Chiropractors are notorious for their overuse and misuse of x-rays for non-specific back and neck pain as well as other conditions. A recent study from the US has shown that the rate of spine radiographs within 5 days of an initial patient visit to a chiropractor is 204 per 1000 new patient examinations. Considering that X-rays are not usually necessary for patients with non-specific back pain, such rates are far too high. Therefore, a team of US/Canadian researchers conducted a study to evaluate the impact of web-based dissemination of a diagnostic imaging guideline discouraging the use of spine x-rays among chiropractors.
They disseminated an imaging guideline online in April 2008. Administrative claims data were extracted between January 2006 and December 2010. Segmented regression analysis with autoregressive error was used to estimate the impact of guideline recommendations on the rate of spine x-rays. Sensitivity analysis considered the effect of two additional quality improvement strategies, a policy change and an education intervention.
The results show a significant change in the level of spine x-ray ordering weeks after introduction of the guidelines (-0.01; 95% confidence interval=-0.01, -0.002; p=.01), but no change in trend of the regression lines. The monthly mean rate of spine x-rays within 5 days of initial visit per new patient exams decreased by 10 per 1000, a 5.26% relative decrease after guideline dissemination.
The authors concluded that Web-based guideline dissemination was associated with an immediate reduction in spine x-ray claims. Sensitivity analysis suggests our results are robust. This passive strategy is likely cost-effective in a chiropractic network setting.
These findings are encouraging because they suggest that at least some chiropractors are capable of learning, even if this means altering their practice against their financial interests – after all, there is money to be earned with x-ray investigations! At the same time, the results indicate that, despite sound evidence, chiropractors still order far too many x-rays for non-specific back pain. I am not aware of any recent UK data on chiropractic x-ray usage, but judging from old evidence, it might be very high.
It would be interesting to know why chiropractors order spinal x-rays for patients with non-specific back pain or other conditions. A likely answer is that they need them for the diagnosis of spinal ‘subluxations’. To cite just one of thousands of chiropractors with the same opinion: spinography is a necessary part of the chiropractic examination. Detailed analysis of spinographic film and motion x-ray studies helps facilitate a specific and timely correction of vertebral subluxation by the Doctor of Chiropractic. The correction of a vertebral subluxation is called: Adjustment.
This, of course, merely highlights the futility of this practice: despite the fact that the concept is still deeply engrained in the teaching of chiropractic, ‘subluxation’ is a mystical entity or dogma which “is similar to the Santa Claus construct”, characterised by a “significant lack of evidence to fulfil the basic criteria of causation”. But even if chiropractic ‘subluxation’ were real, it would not be diagnosable with spinal x-ray investigations.
The inescapable conclusion from all this, I believe, is that the sooner chiropractors abandon their over-use of x-ray studies, the better for us all.
Some sceptics are convinced that, in alternative medicine, there is no evidence. This assumption is wrong, I am afraid, and statements of this nature can actually play into the hands of apologists of bogus treatments: they can then easily demonstrate the sceptics to be mistaken or “biased”, as they would probably say. The truth is that there is plenty of evidence – and lots of it is positive, at least at first glance.
Alternative medicine researchers have been very industrious during the last two decades to build up a sizable body of ‘evidence’. Consequently, one often finds data even for the most bizarre and implausible treatments. Take, for instance, the claim that homeopathy is an effective treatment for cancer. Those who promote this assumption have no difficulties in locating some weird in-vitro study that seems to support their opinion. When sceptics subsequently counter that in-vitro experiments tell us nothing about the clinical situation, apologists quickly unearth what they consider to be sound clinical evidence.
An example is this prospective observational 2011 study of cancer patients from two differently treated cohorts: one cohort with patients under complementary homeopathic treatment (HG; n = 259), and one cohort with conventionally treated cancer patients (CG; n = 380). Its main outcome measures were the change of quality life after 3 months, after one year and impairment by fatigue, anxiety or depression. The results of this study show significant improvements in most of these endpoints, and the authors concluded that we observed an improvement of quality of life as well as a tendency of fatigue symptoms to decrease in cancer patients under complementary homeopathic treatment.
Another, in some ways even better example is this 2005 observational study of 6544 consecutive patients from the Bristol Homeopathic Hospital. Every patient attending the hospital outpatient unit for a follow-up appointment was included, commencing with their first follow-up attendance. Of these patients 70.7% (n = 4627) reported positive health changes, with 50.7% (n = 3318) recording their improvement as better or much better. The authors concluded that homeopathic intervention offered positive health changes to a substantial proportion of a large cohort of patients with a wide range of chronic diseases.
The principle that is being followed here is simple:
- believers in a bogus therapy conduct a clinical trial which is designed to generate an apparently positive finding;
- the fact that the study cannot tell us anything about cause and effect is cleverly hidden or belittled;
- they publish their findings in one of the many journals that specialise in this sort of nonsense;
- they make sure that advocates across the world learn about their results;
- the community of apologists of this treatment picks up the information without the slightest critical analysis;
- the researchers conduct more and more of such pseudo-research;
- nobody attempts to do some real science: the believers do not truly want to falsify their hypotheses, and the real scientists find it unreasonable to conduct research on utterly implausible interventions;
- thus the body of false or misleading ‘evidence’ grows and grows;
- proponents start publishing systematic reviews and meta-analyses of their studies which are devoid of critical input;
- too few critics point out that these reviews are fatally flawed – ‘rubbish in, rubbish out’!
- eventually politicians, journalists, health care professionals and other people who did not necessarily start out as believers in the bogus therapy are convinced that the body of evidence is impressive and justifies implementation;
- important health care decisions are thus based on data which are false and misleading.
So, what can be done to prevent that such pseudo-evidence is mistaken as solid proof which might eventually mislead many into believing that bogus treatments are based on reasonably sound data? I think the following measures would be helpful:
- authors should abstain from publishing over-enthusiastic conclusions which can all too easily be misinterpreted (given that the authors are believers in the therapy, this is not a realistic option);
- editors might consider rejecting studies which contribute next to nothing to our current knowledge (given that these studies are usually published in journals that are in the business of promoting alternative medicine at any cost, this option is also not realistic);
- if researchers report highly preliminary findings, there should be an obligation to do further studies in order to confirm or refute the initial results (not realistic either, I am afraid);
- in case this does not happen, editors should consider retracting the paper reporting unconfirmed preliminary findings (utterly unrealistic).
What then can REALISTICALLY be done? I wish I knew the answer! All I can think of is that sceptics should educate the rest of the population to think and analyse such ‘evidence’ critically…but how realistic is that?
Chiropractors across the world tend to make false claims. This has been shown with such embarrassing regularity that there is no longer any question about it. Should someone have the courage to disclose and criticises this habit, chiropractors tend to attack their critic, rather than putting their house in order. One of their more devious strategies, in my view, is their insistence on claiming to effectively treat all sorts of childhood conditions.
What could be more evil than treating sick children with ineffective and harmful spinal manipulations? The answer is surprisingly simple: PREVENTING CHILDREN FROM PROFITTING FROM ONE OF THE MOST BENEFICIAL INTERVENTIONS EVER DISCOVERED!
The National Vaccine Information Center (NVIC) is an organisation which seems to support anti-vaxers of various kinds. Officially they try hard to give the image of being neutral about vaccinations and state that they are dedicated to the prevention of vaccine injuries and deaths through public education and to defending the informed consent ethic in medicine. As an independent clearinghouse for information on diseases and vaccines, NVIC does not advocate for or against the use of vaccines. We support the availability of all preventive health care options, including vaccines, and the right of consumers to make educated, voluntary health care choices.
In my view, this is thinly disguised promotion of an anti-vaccination stance. The NVIC recently made the following announcement:
The International Chiropractic Pediatric Association (ICPA), which was founded by Dr. Larry Webster and represents doctors of chiropractic caring for children, has supported NVIC’s mission to prevent vaccine injuries and deaths through public education and to protect informed consent rights for more than two decades. ICPA’s 2013 issue of Pathways to Family Wellness magazine features an article written by Barbara Loe Fisher on “The Moral Right to Religious and Conscientious Belief Exemptions to Vaccination.”
Pathways to Family Wellness is a full-color, quarterly publication that offers parents timely, relevant information about health and wellness options that will help them make conscious health choices for their families. ICPA offers NVIC donor supporters and NVIC Newsletter subscribers a complimentary digital version or print version of Pathways to Family Wellness magazine at a significant discount. Visit the Pathways subscription page and, when checking out in the shopping cart, add the exclusive code: NVIC.
ICPA also has initiated parenting support groups that meet monthly to discuss health and parenting topics. Meetings are hosted by local doctors of chiropractic and the Pathways website features a directory of local groups. ICPA Executive Director Dr. Jeanne Ohm said “We look forward to many more years of collaborating with NVIC to forward our shared goal of enhancing and protecting the ability of parents to make fully informed health and wellness choices for their children.”
Why, we may well ask, are so many chiropractors against immunisations? The answer might be found in the history of chiropractic. Their founding fathers believed and taught that “subluxations” are the cause of all human diseases. To uphold this ridiculous creed, it was necessary to deny that infections play an important role in many illnesses. In other words, early chiropractors negated the germ theory of disease. Today, of course, they claim that all of this is ancient history – but the stance of many chiropractors against immunisations discloses fairly clearly, I think, that this is not true. Many chiropractic institutions still teach obsolete pseudo-knowledge and many chiropractors seem unable to totally free themselves from such obvious nonsense.
But back to the ICPA: they profess to be a non-profit organization whose mission is to engage and serve family chiropractors worldwide through education, training, and research, establishing evidenced informed practice, excellence in professional skills and unity in a global community which cooperatively and enthusiastically participates in advancing chiropractic for both the profession and the public.
What does “evidence informed practice” mean? This bizarre creation is alarmingly popular with quacks of all kinds and seems to aim at misleading the unsuspecting public. It clearly has little to do with EVIDENCE-BASED PRACTICE as globally adopted by responsible clinicians. If not, the ICPA would inform its members and the public at large that immunisations are amongst the most successful preventive measures in the history of medicine. It is hard to think of another medical intervention where the benefits so clearly and hugely outweigh the risks. Immunisations have saved more lives than most other medical treatments. To not make this crystal clear to concerned parents is, in my view, wholly irresponsible.
Two of the top US general medical journals have just published articles which somehow smell of the promotion of quackery. A relatively long comment on alternative medicine, entitled THE FUTURE OF INTEGRATIVE MEDICINE appeared in THE AMERICAN JOURNAL OF MEDICINE and another one entitled PERSPECTIVES ON COMPLEMENTARY AND ALTERNATIVE MEDICINE RESEARCH in THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION. As this sort of thing does not happen that often, it is perhaps worth having a closer look at these publications. The JAMA-article has already been analysed skilfully by Orac, so I will not criticise it further. In the following text, the passages which are in italics are direct quotes from the AJM-article, while the interceptions in normal print are my comments on it.
…a field of unconventional medicine has evolved that has been known by a progression of names: holistic medicine, complementary and alternative medicine, and now integrative medicine. These are NOT synonyms, and there are many more names which have been forgotten, e.g. fringe, unorthodox, natural medicine It is hoped that the perspectives offered by integrative medicine will eventually transform mainstream medicine by improving patient outcomes, reducing costs, improving safety, and increasing patient satisfaction. Am I the only one to feel this sentence is a platitude?
Integrative medicine has been defined as “the practice of medicine that reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches, healthcare professionals and disciplines to achieve optimal health and healing.” There is, in fact, no accepted definition; the most remarkable bit in this one is perhaps the term “informed by evidence” which, as we will see shortly, is by no means the same as “evidence-based”, the accepted term and principle in medicine.
The most obvious differences between integrative and conventional medicine are its practitioners, who offer longer consultations and emphasize minimally invasive therapies, such as mind-body approaches, nutrition, prevention, and lifestyle changes, and focus on healing and wellness. Come again! Is that supposed to mean that conventional doctors do not employ “minimally invasive therapies or prevention or nutrition etc.”? In addition to conventional therapies, they may recommend alternatives, such as acupuncture, dietary supplements, and botanicals. BINGO! The difference between integrative and conventional physicians is quite simply that the former put an emphasis on unproven treatments; evidence my foot! This is just quackery by a different name. The doctor-patient relationship emphasizes joint decision-making by the patient and the physician. Yes, that may be true, but it does so in any type of good health care. To imply that the doctor-patient relationship and joint decision-making is an invention of integrative medicine is utter nonsense.
More and more patients seek integrative medicine practitioners. By 2007, approximately 40% of adult Americans and 12% of children were using some form of alternative therapies compared with 33% in 1991.
The number of US hospitals offering integrative therapies, such as acupuncture, massage therapy, therapeutic touch, and guided imagery, has increased from 8% in 1998 to 42% in 2010.Many academic cancer centers offer these integrative practices as part of a full spectrum of care. Other hospitals offer programs in integrative women’s health, cardiology, and pain management. But why? I think the authors forgot to mention that the main reason here is to make money.
Despite the increasing number of patients seeking alternative therapies, until recently, many of these skills were not routinely offered in medical schools or graduate medical education. Yet they are critical competencies and essential to stemming the tide of chronic diseases threatening to overwhelm both our health care and our financial systems. Essential? Really? Most alternative therapies are, in fact, unproven or disproven! Further, conventional medical journals rarely contained articles about alternative therapies until 1998 when the Journal of the American Medical Association and its affiliated journals published more than 60 articles on the theme of complementary and alternative medicine.
The National Institutes of Health established an office in 1994 and a National Center for Complementary and Alternative Medicine in 1998. Because many alternative therapies date back thousands of years, their efficacy has not been tested in randomized clinical trials. The reasons for the lack of research may be complex but they have very little to do with the long history of the modalities in question. The National Center for Complementary and Alternative Medicine provides the funds to conduct appropriate trials of these therapies. The NCCAM- funded studies have been criticised over and over again and most scientists find them not at all “appropriate”. They also have funded education research and programs in both conventional medical nursing schools and complementary and alternative medicine professional schools. Outcomes of these studies are being published in the conventional medical literature. Not exactly true! Much of it is published in journals of alternative medicine. Also, the authors forgot to mention that none of the studies of NCCAM have ever convincingly shown an alternative treatment to work.
Integrative medicine began to have an impact on medical education when 8 medical school deans met in 1999 to discuss complementary and alternative medicine. This meeting led to the establishment of the Consortium of Academic Health Centers for Integrative Medicine, composed initially of 11 academic centers. By 2012, this group had grown to 54 medical and health profession schools in the United States, Canada, and Mexico that have established integrative medicine programs. The consortium’s first international research conference on integrative medicine was held in 2006, with subsequent research conferences being held in 2009 and 2012. Three conferences? Big deal! I have hosted 14 research conferences in Exeter in as many years. I think, the authors are here blowing up a mouse to look like an elephant.
Multiple academic integrative medicine programs across the country have been supported by National Institutes of Health funding and private contributions, including the Bravewell Collaborative that was founded in 2002 by a group of philanthropists. The goal of the Bravewell Collaborative is “to transform the culture of healthcare by advancing the adoption of Integrative Medicine.” It foremost was an organisation of apologists of alternative medicine and quackery. A high water mark also occurred in 2009 when the Institute of Medicine held a Summit on Integrative Medicine led by Dr Ralph Snyderman.
There is clear evidence that integrative medicine is becoming part of current mainstream medicine. Really? I would like to see it. Increasing numbers of fellowships in integrative medicine are being offered in our academic health centers. In 2013, there are fellowships in integrative medicine in 13 medical schools. In 2000, the University of Arizona established a 1000-hour online fellowship that has been completed by more than 1000 physicians, nurse practitioners, and physician assistants. This online fellowship makes it possible for fellows to continue their clinical practice during their fellowship. I see, this is supposed to be the evidence?
A 200-hour curriculum for Integrative Medicine in Residency has been developed and is now in place in 30 family practice and 2 internal medicine residencies. The curriculum includes many of the topics that are not covered in the medical school curriculum, such as nutrition, mind–body therapies, nutritional and botanical supplements, alternative therapies (eg, acupuncture, massage, and chiropractic), and lifestyle medicine. It is not true that conventional medical schools do not teach about nutrition, psychology etc. Not all might, however, teach overt quackery. A similar curriculum for pediatric residencies is being developed. The eventual goal is to include integrative medicine skills and competencies in all residency programs.
Integrative medicine now has a broad presence in medical education, having evolved because of public demand, student and resident interest, increased research, institutional support, and novel educational programs. Now on the horizon is a more pluralistic, pragmatic approach to medicine that is patient-centered, that offers the broadest range of potential therapies, and that advocates not only the holistic treatment of disease but also prevention, health, and wellness.
Is it not an insult to conventional medicine to imply it is not pluralistic, pragmatic, patient-centred, that it does not offer a broad range of therapies, holism and prevention? This article displays much of what is wrong with the mind-set of the apologists of alternative medicine. The more I think about it, the more I feel that it is a bonanza of fallacies, follies and attempts to white-wash quackery. But I would be interested in how my readers see it.
Whenever I have the occasion to discuss with practitioners of alternative medicine the pros and cons of their methods, I hear sooner or later the argument “WE TREAT THE ROOT CAUSES OF DISEASE !!!” This remark emerges regularly regardless of the type of treatment the practitioner uses, and regardless of what disease we might have been talking about.
The statement is regularly pronounced with such deep conviction (and almost audible exclamation marks) that I am inclined to conclude these practitioners fully and wholeheartedly believe it. The implication usually is that, in conventional medicine, we only treat the symptoms of our patients. Quite often, this latter notion is not just gently implied but also forcefully expressed.
I have often wondered where this assumption and the fierce conviction with which it is expressed come from. The answer, I have come to conclude after many years of having such debates, is quite simple: it is being taught over and over again during the practitioners’ training, and it constitutes a central message of most ‘textbooks’ for the aspiring alternative practitioner.
It is not difficult to find the actual origin of all this. The notion that alternative practitioners treat the root causes is clearly based on the practitioners’ understanding of aetiology. If a traditional acupuncturist, for instance, becomes convinced that all disease is the expression of an imbalance of life-forces, and that needling acupuncture points will re-balance these forces thus restoring health, he must automatically assume that he is treating the root causes of any condition. If a chiropractor believes that all diseases are due to ‘subluxations’ of the spine, it must seem logical to him that spinal ‘adjustment’ is synonymous with treating the root cause of whatever complaint his patient is suffering from. If a Bowen therapist is convinced that “the Bowen Technique aims to balance the whole person, not just the symptoms“, he is bound to be equally sure that “practically any problem can potentially be addressed” by this intervention.
Let us assume for a minute that all these practitioners are correct in believing that their interventions are causal treatments, i.e. therapies directed against the cause of a disease. Successful treatment of any root cause can only mean that the therapy in question completely heals the problem at hand. If we abolish the cause of a disease, we would expect the disease to disappear for good.
This, I think, begs a crucial question: ARE THERE ANY DISEASES WHICH ARE REPRODUCIBLY CURED BY AN ALTERNATIVE THERAPY?
I have contemplated it frequently and discussed it often with practitioners but, so far, I have not identified a single one. I have no problem naming diseases which conventional medicine can cure - but, in alternative medicine, I only draw blanks. Even those alternative therapies which might be effective are not causal but symptomatic by nature. Honestly, I have not yet come across a single alternative treatment for which there is compelling evidence proving that it can produce more than symptom-relief.
But, of course, I might be wrong, over-critical, blind, bought by the pharmaeutical industry, dishonest or stupid. So, the purpose of this post is to clarify this issue once and for all. I herewith invite practitioners to name a disease for which there is sound evidence proving that it can be cured by their therapy.
On January 27, 1945, the concentration camp in Auschwitz was liberated. By May of the same year, around 20 similar camps had been discovered. What they revealed is so shocking that it is difficult to put it in words.
Today, on ‘HOCOCAUST MEMORIAL DAY’, I quote (shortened and slightly modified) from articles I published many years ago (references can be found in the originals) to remind us of the unspeakable atrocities that occurred during the Nazi period and of the crucial role the German medical profession played in them.
The Nazi’s euthanasia programme, also known as “Action T4″, started in specialized medicinal departments in 1939. Initially, it was aimed at children suffering from “idiocy, Down’s syndrome, hydrocephalus and other abnormalities”. By the end of 1939, the programme was extended to adults “unworthy of living.” We estimate that, when it was stopped, more than 70,000 patients had been killed.
Action T4 (named after its address: Tiergarten Strasse 4) was the Berlin headquarters of the euthanasia programme. It was run by approximately 50 physicians who, amongst other activities, sent questionnaires to (mostly psychiatric) hospitals urging them to return lists of patients for euthanasia. The victims were transported to specialized centers where they were gassed or poisoned. Action T4 was thus responsible for medically supervised, large-scale murder. Its true significance, however, lies elsewhere. Action T4 turned out to be nothing less than a “pilot project” for the extinction of millions of prisoners of the concentration camps.
The T4 units had developed the technology for killing on an industrial scale. It was only with this know-how that the total extinction of all Jews of the Reich could be planned. This truly monstrous task required medical expertise.
Almost without exception, those physicians who had worked for T4 went on to take charge of what the Nazis called the ‘Final Solution’. While action T4 had killed thousands, its offspring would murder millions under the trained instructions of Nazi doctors.
The medical profession’s role in these crimes was critical and essential. German physicians had been involved at all levels and stages. They had created and embraced the pseudo-science of race hygiene. They were instrumental in developing it further into applied racism. They had generated the know-how of mass extinction. Finally, they also performed outrageously cruel and criminal experiments under the guise of scientific inquiry [see below]. German doctors had thus betrayed all the ideals medicine had previously stood for, and had become involved in criminal activities unprecedented in the history of medicine (full details and references on all of this are provided in my article, see link above).
It is well-documented that alternative medicine was strongly supported by the Nazis. The general belief is that this had nothing to do with the sickening atrocities of this period. I believe that this assumption is not entirely correct. In 2001, I published an article which reviews the this subject; I take the liberty of borrowing from it here.
Based on a general movement in favour of all things natural, a powerful trend towards natural ways of healing had developed in the 19(th)century. By 1930, this had led to a situation in Germany where roughly as many lay-practitioners of alternative medicine as conventional doctors were in practice.This had led to considerable tensions between the two camps. To re-unify German medicine under the banner of ‘Neue Deutsche Heilkunde’ (New German Medicine), Nazi officials eventually decided to create the profession of the ‘Heilpraktiker‘ (healing practitioner). Heilpraktiker were not allowed to train students and their profession was thus meant to become extinct within one generation; Goebbels spoke of having created the cradle and the grave of the Heilpraktiker. However, after 1945, this decision was challenged in the courts and eventually over-turned – and this is why Heilpraktiker are still thriving today.
The ‘flag ship’ of the ‘Neue Deutsche Heilkunde’ was the ‘Rudolf Hess Krankenhaus‘ in Dresden (which was re-named into Gerhard Wagner Krankenhaus after Hess’ flight to the UK). It represented a full integration of alternative and orthodox medicine.
An example of systematic research into alternative medicine is the Nazi government’s project to validate homoeopathy. The data of this massive research programme are now lost (some speculate that homeopaths made them disappear) but, according to an eye-witness report, its results were entirely negative (full details and references on alt med in 3rd Reich are in the article cited above).
There is,of course, plenty of literature on the subject of Nazi ‘research’ (actually, it was pseudo-research) and the unspeakable crimes it entailed. By contrast, there is almost no published evidence that these activities included in any way alternative medicine, and the general opinion seems to be that there are no connections whatsoever. I fear that this notion might be erroneous.
As far as I can make out, no systematic study of the subject has so far been published, but I found several hints and indications that the criminal experiments of Nazi doctors also involved alternative medicine (the sources are provided in my articles cited above or in the links provided below). Here are but a few leads:
Dr Wagner, the chief medical officer of the Nazis was a dedicated and most active proponent of alternative medicine.
Doctors in the alternative “Rudolf Hess Krankenhaus” [see above] experimented on speeding up the recovery of wounded soldiers, on curing syphilis with fasting, and on various other projects to help the war effort.
The Dachau concentration camp housed the largest plantation of medicinal herbs in Germany.
Dr Madaus (founder of the still existing company for natural medicines by the same name) experimented on the sterilisation of humans with herbal and homeopathic remedies, a project that was deemed of great importance for controlling the predicted population growth in the East of the expanding Reich.
Dr Grawitz infected Dachau prisoners with various pathogens to test the effectiveness of homeopathic remedies.
Schuessler salts were also tested on concentration camp inmates.
So, why bring all of this up today? Is it not time that we let grass grow over these most disturbing events? I think not! For many years, I actively researched this area (you can find many of my articles on Medline) because I am convinced that the unprecedented horrors of Nazi medicine need to be told and re-told – not just on HOLOCAUST MEMORIAL DAY, but continually. This, I hope, will minimize the risk of such incredible abuses ever happening again.
In my last post, I strongly criticised Prince Charles for his recently published vision of “integrated health and post-modern medicine”. In fact, I wrote that it would lead us back to the dark ages. “That is all very well”, I hear my critics mutter, “but can Ernst offer anything better?” After all, as Prof Michael Baum once remarked, Charles has his authority merely through an accident of birth, whereas I have been to medical school, served as a professor in three different countries and pride myself of being an outspoken proponent of evidence-based medicine. I should thus know better and have something to put against Charles’ odd love affair with the ‘endarkenment’.
I have to admit that I am not exactly what one might call a visionary; all my life I have been slightly weary of people who wear a ‘vision’ on their sleeve for everyone to see. But I could produce some concepts about what might constitute good medicine (apart from the obvious statement that I think EBM is the correct approach). To be truthful, these are not really my concepts either - but, as far as I can see, they simply are ideas held by most responsible health care professionals across the world. So, for what it’s worth, here it is:
In a nut-shell, good medicine consists of two main elements: the science and the ‘art’ of medicine. This division is, of course, somewhat artificial; for instance, the art of medicine does not defy science, and compassion is an empty word, if it is not combined with effective therapy. Yet for clarity it can be helpful to separate the two elements.
Medicine has started to make progress about 150 years ago when we managed to free ourselves from the dogmas and beliefs that had previously dominated heath care. The first major randomised trial was published only in 1948. Since then, progress in both basic and clinical research has advanced at a breath-taking speed. Consequently, enormous improvements in health care have occurred, and the life-expectancy as well as the quality of life of millions have grown to a remarkable degree.
These developments are fairly recent and tend to be frustratingly slow; it is therefore clear that there is still much room for improvement. But improvement is surely being generated every day: the outlook of patients who suffer from MS, AIDS, cancer and many other conditions will be better tomorrow than it is today. Similar advances are being made in the areas of disease prevention, rehabilitation, palliative care etc. All of these improvements is almost exclusively the result of the hard work by thousands of brilliant scientists who tirelessly struggle to improve the status quo.
But the task is, of course, huge and virtually endless. We therefore need to be patient and remind ourselves how very young medicine’s marriage with science still is. To change direction at this stage would be wrong and lead to disastrous consequences. To doubt the power of science in generating progress displays ignorance. To call on “ancient wisdom” for help is ridiculous.
The ‘art of medicine’ seems a somewhat old-fashioned term to use. My reason for employing it anyway is that I do not know any other word that captures all of the following characteristics and attributes:
Time to listen
Good therapeutic relationships
Provision of choice, information, guidance
They are all important features of good medicine – they always have been and always will be. To deny this would be to destroy the basis on which health care stands. To neglect them risks good medicine to deteriorate. To call this “ancient wisdom” is grossly misleading.
Sadly, the system doctors have to work in makes it often difficult to respect all the features listed above. And sadly, not everyone working in health care is naturally gifted in showing compassion, empathy etc. to patients. This is why medical schools do their very best to teach these qualities to students. I do not deny that this endeavour is not always fully successful, and one can only hope that young doctors make career-choices according to their natural abilities. If you cannot produce a placebo-response in your patient, I was taught at medical school, go and train as a pathologist!
Science and art
Let me stress this again: the science and the art of medicine are essential elements of good medicine. In other words, if one is missing, medicine is by definition not optimal. In vast areas of alternative medicine, the science-element is woefully neglected or even totally absent. It follows, that these areas cannot be good medicine. In some areas of conventional medicine, the art-element is weak or neglected. It follows that, in these areas, medicine is not good either.
My rough outline of a ‘vision’ is, of course, rather vague and schematic; it cannot serve as a recipe for creating good medicine nor as a road map towards improving today’s health care. It is also somewhat naive and simplistic: it generalises across the entire, diverse field of medicine which problematic, to say the least.
One challenge for heath care practitioners is to find the optimal balance between the two elements for the situation at hand. A surgeon pulling an in-grown toenail will need a different mix of science and art than a GP treating a patient suffering from chronic depression, for instance.
The essential nature of both the science and the art of medicine also means that a deficit of one element cannot normally be compensated by a surplus of the other. In the absence of an effective treatment, even an over-dose of compassion will not suffice (and it is for this reason that the integration of alt med needs to be seen with great scepticism). Conversely, science alone will do a poor job in many others circumstances (and it is for that reason that we need to remind the medical profession of the importance of the ‘art’).
We cannot expect that the introduction of compassionate quacks will improve health care; it might make it appear more human, while, in fact, it would only become less effective. And is it truly compassionate to pretend that homeopathic placebos, administered by a kind and empathetic homeopath, generate more good than harm? I do not think so. The integration of alternative medicine makes sense only for those modalities which have been scientifically tested and demonstrated to be effective. True compassion must always include the desire to administer those treatments which demonstrably generate more good than harm.
I must admit, I do feel slightly embarrassed to pompously entitle this post “a vision of good medicine”. It really amounts to little more than common sense and is merely a reflection of what many health care professionals believe. Yet it does differ significantly from the ‘integrated health and post-modern medicine’ as proposed by Charles – and perhaps this is one reason why it might not be totally irrelevant.
Guest post by Louise Lubetkin
A few months ago The Economist ran one of its Where Do You Stand? polls asking readers whether alternative medicine should be taught in medical schools:
In Britain and Australia, horrified scientists are fighting hard against the teaching of alternative therapies in publicly funded universities and against their provision in mainstream medical care. They have had most success in Britain. Some universities have been shamed into ending alternative courses. The number of homeopathic hospitals in Britain is dwindling. In 2005 the Lancet, a leading medical journal, declared “the end of homeopathy”. In 2010 a parliamentary science committee advised that “the government should not endorse the use of placebo treatments including homeopathy.” So, should alternative medicine be treated on a par with the traditional sort and taught in medical schools?
It may surprise you to discover that more than two thirds of the almost 43,000 respondents were of the opinion that yes, it should.
Given that the use of alternative therapies is now so widespread, a plausible case can be made for giving medical students a comprehensive overview of the field as part of their training. But that’s not at all what the poll asked. Here again is how it was worded:
So, should alternative medicine be treated on a par with the traditional sort and taught in medical schools? (emphasis added)
That such a hefty majority of those who responded – and Economist readers are generally affluent and well-educated – came out firmly in favour not just of the teaching of alternative medicine but explicitly of parity between it and standard medicine, is both a reflection of the seemingly unstoppable popularity of alternative medicine and also, in a wider sense, of just how respectable it has become to be indifferent to, or even overtly hostile towards science.
It is ironic that since its very first issue in 1843 The Economist has proudly displayed on its contents page a mission statement declaring that the magazine is engaged in “a severe contest between intelligence, which presses forward, and an unworthy, timid ignorance obstructing our progress.”
It would seem that a significant sample of its poll-answering readership has a somewhat distorted vision of the struggle between intelligence and ignorance. In this postmodern worldview truth is relative: science is simply one version of reality; anti-science is another – and the two carry equal weight.
The very term “alternative medicine” – I use that expression with the greatest reluctance – is itself an outgrowth of this phenomenon, implying as it does that there are two valid, indeed interchangeable, choices in the sphere of medicine, a mainstream version and a parallel and equally effective alternative approach. That the term “alternative medicine” has now so seamlessly entered our language is a measure of how pervasive this form of relativism has become.
In fact, alternative medicine and mainstream medicine are absolutely not equivalent, nor are they by any means interchangeable, and to speak about them the way one might when debating whether to take the bus or the subway to work – both will get you there reliably – constitutes an assault on truth.
How did alternative medicine, so very little of which has ever been conclusively shown to be of even marginal benefit, achieve this astounding degree of acceptance?
Certainly the pervasive and deeply unhealthy influence of the pharmaceutical industry over the practice of medicine has done much to erode public confidence in the integrity of the medical profession. Alternative medicine has nimbly stepped into the breach, successfully casting itself as an Everyman’s egalitarian version of medicine with a gentle-sounding therapeutic philosophy based not on pharmaceuticals with their inevitable side effects, but on helping the body to heal itself with the assistance of “natural” and freely available remedies.
This image of alternative medicine as a humble David bravely facing down the medico-pharmaceutical establishment’s bullying Goliath does not, however, stand up well to scrutiny. Alternative medicine is without question a hugely lucrative enterprise. Moreover, unlike the pharmaceutical industry or mainstream medicine, it is almost entirely unregulated.
According to the US National Institutes of Health, in 2007 Americans spent almost $40 billion out of their own pockets (i.e., not reimbursed by health insurance) on alternative medicine, almost $12 billion of which was spent on an estimated 350 million visits to various practitioners (chiropractors, naturopaths, massage therapists, etc.) The remaining $28 billion was spent on non-vitamin “natural” products for self-care such as fish oils, plant extracts, glucosamine and chondroitin, etc. And that’s not all: on top of this, sales of vitamin and nutritional supplements have been estimated to constitute a further $30 billion annually.
And then, of course, there’s the awkward fact of its almost total lack of effectiveness.
Look at it this way: illness is the loneliest and most isolating of all journeys. In that bleak landscape, scientifically validated medicine is not just the best compass and the most reliable map; it’s also the truest friend any of us can have.
So, should alternative medicine be treated on a par with the traditional sort and taught in medical schools?
Not on your life.