCP visit or a chiropractic visit for neck pain and found no difference in stroke:

Among the commercially insured, 1.6% of stroke cases had visited chiropractors within 30 days of being admitted to the hospital, as compared to 1.3% of controls visiting chiropractors within 30 days prior to their index date. Of the stroke cases, 18.9% had visited a PCP within 30 days prior to their index date, while only 6.8% of controls had visited a PCP

Which really says nothing. There is no information about why those who had a stroke were visiting either provider.

We do not know which patients had neck manipulation or even spinal manipulative therapy (SMT) since:

Less than 70% of stroke cases (commercial and MA) associated with chiropractic care included SMT.

Also:

There were statistically significant differences (p = <0.05) between groups for most comorbidities.

So it would appear that the two populations were not even remotely comparable.

Unlike Cassidy et al. and most other case–control studies our results showed there was no significant association between VBA stroke and chiropractic visits. This was the case for both the commercial and MA populations. In contrast to two earlier case–control studies, this lack of association was found to be irrespective of age. Although, our results (Table 8) did lend credence to previous reports that VBA stroke occurs more frequently in patients under the age of 45 years.

As the authors note:

Our results add weight to the view that chiropractic care is an unlikely cause of VBA strokes.

A conclusion based on comparing different populations whose intervention is uncertain. That is a “robustly designed investigation”? Perhaps chiropractic care is safe but how about neck manipulation? They are not the same thing. It is a fine point distinguishing between chiropractic care and neck manipulation, one that the authors recognize:

However, the current study does not exclude cervical manipulation as a possible cause or contributory factor in the occurrence of VBA stroke.

It is not death row care that matters, but that short drop through the trap door at the end. I suspect that the chiropractic organizations will fail to recognize this distinction.

I can’t see where the paper adds any information about the safety of chiropractic neck manipulation and will stick with the preponderance of data and the AHA/ASA Guideline.

But it does add FUD and I am sure there will be no end of blog entries trumpeting the paper and declaring that chiropractic is safe. It would appear that the approach to patient safety by chiropractors is embrace the good, yet flawed studies and rationalize away the bad, and who cares about patient safety when their subluxations need a fixin’.

The striking thing about chiropractic, and SCAM in general, is the aggressive denial that their interventions could and do cause harm, and the unwillingness to alter or abandon practices for increased patient safety.

Chiropractic advocates, and SCAM apologists in general, do love to mention the harm caused by NSAIDS or the deaths due to medications.

I have sat on hospital Quality Councils for 25 years as well as chaired my hospital’s infection control programs. I can proudly point to an enormous amount of work in that time to slowly drive down infections, morbidity and mortality. My hospitals are markedly safer than they were 25 years ago. This has occurred because we recognize that our interventions can harm and continually refine practice to minimize those risks. And because we apply the medical literature, always erring on the side of patient safety.

There still remains only one quality intervention to improve patient care in the entire SCAM universe, using sterile acupuncture needles, and the practice of acupuncture renders that intervention useless. Gloves are not high on their to-do list.

There are, to the best of my ability to locate, no other examples of SCAM practice being modified or abandoned due to evidence of harm.

And of course harm has to be balanced with efficacy. The first rule of medicine is not “do no harm.” Any and all interventions can harm. The first rule should be “on balance the good should outweigh the harm.” Chiropractic fails on that measure as well, since the benefit is negligible, applies only to low back pain, and is no better than safer interventions.

We do need better data. Many hospitals have stroke programs to maximize care for patients with stroke. When I last asked, the programs do not enquire into recent neck manipulation. Some clever epidemiologist needs to leverage information from all the stoke programs to help determine what the real risk of a brief hanging is.

And the pilot has let us know it is time to shut things down for landing. This is as good as it is going to get.

 

 

via Medicine Joint Channels

FDA & CDC find raw pet food unpalatable

Awww!

The FDA recently announced it would send field staff out to collect samples of commercially-manufactured raw dog and cat food. The samples will be analyzed for Salmonella, Listeria monocytogenes and E. coli, all of which have been found in raw pet food, in the animals who eat it, in their feces, on their bodies after eating it, in the areas they inhabit, and on their owner’s bodies. Not surprisingly, this has led to both pet and human infection and illness. If the FDA finds pathogens, it could result in a recall, a press release and Reportable Food Registry Submission. The next day, the CDC joined the effort to curb illness caused by pathogens in raw pet food by posting information on safe handling.

Because of the risk to public health, and the lack of any proven benefit of raw pet food diets, the FDA does not recommend them.

However, we understand that some people prefer to feed these types of diets to their pets.

And why is that? For some of the same reasons humans follow absurd diet fads: the “lone genius” discovery, it’s “natural,” anecdotal evidence, appeal to antiquity, anti-corporate sentiment, and “holistic” practitioner recommendations.

The “lone genius” discovery

Although he may not have been original inventor of the raw pet food diet, Australian vet Ian Billinghurst is its most ardent popularizer, in the form of his trademarked “Dr. Billinghurst’s BARF Diet.” BARF is an acronym for “Biologically Appropriate Raw Food,” although other gastrointestinal-related events are called to mind.

Billinghurst recounts how the health of his own dogs declined after he started feeding them high quality commercial pet food. (Oddly missing from this story is information about what he was feeding his pets before he started them on commercial pet food and why he didn’t just go back to this diet.) However, it took him two years to realize his error. That realization came only when he switched them to a diet of raw meat, including bones, and household scraps. The results, as you might imagine, were “immediate and dramatic.” He urged his clients to switch their pets’ diets as well, with the same amazing results.

He reasoned that raw meaty bones and vegetable scraps were “very close to the evolutionary diet of cats and dogs.” He was also influenced by his study of acupuncture, although it is unclear how that led to the BARF diet, other than a willingness to trade the scientific method for anecdotal evidence as a basis of one’s practice.

Billinghurst wrote a book in the 1980s, catchily titled Give Your Dog a Bone, setting forth his unique pet nutritional theories. It became something of a pet-owner cult hit and was followed by more books. He later partnered with Robert Mueller, a pharmacist (not the former FBI director) who wrote the similarly lone-genius discovery book, Living Enzymes: The World’s Best Kept Pet Food Secret. Together with another partner, they created “BARF World,” which sells, among other things, commercially prepared raw pet food. We’ll return to this enterprise in a moment.

Billinghurst makes big claims for BARF, or at least the “raw meaty bone-eating” element:

Raw meaty bone-eating dogs lived much longer than their commercially fed counterparts, . . . Bone-eating dogs have the wonderful benefits of clean teeth with no periodontal disease, wonderfully improved digestion, a reduction in obesity, fabulous eating exercise, healthy stools, no anal sac problems, and the wonderful psychological, emotional, and immune system benefits that eating raw meaty bones has conferred on dogs for millions of years.

The raw food diet for dogs is based on a combination of the naturalist and appeal to antiquity fallacies: the notion that your dog is really, at heart (and stomach, I guess), a wolf. And cats are tiny tigers, I suppose. While raw cat food is promoted as well, the whole “theory” appears to be largely dog-centric. Because wolves ate a raw diet, it must necessarily follow that raw meat, with a few herbs, is best for your dog. (Wolves got their plant matter by eating the stomach contents of their prey.)

In this, the diet also is a form of evolutionary medicine, which is based on the faulty assumption that chronic diseases and degenerative conditions arise from a mismatch between our (and our pet’s) Stone Age genes and recently adopted lifestyles, including diet. It is the same fallacy that lies at the heart of the paleo diet for us humans.

Brennen McKenzie, DVM, sliced and diced the “dog as wolf” theory nicely in a previous SBM post. (You can find more raw pet food posts on his blog, Skeptvet.) In summary,

• Yes, dogs and wolves are both in the order Carnivora, but so are giant Pandas, who are almost exclusively herbivores.
• Dogs have not been wolves for a very long time — like 100,000 years or so.
• The claim that dogs and wolves are anatomically identical with respect to an appropriate diet is simply untrue:

If you try to picture a pack of Chihuahuas bringing down and savaging an elk, the impact of thousands of years of artificial selection is obvious. . . . Dogs have lived with humans, eaten our table scraps, and been intensively bred for features we desire, none of which is likely to make them ideally designed for the diet of a wolf.

• Wolves don’t have such a great life in the wild anyway. Disease, parasites and malnutrition are major factors in wild wolf mortality and they don’t live as long as captive wolves. And captive wolf breeders have found that the best diet for their wolves is – guess what? – commercial dog food.

An analogous argument has sprung up that feral dogs and cats eat raw meat, as if this is some conscious healthy lifestyle choice on the animal’s part instead of the result of appalling neglect and irresponsibility on the part of pet owners. Of course, feral dogs and cats also lead terrible lives, subject to malnutrition and early death, and don’t live as long as pet dogs and cats.

Bad, bad commercial dog food

The other main argument in favor of raw pet food has the flavor of “death by medicine.” Like that argument, trotted out to demonize “conventional medicine,” the failings of the commercial pet food industry do nothing to make raw pet food more nutritious, less risky, or otherwise better for your pet.

It is also underpinned by some grossly exaggerated and downright false claims about the commercial pet food industry. (And here we use the term “commercial pet food” to mean “conventional” commercial pet food, even though raw pet food has become plenty “commercial” as well.) While the commercial dog food industry has its problems, it is not the bogeyman that raw pet enthusiasts make it out to be. Dr. McKenzie has shredded these arguments for us as well. Briefly:

• No, commercial pet food doesn’t make your pet sick. Like humans, pets live longer because of better nutrition and medical care. This means that illnesses of the aging pet, like cancer and degenerative diseases, are more prevalent. Coupled with the lack of a full understanding of what causes these diseases, this leaves raw food enthusiasts an opening to claim it must be the food.
• No, commercial pet food is not “toxic.” This is based on the fact that commercial pet food contains preservatives and artificial coloring, two favorite boogeymen of the “natural food” crowd.
• Yes, dogs can digest the grains used in pet food, contrary to claims otherwise.
• No, cooking does not destroy all the nutrients. Some, but not all, by a long shot. It also kills bacteria and parasites, two big plusses in any food.
• No, dog food is not made from dead pets. This offensive urban myth was investigated by the FDA and found wanting.

There are other myths raw pet foodies like to promote, such as veterinary schools not teaching nutrition, and what little they learn is controlled by the pet food industry. But let’s get to the facts.

Once fully digested, the raw pet food movement doesn’t seem so palatable.

As noted, the FDA plans to send agents out into the field for testing. Why? Because:

the scientific literature indicates that feeding raw foods to household pets such as dogs or cats carries a risk to human and animal health. Even if the pets do not appear to be sick after consuming raw pet foods containing pathogens such as Salmonella and Listeria monocytogenes, they can become carriers of such pathogens and transfer the pathogens to the environment. Humans can be infected by contacting pathogens in the contaminated environment. Raw pet foods containing pathogens can also contaminate food contact surfaces and human hands that increase the risk of human exposure.

But that’s not the only risk. Julie Churchill, DVM, a specialist in companion animal nutrition at the University of Minnesota’s College of Veterinary Medicine, strongly disagrees with the BARF diet, because eating bones can be fatal.

Bones, even raw and ground ones, can perforate the [gastrointestinal] tract. This can lead to peritonitis, severe infections, require emergency surgery, and dogs die from this each year…

Risks aside, what about evidence that a raw food diet is better for your pet? There is none. In fact,

on the basis of published diet reviews, most home-prepared diets (both raw and cooked) are deficient in 1 or more essential fatty acids, vitamins, or minerals or a combination thereof. Although the perceived benefits of home-prepared diets may be reinforced daily to owners through a pet’s appetite or coat quality, nutrient deficiencies and excesses in adult animals are insidious and can lead to long-term complications if not detected and corrected.

In addition to the FDA and the CDC, the American Veterinary Medical Association, American College of Veterinary Nutritionists, American Animal Hospital Association, National Association of State Public Health Veterinarians and American Association of Feline Practitioners have all warned of the lack of benefit, as well as the dangers, of raw pet food diets. The American Holistic Veterinary Medical Association doesn’t take a position, in deference to the “holistic” vets who recommend raw diets and sell raw pet food products.

So, risks to pets and their owners from infections and, to pets, from bone fragments and nutritional deficiencies, and no evidence to support it supposed benefits.

Billinghurst rejects the lack of evidence with that ubiquitous CAM practitioner claim – “I’ve seen it work.” As far as the risks, he blows them off with the unfounded assertion that eating pathogens is no big deal, because dogs are “designed” to eat these things. It’s even ok for immune-compromised animals.

All of this is nonsense, but Billinghurst has his reputation and a raw pet food empire to think about. For example, you can get two 3 lb. bags of BARF World “Juicy Chicken Nuggets,” which contains not only chicken, but also vegetables, fruits, cayenne pepper and garlic, for a mere $37.97, plus $15.50 in shipping costs. If this is really what wolves eat, they are surely the unheralded gourmets of the animal world. Who knew animals used herbs and spices? But wait – there’s more: if you sign up for the BARF World automatic shipping plan (meaning, they’ll automatically send you the right amount of food, expertly calculated for your pet, in perpetuity) you get free shipping.

But what if your dog or cat doesn’t tolerate BARF World pet food? Not to worry. Some may exhibit brief symptoms of “detox,” like diarrhea and vomiting, but this is normal, especially when converting from a “processed diet.”

BARF World also sells a lot of other CAM stuff for your pet, such as Kefir and “Eastern Medicine” herbal supplement formulas. For example, “G.I Tract Herbal Formula for Dogs,” “harmonizes the stomach,” and, as an added bonus, “helps maintain contentment during travel” for dogs that have digestion issues, as well as those who “don’t want to travel in a vehicle.” You can even get a consultation with a “holistic” vet.

Although BARF World may have the imprimatur of Billinghurst himself, several other raw pet food companies have gotten on the gravy train, and at similar prices. No benefit, more risk, and higher prices. Yep, sounds like CAM to me.

If you want to subject yourself to unproven raw food fads, I suppose that’s your business. But leave your poor pet out of it.

 

 

via Medicine Joint Channels

Trying to Impose Religion on Medicine

One of the major themes of science-based medicine (unsurprisingly) is that medicine should be based on science. We consider ourselves specialists in a larger movement defending science in general from mysticism, superstition, and spiritualism. We are not against anyone’s personal belief, and are officially agnostic toward any faith (as is science itself), but will vigorously defend science from any intrusion into its proper realm.

The so-called alternative medicine movement (CAM) is largely an attempt to insert religious beliefs into the practice and profession of medicine. CAM is also an attempt to create a double standard or even eliminate the standard of care so that any nonsense can flourish and con-artists and charlatans can practice their craft freely without being hounded by pesky regulations designed to protect the public. These are both insidious aspects of CAM that need to be exposed and vigorously opposed.

A recent article by Dr. Michel Accad demonstrates how brazenly some are trying to insert faith healing and spiritualism back into medicine. He does so by couching his arguments in philosophy and marketing terms, but in the end he is essentially saying that doctors should practice his faith. He doesn’t really make any arguments for this position, but rather simply gives a history of progress in Western thought as if that is sufficient.

Why medicine needs to be science-based

Before I deconstruct Accad’s article let me explore the arguments for SBM. As a profession, medicine enjoys a special privilege in our society. Practitioners are licensed, which is a contract giving them exclusive rights to practice their trade in exchange for requirements to ensure quality control and ethical behavior. The health professions also benefit from public funding to pay for research, education, institutions, and patient care.

In exchange for this public support, the public has a right to demand regulations to ensure honesty, transparency, and quality in healthcare products and services. Such guarantees are only possible within a strictly scientific practice.

Science is transparent, and fairly and thoroughly considers all evidence in order to determine safety and efficacy. A science-based system is the only system that can ensure claims are fair and accurate. Once you erode the scientific basic of healthcare, then anything goes, and there is no possible way to maintain standards. Anything you do to ensure quality standards is essentially doing science, and then the only question is – are you doing it well?

CAM proponents want to allow what is essentially magic back into the practice of medicine precisely because magic cannot be held to any standard. Magic can also be optimized for marketing purposes – you can make grandiose claims without having to back them up with rigorous evidence. It is for this reason that CAM proponents have been attacking science and the scientific standard in medicine from every angle.

“Holistic” medicine

Accad falls for many CAM tropes in his article, but the main one is to confuse religion-based medicine for “holistic” medicine. He writes:

So why does conventional medicine seem so unable to attend to the complete welfare of the patient? Why, despite the manifest efficacy of scientific treatments, do growing numbers of patients consider their medical care altogether unhealthy?

The answer may have to do with what is meant by a whole person.

Each of his premises is false. First, medicine does address the whole patient. This is referred to as the “biopsychosocial” approach to medicine, and I learned it in medical school long before “holistic” medicine became hip. Every medical student at some point in their training will be told by an attending that they cannot treat their patient as if they were a disease – they have to treat the patient. You need to understand the patient’s psychological and social background and how that influences their understanding of their own symptoms and disease. Treatments need to be individualized to the patient’s values, desires, goals, and beliefs. This all needs to be done while respecting the need for informed consent.

Accad and other CAM apologists, however, ignore this reality. They have created the fiction that “Western” medicine is mechanistic, cold, and reductionist. To be fair, the demands of modern medicine can make it challenging at times to maintain the more cuddly aspects of medicine. We do use procedures and diagnostic tools that can be scary and unpleasant. We do try, at least in principle, to manage the patient experience to mitigate the demands of the modern technology of medicine, and don’t always succeed. This is not a philosophical problem with “Western” medicine, however, just a practical challenge of trying to balance the benefits of modern technology with the patient experience. We don’t always succeed, but good doctors, practices, and hospitals do this well.

The second premise is simply a naked assertion, also part of the CAM mythology. Surveys do not support the notion that people are increasingly seeking CAM because of negative attitudes toward scientific medicine. People who use CAM generally report they did so for philosophical reasons, or because they heard it might work, not because they are unhappy with their doctors. In fact, people are not seeking CAM in increasing numbers, the numbers are stable and low (unless you artificially inflate them by including things like prayer and nutrition in CAM).

These CAM claims are all about marketing – this is one brand trashing a competitor. For the record, I don’t think there should be any “brands” within medicine. There should be one fair and consistent science-based standard of care.

“What is meant by the whole person”

Accad has set up his false premise, that “Western” medicine is not holistic, and then defines “holistic” in a specific way that leads to the specific point he is trying to make. He asks, “what is meant by the whole person,” and his answer essentially encompasses his religious faith. “Holistic,” he asserts (again, he doesn’t actually make any arguments) means treating the soul.

If his essay can be construed as an argument, through inference, he is only making an argument from antiquity – we should treat the soul because people did it in the past. He writes:

St. Thomas Aquinas, borrowing from Aristotle’s philosophy of nature, explained that a human being is a substantial unity of body and soul or, to be more technically precise, a composite of “prime matter” (the principle of potency) informed by a rational soul (the principle of act).

He never states why we should care what Aquinas or Aristotle believed. Ironically, he reviews the progression of thought in this area sufficiently to explain why science has rejected the notion of a soul. He acknowledges:

The heightened attention given to the material aspects of the universe promoted the achievements of a bewildering revolution in the empirical sciences. And under the influence of the new sciences, diseases came to be conceptualized in similar terms: illnesses are accident [sic] of nature due to defective arrangements or to faulty motions of material stuff. Fix the defect and you fix the patient. This approach has yielded such astounding benefits to mankind that Descartes’ dream of conquering illness through the methodical application of empirical science seems to be well under way.

That is a wordy way of saying that “science works.” Over the centuries we tended to go with what works, and science undeniably “delivers the goods,” as Carl Sagan said. Why would we stick with a pre-scientific philosophy of illness that accomplished nothing in thousands of years, when a scientific approach revolutionized healthcare in tens of years?

Accad still has to cling to this notion that, despite scientific medicine’s undeniable success, something is missing. He accomplishes this by confusing “mind” and “spirit.”

But when medical science rests on a basis of material reductionism, the human mind—the intellectual and willful aspects of the soul—has a hard time finding its proper place. Descartes dealt with this difficulty by splitting apart the body and the soul of man

The human mind is not an aspect of the soul, it is what the brain does. The material reductionist approach to the mind is progressing quite well, thank you, without the need to appeal to any dualist notions. The mind, the psychological and social aspects of patients, is fully considered in modern medicine. We do not have to appeal to a “ghost in the machine” to be holistic. The only reason to appeal to such notions is to open the door for religious belief to enter into medicine.

Accad himself gives a partial explanation for why this is:

Following Descartes’ conceptual sundering of body and soul, scientists sought for a time to identify and isolate the vital principle of living organisms—as if that were possible. Vitalism, mesmerism, romanticism, and idealism became influential currents in Western Medicine in the eighteenth and nineteenth century. But when these efforts at grasping the essence of life proved futile or problematic, the inconvenient soul fell into neglect and was finally abandoned altogether as a subject worthy of inquiry or acknowledgment in polite scientific company.

That’s right – scientists gave a fair hearing to the notion of a vital force or spirit. In fact, this was the default assumption for a long time; it is what scientists assumed to be true. After a couple centuries of failing to find even the slightest bit of evidence for a vital force, scientists properly dropped the concept as a dead end.

There is another aspect to this that Accad misses, however. The vital force was also dropped because it ceased to become necessary. In the early days of science, before much was known about biology, vitalism was used to explain biological processes that were currently mysterious. It was a placeholder for our ignorance. Over time, however, everything that the vital force was supposed to do was eventually explained as a natural biological process. The role of the vital force shrank and shrank until it finally disappeared.

Can you blame scientists for discarding a pre-scientific notion that was of no value (it had no explanatory power and made no predictions) and for which there was no evidence? The history of progress in science is largely a history of discarding such notions. Scientists today don’t even think about vitalism because it’s “not even wrong” – it is of no scientific value.

The same is true of dualism, the notion of a spirit separate from the functioning of our brains. Neuroscientists have no need for such a notion, which adds no explanatory power, solves no problems, and makes no successful predictions.

Conclusion

Science-based medicine not only works, it is necessary if we are to have any effective regulations and standard of care. Introducing philosophical and religious beliefs into medicine goes hand-in-hand with eroding the standard of care and failing to protect the public from false or misleading claims, and unsafe or ineffective practices.

Further, similar to creationism and other anti-science movements, CAM proponents want to roll back the clock to a pre-scientific era. They want to rehash a fight they lost a couple centuries ago. Vitalism and dualism were given more than a fair chance, and they completely failed, because they are not scientific notions and they are not based in reality.

We should no more integrate these discarded notions back into science than we should reintroduce astrology back into astronomy, phrenology back into neuroscience, or alchemy back into chemistry. These ideas are best left on the trash heap of history.
 
 

via Medicine Joint Channels

Functional Disc Rehydration for Chronic Back Pain

A chiropractor in Illinois named Jeff Winternheimer claims to have discovered an effective way to heal herniated discs by rehydrating them. He calls it Functional Disc Rehydration and he offers it through a network of four offices in the Chicago area called the Illinois Back Clinic. He has lots of testimonials and one sorry amateurish attempt at a scientific study that claimed to show 100% improvement; but there is no published evidence, no controlled observations, and no comparison of his methods with other methods.

Degenerative disc disease

Between the spinal vertebrae there are soft, jelly-like compressible discs that act as shock absorbers. They are “corralled” by a fibrous annulus. As we get older, the disc material loses water and becomes less flexible; the disc thins, and the space between the vertebrae narrows, so in old age we are not quite as tall as we once were. Cracks in the annulus develop with age or with trauma, allowing the disc material to bulge out or rupture. Herniated discs don’t necessarily cause pain; disc degeneration can be seen on MRI in 37% of asymptomatic people over the age of 60.

by “debivort,” licensed under CC BY-SA 3.0 via Wikimedia Commons

An unusual approach to providing evidence

In looking for scientific evidence on the Illinois Back Institute website, I encountered something I had never seen before. They offer one study as evidence that Functional Disc Rehydration works, but before they will let you read it you have to supply your name and e-mail address, tell them what kind of back problem you have, and tell them which of their clinics you live closest to. There is an opportunity to make an appointment and supply your insurance data before you have even downloaded the study.

The study

The downloadable “study” itself is a travesty. It is not a published study and is not presented in the format of a scientific paper. It consists of five pages on the Institute’s letterhead. The first page explains the purported mechanism of the treatment and makes the claim that Functional Disc Rehydration provides better results than surgery. Page 3 is a testimonial from a patient. Pages 4 and 5 offer a free consultation and a clickable link to schedule an appointment. Only page 2 is devoted to the study itself. The two researchers who invented Functional Disc Rehydration are “Dr. Jeff Winternheimer, D.C.” and “a PAC 10 university medical researcher” who is not named. There was no control group. The subjects were “more than 50″ people (they didn’t bother to get an exact count?) ranging in age from 39 to 83 who had chronic back pain and had already tried other treatments. After one treatment, “all patients experienced disc rehydration of at least 18%.” After 10 weeks, there was 80% rehydration, and at 25 weeks there was 100% rehydration. In addition to the rehydration, “All patients experienced complete elimination of herniated and bulging discs.” They don’t tell us how they measured hydration or confirmed the elimination of degenerated discs. They conclude:

The statistics overwhelmingly prove that re-hydration through Functional Disc Rehydration will help reverse a degenerated discs [sic], neck pain and back pain permanently.

Of course, this abominable, pathetic, laughable, puerile excuse for a “study” proves no such thing. It’s as if they didn’t even try. With only a little effort, they could have put it in proper format and made it at least sort of look like a publishable study. Anyone with any sense would have known that 100% success is suspicious and is seldom if ever reported in a scientific paper, and it would have been so simple to write “52 patients” instead of “more than 50.” What were they thinking?

More evidence

In addition to a few testimonials, they offer three before-and-after MRIs that show a reduction in disc protrusion, one after 50 treatments, one after seven months, and the third simply labeled “before” and “after”. Pretty impressive, unless you happen to know that similar improvement can occur over time with no treatment at all. Without a control group, there is no way to tell whether the treatment had anything to do with the improvement.

I watched a video where Dr. Jeff says that in 2007 an experienced researcher told him he would have to study eight patients with severe back pain with before and after MRIs to show that the treatment gets oxygen, nutrients, and fluid into the disc. He claims his study showed that, but he doesn’t explain how the measurements were made. He seems to be describing eight of the patients who were included in the larger study reported on the website. He seems to be saying they could measure rehydration by MRI and that they were surprised when they found that the disc protrusions also resolved. The MD who did the MRIs supposedly said he had never seen a disc protrusion resolve. I find that hard to believe.

How it works

They claim it “reverses” disc degeneration. They tell us a healthy disc is filled with a gel-like substance; a disc that has been worn down has lost its gel and is therefore dehydrated, and a dehydrated disc can bulge or herniate. Functional Disc Rehydration takes the pressure off the discs through cycles of compression and traction movements, allowing the spine to replenish the missing fluids back into the discs naturally. Then physical therapy is used to strengthen and stabilize the spine.

With the advent of MRIs, many studies have documented the regression of disc protrusions, and spontaneous improvement is thought to be a result of inflammatory processes and reabsorption of disc material, not to “rehydration” or sucking the material back into place. One study found that in 14 out of 15 patients with massive lumbar disc herniation, there was dramatic resolution after 24 months of conservative therapy. Discs naturally lose water content with aging and become brittle and deformed, but this is usually asymptomatic until the annulus tears and allows the disc material to protrude and put pressure on a nerve. If there were a way to rehydrate the disc, that might conceivably be helpful, but it would not reverse the tears in the annulus. And even if the remaining disc material became better hydrated, how would we know that from an MRI? Would it show up as increased space between the vertebrae? Would that say anything about oxygen and nutrients? And if you hydrate the disc material wouldn’t that cause it to swell and possibly increase the pressure on the nerves that is causing the pain?

They don’t really define their approach, but apparently it involves cycles of compression and traction movements along with stretching, exercise, PT treatments, listening to patients, etc. In one testimonial a woman describes two-hour visits three times a week. One patient describes feeling a little better, then doing too much, having increased pain, and having to slow down again.

Does it make sense?

Not to me. I couldn’t find any evidence that increased hydration had been measured in discs after compression/traction cycles and PT, or that oxygen and nutrient levels in the disc increased. We have a generally-accepted explanation of spontaneous improvement on MRI (inflammation and reabsorption) that doesn’t involve rehydration.

Similar claims

Chiropractors have made similar claims for spinal decompression devices, which are all versions of the original VAX-D that Stephen Barrett has written about on Quackwatch. I wrote about one of the newer versions, the DRX-9000 and a couple of years later the Canadian Broadcasting Corporation show Marketplace did a scathing exposé. These glorified traction devices claim to relieve pressure on the disc, improve circulation, supply nutrients to the disc, and even suck the extruded part of the disc back into place by creating a vacuum. No studies have yet shown that that is even possible.

Conclusion

I’ll say what I’ve said many times before about other questionable treatments. I don’t know if this treatment works, and neither do they, because it has not been submitted to controlled scientific testing. My impression is that this is more of a business model than a revolutionary new treatment for back pain. If they publish credible evidence from well-designed studies in peer-reviewed journals, I’ll reconsider.
 
 

via Medicine Joint Channels

Are we ready for a single-dose HPV vaccine?

A new paper in the journal Lancet Oncology evaluates outcomes after vaccination with Cervarix, which is the HPV vaccine that is effective against the 2 most oncogenic (cancer-causing) strains: HPV 16 and 18. The paper is actually a compilation of results from two studies of Cervarix among women ages 15-25 and now has four years of […]

via Medicine Joint Channels

Should radiologists disclose results to patients? The answer isn’t what you think.

Merriam-Webster defines “value” as follows: The amount of money that something is worth: the price or cost of something Something that can be bought for a low or fair price Usefulness or importance I find this intuitive, really. The value of something is what it is worth. However, is that something worth the same to […]

via Medicine Joint Channels

Indian radiologists have more to worry about than teleradiology

Teleradiology has the same effect on radiologists as Lord Voldemort has on Muggles. It’s the feared end point of the commoditization of imaging, with Rajeev in Bangalore outpricing Rajeev in Chicago for reading follow-up CTs for lung nodules. But despite the fears of U.S. radiologists, their counterparts in India have more pressing things on their […]

via Medicine Joint Channels

Use physician rating sites to establish an online reputation

A continuing series on physician online reputation.  Created in partnership with The Doctors Company as part of their social media resources for physicians.  Physicians can use online rating sites to establish your online reputation by asking more patients to rate them online. Don’t just cherry pick or pressure patients into giving you good ratings. Ask all […]

via Medicine Joint Channels

7 things this med student learned about being an innovator

Years ago as a first-year medical student, I wrote a piece titled “Be an Innovator in Medical School.” The content was meant to be a starter guide for medical students interested in creating change at their institution or community. Now, at the tail end of medical school, I reflect on lessons I have learned along […]

via Medicine Joint Channels

Patient engagement is in search of a definition

Ask anyone connected with health care these days to provide a definition for patient engagement and you will likely receive as many answers as there are agendas surrounding the discipline. While patient engagement has evolved as a critical strategy in support of the ultimate goal of creating improved health for a total population, you would […]

via Medicine Joint Channels

Idioms and axioms provide a glimpse into medical culture

Idioms are expressions everyone understands as something other than what the literal words say.  For example, when I talk about “putting all of my eggs in one basket,” everyone knows I’m not really talking about eggs. We say things like: It’s raining cats and dogs. It was a piece of cake! I heard it straight […]

via Medicine Joint Channels

A letter to parents hesitant about vaccines

Below is a letter I have written to parents who are hesitant about giving vaccinations to their children.  I don’t know how many it will convince, but I needed a respectful and informative way to follow up with parents who expressed concerns or declined vaccinations, and this is what I now share with them after […]

via Medicine Joint Channels

Use antibiotic stewardship programs to help reduce antibiotic resistance

Antibiotic resistance is an alarming and increasing threat to global public health. According to the Centers for Disease Control and Prevention (CDC), two million people a year become infected with bacteria resistant to antibiotics and lead to 23,000 deaths in the United States alone. Simply put, the bugs are getting stronger and smarter, our antibiotic […]

via Medicine Joint Channels

5 types of doctors you will meet on social media

Twitter is a communication platform, and, therefore, it is a neutral medium. It’s not the medium itself, but how you use the medium that makes Twitter “good” or “bad.” In my five years of being an anonymous and five months of being a named individual on Twitter, I have come to realize that different people […]

via Medicine Joint Channels

Work-life balance in medicine: Your best is more than enough

My daughter was born, three months premature, during my third year of residency.  Following a harrowing three months in the NICU, we joyfully welcomed her home. After eight blissful but isolating weeks, I was eager to return to the wards. I happily reunited with colleagues and patients, but I also deeply missed being home. During […]

via Medicine Joint Channels

Patients rating doctors on Yelp: It’s better to embrace it

I have written previously about some “aha moments” that I have had as a clinician, when something that I knew was coming seemed to arrive with a thud in my own practice. I had another one of those moments a couple of weeks ago. I was finishing up with a new patient, and had explained […]

via Medicine Joint Channels

Test your medicine knowledge: 72-year-old woman with COPD

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians. A 72-year-old woman is evaluated during a routine examination. She has very severe COPD with multiple exacerbations. She has dyspnea at all times with decreased exercise capacity. She does not have cough or any change in baseline sputum production. She is […]

via Medicine Joint Channels