Guest post by Toby Katz
Who am I?
I’m a final-year graduate medic (also hold an Economics degree) studying at St George’s University. I founded the Integrative Medicine Society at the university, with the aim of hosting talks on evidence-based CAM. My interest in evidence-based CAM arose as many of my family members have benefitted from different CAM interventions (mostly due to chronic MSk pain), where conventional interventions (physiotherapy and chronic pain teams) have failed to resolve their issues.
When it comes to the CAM debate, I see myself as a centrist. I am both a CAM apologist and sceptic and in recent years I have looked to educate myself around this subject. I have read Ernst’s Desktop Guide to CAM and Moral Maze books, spoken to Professor Colquhoun and most recently I undertook the Foundation Course in CAM run by the College of Medicine. My review of the course follows.
Overall, there’s a lot to learn from both sides of the debate and the debate continues due to systematic issues in the UK. Ad hominem attacks don’t help anyone, but conversation can. I hope I can converse with many of you in the future.
The Foundation Course
Two days of fast-paced talks on Integrative/Complementary and Alternative Medicine. The topics included: Resilience, nutritional therapy, medical acupuncture, MSk methods for non-osteopaths, homeopathy, herbs and spices, imagery and relaxation, cancer, hypnotherapy and social prescribing.
The speakers included: Professor David Peters, Dr Catherine Zollman (Medical Director for Penny Brohn), Heather Richards (Nutritional Therapist), Dr Elizabeth Thompson (GP and homeopath), Trevor Hoskisson (Hypnotherapist), Dr Mike Cummings (BMAS), Simon Mills (Medical Herbalist) – at least two of these are already in the infamous Alt Med Hall of Fame!
Initial feelings
My initial feelings upon hearing the talks were that most of these individuals are inherently good people, who want the best outcomes for their patients. Their aim is to operate in the areas of medicine where conventional medicine doesn’t hold the answers – chronic pain, idiopathic headache, IBS etc. But there were also people who were advocating the use of unproven alternative therapies.
These were some of my thoughts I jotted down during the two days:
Professor Peters – Constantly speaking in generalisations. Uses historic references, romantic and philosophical language to entice listeners but generally has little point to what he says. Suffers from tangential thinking. Loses track of his own point. Very Freudian-like thinking (everyone has gone through childhood trauma according to him).
Dr Catherine Zollman – Brilliant. Absolutely brilliant. The doctor I resonate most closely with out of everyone speaking. Promoting the holistic management of a cancer diagnosis; integrating (not undermining) conventional medicine with complementary ways of dealing with the stress surrounding the diagnosis and much more. Works for a non-for-profit organisation. She has many years of oncology experience and strives to create a patient-centred approach to management.
Dr Mike Cummings – promoting medical acupuncture mainly for myofascial pain syndrome. I volunteered to receive acupuncture in my shoulder (have had post-op muscular pain since April). He dry-needled one of my trigger points and it helped, for a few days – this is better than anything a physio has done for me so far. I don’t know why dry-needling isn’t taught at medical school to help with myofascial pain syndrome.
Dr Elizabeth Thompson – Very respectable but I do feel the homeopathy ship has well and truly sailed. Provided ‘evidence’ on how ‘succussion’ changes the make-up of water molecules. Though Dr Thompson is medically trained, there are many non-medical homeopaths who promote things such as homeoprophylaxis and anti-vaccine views and I’m more worried about these such homeopaths. I do respect Dr Thompson and believe her when she says she has helped many patients. Whether this is due to placebo or the get-better-anyway effect I don’t know.
What they were promoting
On reflection, it’s clear that there was a real mix in promoting evidence-based therapies and eyebrow-raising alternatives – this is often difficult for those with an untrained eye to spot the difference. There was a general air of distrust with modern science and EBM floating around the room at all times. Sure, there are things wrong with it, but I think it’s done us pretty well over the last few decades!
I irritated a few speakers when I asked about the evidence behind their claims!
What to take away
There were many GPs present, who stated they’re often in a difficult position in the current system of healthcare we have in the UK. Around half of all consultations are MSk based, many of which are associated with chronic, muscular pain. The WHO analgesic pathway does little for these patients (unless you want to knock them for six with oxycodone) and physiotherapists struggle to make a real difference in a 30-minute appointment. The truth is, we are not providing GPs with the right toolkit to cope with these “difficult” patients.
Going forward
– Get a copy of Ernst et al.’s Desktop Guide for CAM
– Release more formal guidelines using this book as a base for any positive evidence
– Engage in conversation with those from both sides. We have a lot to learn from one another
– SCRAP the forms of CAM that have no plausibility
Food for thought
– If a patient’s pain improves after a session of acupuncture and not from physiotherapy, does it fit with a utilitarian ethical model to deny this person access to acupuncture if EBM shows acupuncture has rates similar to placebo?
– Chronic myofascial pain syndrome. Can we manage it better in primary care? Why not teach dry needling to healthcare professionals? (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4107879/ – Desai et al suggest it works)
– What is the alternative for no CAM for many patients who suffer? If patient’s choice is reduced, does that not reduce their autonomy?
If anyone wishes to contact me, you can at [email protected]
53 Responses to The ‘Foundation Course’ of the UK College of Medicine and Integrated Health
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The ignorance of youth, I remember it well, too well. Age does one thing at least; it sharpens and hones the bullshit meter, and the realisation of imperfect knowledge arrives.
I hope this young person has the opportunity to read their folly of youth in years when real scepticism kicks in. He seems to be impressed by the manner of presentation, rather than the content.
May be, hopefully, he will realise CAM is nonsense and compromises are only catering to the irrational and/or insane.
Frank, I appreciate your feedback.
But talk to me about the content. Evidence is positive for dry-needling and myofascial pain syndrome. In fact, it is equal to cortisol trigger point injections that are currently used in the NHS – look at the paper I linked in the article.
Tell me about the positive results for medical acupuncture: chronic back pain, dental pain, fibromyalgia, idiopathic headache, post-op N+V, it’s current use in alleviating symptoms of medical menopause in breast cancer.
The positive evidence for hypnotherapy as an analgesic and as an adjunct for IBS?
Converse with me without generalising: “he will realise CAM is nonsense and compromises are only catering to the irrational”. We can do better than that.
@Toby, it’s great to see someone putting across such a balanced and open-minded take here. Credit to Edzard for including your thoughts on his blog. And even more credit to you for responding so calmly to Frank’s incredibly arrogant and patronising comments.
I’ve had the pleasure of working alongside Dr Zollman at Penny Brohn, and agree she is brilliant – someone with depth of knowledge, compassion, and just the right level of pragmatism. If there were more people in positions of power in the NHS it would undoubtedly be better off.
Good luck with your own quest to help your patients in ways that best serve them as individuals.
Thank you Tom! I do appreciate it. Dr Zollman is incredible and you’re lucky to have worked with her! Feel free to message me on email if you want to talk more.
BW
Toby
@ Toby,
Caution: I would not be too appreciative of praise from Mr. Kennedy.
He provided proof for the notion that his moral compass is (at least) severely off and that he has a dubious perception of medical ethics.
For example, he has a video online where he uses his baby daughter for some “home experiments”, cynically calling her a “willing volunteer”.
https://www.youtube.com/watch?v=AbiWtpbJK8I
From his past comments on this blog, I conclude that he is one of the apologist not willing or able to assess the SCAM he is so deeply involved in critically (which is no surprise, since his livelihood depends on it).
From an epistemological standpoint, there is a fundamental difference between scientifically minded sceptics and believers like Mr. Kennedy.
Sceptics try to FOLLOW THE EVIDENCE (and depending on the amount and quality, accept the outcome as provisional truth), whereas believers FOLLOW THEIR PRECONCEIVED NOTION and cling to any piece of information in favour of it, while finding far-fetched excuses when being presented with information contradicting their belief.
Toby, on behalf of the Medicine world I would like to apologise for @Frank Collins.
This article, yes is a bit bold in some instances, is exactly how we progress forward as a profession. I have worked in the Medicine world for 35 years and I sit in the exactly same position, sometimes leaning towards and away from CAM. I have spent 7 of those years trying to gain evidence to prove the skeptics wrong argh…! but I must say that it is incredibly hard to gain evidence in this field, as with many things in our profession (Frank Collins I am more than happy to get you to Harvard Medical School to educate you?)
I am used to seeing comments like Franks in the Daily Mirror and on Facebook as people try to make their mediocre lives and insecurities other peoples’ problems so please don’t listen to his rather horrible comments, I am sure he will regret these comments in a day or two…
Anyway thanks for a fascinating read (it is evident that everyone has read the whole way through…more than I can say for the majority of my papers ha) and best of luck as you explore such an amazing topic.
Tony Parker
“…mediocre lives and insecurities other peoples’ problems…”
you criticise others for something you then do yourself?!?
I remember debating with David Peters on a radio phone-in about 10 years ago. It was like a boxing match with a jelly. No concrete position at which to aim.
Dear Toby,
Thank you for your excellent review of this ‘course’.
You state: “My initial feelings upon hearing the talks were that most of these individuals are inherently good people, who want the best outcomes for their patients.”
Given that they are promoting therapies for which there is no plausible evidence of benefit due to the therapy (pins, pummelling, potions, pillules, preternatural powers etc.), on what basis have you judged them to be “inherently good”?
“Their aim is to operate in the areas of medicine where conventional medicine doesn’t hold the answers – chronic pain, idiopathic headache, IBS etc.”
So, why do you think they have not worked to improve and advance ‘conventional medicine’ as so many others are doing?
Conventional medicine does not, yet, hold many answers. That is why doctors, scientists, and so many others are contentiously working hard to advance health care. That is how it has come to pass that medicine which is currently conventional has left all these CAMs behind.
But why do you think these practitioners have they gone off on a tangent?
“But there were also people who were advocating the use of unproven alternative therapies.”
All those you have quoted are unproven – that’s why they are categorised as ‘complementary and alternative’. ‘Integrated’ is just the latest trendy term devised by marketeers who want to see CAMs integrated with conventional medicine and accepted as having the same validity (and financial value).
This will happen when there is plausible evidence – but we’re still waiting.
Toby, you ask: “What is the alternative for no-CAM for many patients who suffer?”
It’s called counselling, caring.
That is what Dr Zollman does – “brilliantly” as you suggest.
But why invoke CAMs (SCAMs, camistry)? Answer: Because the best placebo effects are achieved thereby.
But is it ethical not to get fully informed consent from patients?
Not to tell them the ‘therapies’ offered have no plausible evidence of benefit?
Not to explain how placebos work?
And that, as Prof Ernst emphasises, benefit from placebos is rarely lasting?
(Fortunately, once over a ‘hump’, perhaps assisted by placebos, a level of equanimity can be maintained.)
There are no ‘sides’ in a ‘debate’ here. Only those of us who practise EBM (or variants!) and those who do not.
More in Real Secrets of Alternative Medicine!
Best wishes and may the Wu be with you.
Dear Richard,
Many thanks for your reply. You raise many valid points. As an orthopaedic consultant, I’d love to hear your views on how we help people with chronic muscular pain. What is not ‘plausible’ about putting a needle into a trigger point? We actually do it, as I eluded to in my comment above.
I think your comments demonstrate the Britishness of argument. Polarisation. Right or wrong. Labour or Tory. You either believe in CAM and you’re wacky or it is all complete baloney. I am striving towards a middle ground to integrate plausible, evidence-based complementary therapies.
“Conventional medicine that has left these CAMs behind” – Sir: Senna, Cayenne pepper, hydrotherapy, exercise, CBT, mindfulness, TENS and more, were all originally CAM and have since been integrated into modern healthcare. These have not been ‘left behind’ but in fact integrated.
Dry needling in acupuncture, trigger-point massage in osteopathy, relaxation in hypnotherapy all seem very plausible to me to treat indications including myofascial pain syndrome, IBS and more. I agree, there are many things they are not suited to and many aspects of their “science” that should be scrapped. But some hold plausibility, don’t you think?
“Why do you think they have not worked to improve and advance ‘conventional medicine’ as so many others are doing?” – The actual fact is many of them have. And many professionals I have met, mainly GPs, struggle to manage patients with the toolkit (including “counselling and caring”) they have.
With my suggestions, there is no reason why we cannot have fully informed consent for SOME CAM therapies, that are plausible. It seems many of us may have forgotten what EBM actually means but this is a snippet from the BMJ written by David Sackett et al., one of the forefathers of EBM:
“Good doctors use both individual clinical expertise and the best available external evidence, and neither alone is enough. Without clinical expertise, practice risks becoming tyrannised by evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient. Without current best evidence, practice risks becoming rapidly out of date, to the detriment of patients.”
BW,
Toby
“Good doctors use both individual clinical expertise and the best available external evidence, and neither alone is enough”. The problem is that CAM enthusiasts want to ignore the latter and only use the former.
And conventional enthusiasts only look at the data and not the human in front of them
‘The problem is that CAM enthusiasts want to ignore the latter and only use the former’
‘And conventional enthusiasts only look at the data and not the human in front of them’
I don’t think either of these are always true by any means. But Toby, if the latter is true, why do you say ‘I think we’re pretty good at diagnosis in conventional medicine’? Surely taking in the data AND the human in front of you is vital in the diagnostic process, whatever your framework?
Toby:
“And conventional enthusiasts only look at the data and not the human in front of them”.
As a patient (myeloma, osteoporosis, and many other conditions accumulated over 73 years) I really don’t think that is true. To be honest I would like my doctors to be more guided by the data than they are. Too many interventions are based on tradition and small effect sizes. For example many patients were killed by traditional use of steroids for head injuries. When an RCT was done it showed that this was not a good idea. Surely the trick in medicine is to get the patient to agree with the proposed treatment? Doesn’t that make it more effective? I’m thinking of compliance more that placebo effect. There are good studies which show that better treatment compliance reduces overall health care costs. You never see this with CAM. If only more patients would ask for the evidence, they would be truly involved in their care.
Hi Les,
I do apologise, my point that you quoted was intended sarcasm.
I may be young in the game but I’m pretty sure the trick is not to get the patient to agree to their treatment. That would be seen as rather paternalistic. The “doctor knows best” way of thinking stopped a while back.
Instead, we need to provide all the information that we can and allow patient autonomy. Then compliance would improve.
please mind that my ‘desktop guide’ (https://www.amazon.co.uk/Desktop-Guide-Complementary-Alternative-Medicine/dp/0723433836/ref=sr_1_1?keywords=edzard+ernst%2C+desktop&qid=1564759368&s=gateway&sr=8-1) is now 13 years old.
much of the evidence has since become considerably weaker.
Toby, I didn’t put my point very clearly. I don’t mean that the patient should be coerced into agreeing, I think they should be presented with the evidence in a way that a lay person can understand, and then asked if they want the treatment. This is informed consent. I also think this hardly ever happens. To give another example, what if a woman was invited for mammography screening, and told that 84 women have to be screened for 44 years to prevent one breast cancer death, and that there is no effect on overall deaths?
But revenons à nos moutons as the French say. Your post is about CAM, and I’m concerned at a number of things that its practitioners do. Firstly, they make up stories about how the body works. Many CAM modalities are vitalistic, but the vital force has never been demonstrated. We know what life is, and can even reproduce it in the lab. There is no need for an imaginary force – that belongs in the Star Wars universe. Do you think it is acceptable for practitioners to tell patients these stories? What could be more paternalistic? They also, as I have implied, deny the evidence from RCTs. One trick they like to pull (and David Peters’ university is a well known perpetrator) is to run `pragmatic’ trials, which have very little control against bias. These can easily come up with a false positive result. Now there is a role for pragmatic trials, but only when the existence of an effect has been shown in a rigorous RCT. A lot of CAM researchers like to skip the RCT and go straight to the pragmatic trial, for obvious reasons. They can then mislead the patient with low quality evidence.
How do you define CAM? To me it’s both implausible and lacking robust evidence. Hence massage for example is not CAM, and chiropractic is almost entirely CAM. But I’d be interested in your definition.
You have not met enough good doctors – yet.
With more experience, you will, I can assure you.
@Toby: so it appears without the infamous, specious and dubious family testimonials regarding MSK pain(??) you might be more of a skeptic on the (S)CAM front? Reminds me of my Scientologist friends who invoke the: “well if you’d experienced what I had you’d be one too”! bullshit argument.
Why don’t you read, try to digest and then do your ‘analysis’ of Dr. Ernst’s book SCAM, or one of his many others? It appears like so many here (SCAM apologists) you enter the discussion without first having recognized many far more informed, observant and erudite travelers have already dedicated exorbitant time, effort and mileage to bring clarity to many if not most of the questions you suggest are still open. FC has your number…as youth allows us to be far more smitten with ourselves and our observations than is often deserved.
@ Michael Kenny:
No need to mince words… tell us what do you REALLY think?
🙂
People keep confusing so called dry needling with acupuncture. The former consists of inducing counterinjury/counterirritation in tissue affected by localised pathology. The latter consist of mostly shallow penetration of skin and subcutaneous tissue in locations, usually distant from the anatomical location of concern and governed by fantasy and archaic philosophical nonsense. This spurious association only causes confusion and misinterpretation. Dry needling has nothing in common with ‘acupuncture’ other than the needles penetrating tissue. Dry needling does have a plausible mechanism ofaction heven if I have my reservations about its utility)! Acupuncture is devoid of plausibility.
@Bjorn, you’re simply wrong in your summary of acupuncture. ‘Ashi’ needling stretches back into antiquity, and is almost indistinguishable from dry needling, other than the conceptual framework behind it, and the language used to describe its actions. And unless you’re talking specifically about Japanese acupuncture, there is great range in the depth of needling employed. A quick glance through any acupuncture text book will tell you this. Dry needling is the appropriation of an aspect of traditional acupuncture, dressed up differently in order not to offend the sensibilities of the medical community.
Toby: if we do what you advise and scrap all SCAM that lacks plausibility, which therapies and diagnostic techniques would remain in your opinion?
Honestly, the way I would love to progress (yes, I’m young and optimistic but here goes nothing):
I would actually argue for banning all non-medical CAM education. (Hear me out). I know this is controversial for many CAM advocates but I think many of the practices are outdated and unethical. Chiropractic as a prime example. It claims that EVERY illness is due to minor subluxations. We have to move on. But there are elements in others that I would keep.
Herbalism should be scrapped but replaced with rational herbalism as you elude to in one of your books – herbs/supplements can be tested using RCTs etc and evaluated as any normal pharmaceutical would – this would benefit those whose philosophy is against conventional medicine for reasons we cannot fathom – it would provide Evidence-based natural alternatives to NHS pills.
I would scrap alternative diagnostic testing – I think we’re pretty good at diagnosis in conventional medicine and alternative diagnostic testing with no scientific basis is unethical.
I would leave diagnosis to doctors but retain some forms of therapy.
I would teach all physiotherapists and GPs dry needling/medical acupuncture (why not teach it to people who have great knowledge and learning of anatomy throughout medical school to reduce the possibility of adverse events?). I would teach physiotherapists trigger point release techniques from Osteopathy.
In essence, I would want to integrate therapies with the MDT we have at our disposal in the NHS, giving them more tools to deal with chronic issues.
This is just a snapshot but would love to hear your thoughts on this
BW
Toby
this is roughly how EBM is progressing: once a therapy has been proven to be effective it ceases to be SCAM and becomes conventional medicine. it takes a while, because independent replications etc are required. but it will happen. nobody rejects a technique because it originates from SCAM!
why did they not teach this in the ‘foundation course’?
Haha very good!
Hello Edzard, the line “once a therapy has been proven to be effective it ceases to be SCAM and becomes conventional medicine” is often used, but in day to day practice I find it difficult to actually recognise any of these. There may be a few the other way around like B12 shots for fatigue, now Aspirin for general heart disease prevention etc. Can you provide a list of SCAM’s that have become conventional medicine?
very few, because very few are proven to be effective
A quote from Toby: “I irritated a few speakers when I asked about the evidence behind their claims!”
I and many others have found ourselves in the same circumstance. Why would simply asking for evidence of an extraordinary claim provoke agitation? The duplicitous nature of scam, where they want the credibility of science based medicine without the hard work of generating an evidence base, and where any call for evidence is greeted with disdain, “irritation” , personal attacks and appeals to emotion are great red flags as to the legitimacy of the science behind the modality. Just as the wizard of Oz was “irritated” when the curtain was pulled back, so too are those who would deceive the public with charlatanism
precisely!
Dear Toby,
Thank you for your interesting guest post.
You state that you are a “sceptic”, but your posts indicates that your sceptical thinking skills could be better.
1.) Paragraph “Who am I?”
When you say that your “interest in evidence-based CAM arose as many of my family members have benefitted from different CAM interventions (…), where conventional interventions (…) have failed to resolve their issues”, it seems to me that your positive view of SCAM is biased. How did you establish that these benefits were not due to placebo?
You should be aware than anecdotes are not evidence for the SPECIFIC (!) efficacy of a SCAM treatment.
Specific effects are detected via RCTs, not via anecdotes or self-observations, even if they appear to be convincing. This is the “post hoc ergo propter hoc” fallacy.
2.) Paragraph “Initial feelings”
Feelings (yours or the feelings of other people) are by no means a measure of truth. This is definitely not sceptical thinking.
When you state “My initial feelings upon hearing the talks were that most of these individuals are inherently good people, who want the best outcomes for their patients”, I recommend that you should stop thinking that you can read minds/intentions of other people. Better judged them by their actions and in case of people promoting SCAM, they can be very detrimental.
3.) Paragraph “What they were promoting”
Quote: “I irritated a few speakers when I asked about the evidence behind their claims!”
Well done. In my view, people using SCAM treatments show parallels to people holding other forms of supernatural beliefs. Therefore, make sure to ask for scientific and objectively reproducible evidence. Believers use the term “evidence” very loosely, so don´t be satisfied with anecdotes, low quality studies, etc..
4.) Paragraph “Going forward”
Quote “SCRAP the forms of CAM that have no plausibility“
Be careful when you pose such general statements, because even if a treatment lacks a plausible explanation today, this does not mean that it couldn´t work (to my knowledge, e.g. the mechanism of the drug Paracetamol is still not elucidated). Don´t get me wrong, when it comes to claims of “spiritual energy”, homeopathy, etc., these beliefs should be addressed very critically.
As with all beliefs, I prefer asking the believer questions regarding the epistemology and if this is flawed, I try to point it out. If you are interested in this sceptical approach, I recommend videos on “street epistemology”, e.g. by Anthony Magnabosco.
5.) Paragraph “Food for thought”
Quote ”What is the alternative for no CAM for many patients who suffer? If patient’s choice is reduced, does that not reduce their autonomy?”
It is all about the risk vs. benefit balance. If the benefit of a treatment outweighs the risk, then go ahead. The problem with pretty much all SCAM treatments is that they lack reliable evidence for specific efficacy. Therefore, the risk/benefit balance cannot be positive. Even if the treatment poses no direct harm, people could be harmed when using it instead of an effective treatment. Furthermore, it certainly will cost money that could be spend in better ways.
If evidence based medicine does not help, it therefore is a fallacy to think that a SCAM treatment should be used.
Jashak,
Amazing feedback. Thank you for your reply.
Would love to hear your replies to my other comments to Edzard and Richard above if you have the time but I appreciate if not.
Points 1 and 2 – I am aware that observation and anecdotes do not provide any real evidence. My point is we must not reduce ourselves to the tyranny of evidence and forget the human side to the job we do.
Point 4 – great point and I will take this forwards.
Point 5 – please see my reply to Edzard and let me know what you think. I am in complete agreement with you that we must have proper risk vs benefit analysis. Even though “pretty much all” may be true, it is not all, and I feel as though there are forms of CAM that have both plausibility and reliable evidence (maybe weakly positive) as I have eluded to in other comments.
BW,
Toby
Dear Toby,
You asked for my opinion regarding your replies to Richard Rawlins and Edzard Ernst.
First, when you say:
“Dry needling in acupuncture, trigger-point massage in osteopathy, relaxation in hypnotherapy all seem very plausible to me to treat indications including myofascial pain syndrome, IBS and more”, then I have to ask you on what evidence your opinion is based.
To my knowledge, the evidence base of all three treatments is quite weak (please correct me if I´m wrong, I am a molecular biologist and therefore not an expert on these treatments).
Second, you mentioned several times that some SCAM ideas seem “plausible” to you.
Be careful: Even if a treatment appears to be plausible (let´s say you can imagine a mode of action, which is in agreement with our current knowledge of science), then this does not mean that the treatment works or even is likely to work. I would recommend not to overestimate your opinion on plausibility. Try to get rid of personal bias and (as objectively as possible) look at the evidence for efficacy derived from well-designed RCTs.
As Prof. Ernst pointed out: Once efficacy is established, a SCAM treatment will be integrated into EBM.
When you say:” My point is we must not reduce ourselves to the tyranny of evidence and forget the human side to the job we do”, then you commit another fallacy by generating a false dichotomy between (scientific) evidence and humanity:
Humans are a part of nature. The scientific method is by far the most reliable path to increasing our understanding of nature, so I do not understand why scientific evidence should lead to “tyranny” (except when intentionally misused for immoral reasons, of course). The medial value of e.g. empathy (as one aspect of the “human side”) is well supported by scientific evidence.
Dear Jashak,
Thank you again for the reply. The evidence can be found in both Edzard’s own Desktop Guide to CAM and the article I linked above, showing dry needling is as effective as cortisol trigger point injections in the treatment of myofascial pain syndrome.
Your second point – this brings in a massive contradiction in the anti-CAM world. According to many CAM ethicists, plausibility must come before efficacy. Personally, I would actually argue for the contrary, as you put it above. If something is efficacious, it will be adopted. Alas, this is not the case as according to the Desktop Guide to CAM, there are vast amounts of positive evidence in relation to different therapies but they are still slated due to lack of plausibility. There is evidence there.
As much as I want to avoid the tu-quoque fallacy – we mustn’t set double standards for ourselves. Taking statins as a prime example the role is reversed. Their plausibility is high but efficacy is v low and in fact can harm. (http://www.thennt.com/nnt/statins-for-heart-disease-prevention-without-prior-heart-disease-2/) Yet these are not slated but efficacious CAM therapies are?
To your last point. Scientific evidence and humanity are not mutually exclusive. The tyranny of evidence I elude to is when the human aspect is forgotten. See the BMJ article I posted about written by the godfather of EBM.
BW,
Toby
Dear Toby,
quote: “(…) there are vast amounts of positive evidence in relation to different therapies but they are still slated due to lack of plausibility. There is evidence there.“
This statement makes me suspect that you use a “believers-version” of the term evidence.
I very much doubt that any treatment with solid, scientifically reproducible evidence for efficacy is not applied, simply because we do not understand the mode of action. Can you name any example?
Many SCAM proponents prefer looking for results in favor of their belief and neglect the negative results (even if these are far more prevalent).
I think it is somewhat funny that you say you want to avoid the tu quoque fallacy – right before committing it.
Anyways, I am in favor of applying the same standards for all treatments.
This is currently not the case for SCAM, the bar is far lower. E.g. in my home country Germany, homeopathic “medicine” does not even have to show any efficacy, in contrast to EBM drugs.
If the evidence base for statins is not convincing, leading to a negative risk/benefit balance (recently I learned the same could be true for many psychotropic drugs), then I am in favor of getting rid of them. But again: this if how EBM is setup to work anyways (in contrast to SCAM)!
You seem to insinuate that practitioners of EBM tend to forget about the human aspects of their patients. I think this judgment is not warranted (from personal experience as a patient and also because several relatives of mine are medical doctors and do not at all fit this description). Do you have any evidence for this claim?
Toby – I love your enthusiasm: thank you for an interesting and thought provoking comment.
I wish you well in your endeavours : you appear to have more maturity and common sense than many who post here.
Youth and enthusiasm are good and our future depends on people like you, who are willing to be open minded and discerning. Contrary to a couple of arrogant accusations about youth being a hindrance, I think the opposite. If you have this ability now, it can only get better.
Disclosure : I have used many effective complementary therapies over 45 years and have benefitted. I have also seen medical professionals excel themselves and have the greatest respect for our NHS.
It’s a great pity there is not room for both; for people to have choices without some skeptics of CAM resorting to unkind comments which serve nobody. May you continue to have a bright future.
Toby Katz wrote: “I would teach all physiotherapists and GPs dry needling/medical acupuncture”
@ Toby Katz
It looks like dry needling is ultimately acupuncture by another name…
QUOTE
“In China, especially in the East, the term dry needling (干针, gan zhen in Chinese pin yin) has been a folk name for acupuncture since Western medicine arrived in China in the late 1800s, when the term of dry needling was created in order to differentiate it from the needles used for injections by Western trained doctors. Many people in China still refer to acupuncture as dry needling, especially after acupuncture point injection therapy and aquapuncture therapy were developed in China in the early 1950s. The term dry needling (gan zhen) has already become a synonym for acupuncture used by many Chinese practitioners.”
Ref: https://journals.sagepub.com/doi/10.1136/acupmed-2015-011010
and, as is becoming increasingly evident, acupuncture is a theatrical placebo:
http://www.ebm-first.com/acupuncture.html
Regarding the content of your post, the following three links might be of interest to you, and others:
‘So does acupuncture work?’ by Simon Singh
“Ever since receiving my first ever acupuncture session last month, I have been repeatedly asked whether or not it was effective. In short, did acupuncture work for me? I refuse to answer for two reasons.”
Ref: http://news.bbc.co.uk/1/hi/health/7436512.stm
‘Mind Over Matter’ by Edzard Ernst
“One observation has puzzled researchers and clinicians for many years. Why are placebo-effects so unreliable? Sometimes figures of around 30 per cent are cited to describe the magnitude of the placebo effect: around 30 per cent of people respond to placebo, or about 30 per cent of the total therapeutic effect is due to placebo. These are approximate averages; they do not mean that we can rely on the 30 per cent figure in individual cases. The somewhat confusing truth is that one patient may respond to placebo today but not tomorrow. Similarly there is no such thing as a placebo responder (someone who always benefits from placebo) and a placebo non-responder (someone who never benefits from it). This unreliability makes it problematic to count on placebo effects in clinical practice….The placebo-effect is a bonus that comes ‘free’ (so to speak) with any treatment regardless whether it also has specific effects or not. It is therefore neither logical nor appropriate to use pure placebos that only rely on placebo effects – one might as well use treatments that have both specific effects and placebo-effects. In this way one makes optimal use of the “free bonus”.”
Ref: https://tinyurl.com/y3mmmet9
‘Social and judgmental biases that make inert treatments seem to work’ by the late Barry Beyerstein
“…many people who are neither foolish nor ill-educated still cling fervently to beliefs that fly in the face of well-established research.”
Ref: https://tinyurl.com/y3rbdqjm
Toby,
That was an interesting post, but you clearly have very little experience of medical practice.
Carl Sagan once described the scientific method as the best way we have of not fooling ourselves (or something along those lines). However, as doctors it is very easy to fool ourselves, and your comments about dry needling show that you have already fallen into that trap. Over the course of your career you will frequently find yourself facing patients with minor (or not-so-minor) problems that are difficult to diagnose or treat. You won’t be very sure about how to manage them, so you will try something (maybe suggested by a colleague, or something you read) and the patient gets better. Next time you are faced with a similar situation you will use the same treatment and it won’t take long before you have convinced yourself of its efficacy. However, most patients get better anyway, and chronic conditions tend to fluctuate (with the patient coming to you when they are at their worst), and this form of learning from experience can be very misleading, particularly for conditions that you may not see very frequently.
On the other hand, the evidence is always incomplete. Even if there is good evidence from clinical trials, it may be difficult to apply to the patient in front of you, who might have been ineligible for the trial, for instance on the grounds of age, or sex, or multiple pathology. You will often find yourself faced with the problem of how to extrapolate from the evidence when it doesn’t fit your patient.
My advice at this point in your career would be:
1. Get the best training you can in statistics and the behaviour of random numbers; your degree in economics suggests that you are probably not totally mathematically illiterate, but without this you will never be able to read medical papers critically and evaluate the evidence yourself (there is a lot of rubbish out there, and most published trials with a p-value of 0.05 will have got there by chance).
2. Always question yourself and your sources of information. How do YOU know something? How do the textbooks? How do your teachers? Remember the Dunning-Kruger effect: The less you know about something the more confident you are in your knowledge of it.
3. Listen carefully to your patients. What do they want from the consultation, and what are you able to give them (these are not the same thing). You won’t help them without a good rapport. On the other hand, you won’t help them either with a wrong diagnosis. Many patients going to their doctors end up in a system which investigates them thoroughly in case they have cancer, then spits them out, still with their original complaint, if they don’t.
4. Go on a really good communication skills course. I would recommend one with mixed attendence (including experienced specialists) and role-playing with actors, so that you can see senior doctors making a fool of themselves and learn from their mistakes.
5. Don’t just believe somebody because they are charismatic. It might just mean that they are a psychopath (there are a lot of those, too, in medicine, particularly among surgeons).
6. Never be afraid to ask the advice of a senior colleague. If your boss has left you in charge they are going to be much happier with the reassurance that you aren’t afraid to ring them in the middle of the night or on the golf course when you aren’t sure, and before things go pear-shaped. When you are the senior yourself, don’t be afraid to ask your colleagues. They will relish the chance to think about an unusual case and won’t think any less of you for not being sure.
7. Listen carefully to what the nurses and other professionals have to say. Patients will put on their Sunday Best (clothes and manner) to impress the doctor, and they will play down any side-effects of treatment because they are in awe of you and want to please you. They will be less on their guard with, and confide in, the other staff, who will see them more often and are likely to be experienced at least in their own area, even if they don’t have your medical training. Better still, work as much as possible within multidisciplinary teams.
8. Learn to read CT and MRI scans yourself. You will be surprised at how bad some radiologists are. Conversely, don’t just tick the boxes or the request form but ask your radiologist colleagues in person how best to investigate your patient – you will be amazed at how helpful they will be and what an educational experience it is.
9. Remember that alternative medicine refers to treatment (and treatment systems) for which there is no evidence, however nice the practioners are and however sincerely they believe in what they are doing. Patients will always think very highly of anybody who treats them (including you) so testimonials are worthless (though do hang onto them when it comes to your appraisal). The only place for such treatment is in a properly designed and conducted clinical trial, and the results will determine whether it should stop being alternative.
10. The only way that a patient can make a proper decision is if they are informed. You will find yourself in this role time and time again, and a large part of what a doctor does is to educate their patients. This empowers them to make appropriate choices.
Regular readers of this blog will know that I am an oncologist with 30 years’ experience in clinical practice, forced to retire early when I was diagnosed with an incurable malignancy; I found this blog when I googled some of the stranger pieces of advice that I have been given by fellow patients, friends and (I hate to say it) health care professionals. As I am no longer seeing patients, I suppose I have tried to continue my educational role as I find it hard to keep quiet when I encounter BS. My definition of BS being a plausible-sounding explanation with nothing to back it up.
Sorry, as usual I have strayed a bit off-topic.
Dr Money-Kyrle. I appreciate this more than you can imagine. Thank you so much for your response.
Toby
Hello Julian,
I think you have just re-written the Rules of The House of God!
However I think the last rule was: THE DELIVERY OF GOOD MEDICAL CARE IS TO DO AS MUCH NOTHING AS POSSIBLE
I wholeheartedly chime in with Julian, there is profound insight and mature experience behind his words. I was fortunate to have mentors with such qualities who helped me become a better person and a better doctor.
Julian’s advice needs no polishing but I still want to add a few remarks to some of his points.
1 and 2. In my view, understanding basic principles of statistics and research methodology is essential to being a good clinician. Conscientious and systematic appraisal of your own performance and outcome of your work adds an invaluable dimension to your professional career. Record your results, participate in trials and audits. Set up your own trials if you have the chance. Be critical and seek the truth about your own performance before you criticise others.
3. and 4. Make a habit of asking the patient what they themselves think. You will be surprised how often the patient (or a relative) is right. This also gives an oportunity to correct misunderstandings and refine the allcimportant information you give. I also made a habit of asking at the end of every consultation if they were content or there were any more questions unanswered. Sometimes you will discover that the patient did not understand or assimilate much of your information. Never turn away from an unsolved problem. If the problem is not solved, at least offer a new appointment. Inform and tell the truth. Even “white lies” will erode trust, the most essential component in good medical practice.
5. This one made me cringe. Being a surgeon I know all too well how people lacking in empathy, humility and other essential personal qualities seek positions where they can fulfill their need for aggrandisement.
7. Listen to your fellow team members, but make sure to establish your own independent assessment of every problem. The triage nurse may tell you the next patient is a well known serial-complainer who comes to the ER every friday night only to make the staff miserable. If you don’t clear the slate and go into the examination room without preformed opinion, you will almost certainly miss the evolving rectal cancer or whatever “Dr. House-diagnosis” that may be lingering under the proverbial rocks you fail to turn over.
8. So true. The best specialist clinicians should be BETTER at reading/performing the diagnostic tests and images WITHIN their field. I would, for example, never fully trust a pulmonologist who does not read lung x-rays or a trauma/emergency surgeon who does not scrutinise the CAT-scan himself. What a good radiologist adds to an examination is primarily the security of a second opinion and the holistic[sic] review to avoid missing important incidental findings.
9 and 10. Hear! – Hear!!
What I wish to add also, is that no one can fully appreciate the difference between CAM and medicine without having a deep understanding of medicine. Many (all?) of our friends here, who promote different alternatives to medicine and heckle us who are critical of their different vocational or quasi-religious interests, have little or no insight into real health care and medicine. They are simply not capable of discerning the difference between make-believe and reality, because they do not know reality.
Bjorn, sorry for not replying sooner. Just wanted to say thanks to you and all the others too. It’s great for me to be involved in this conversation and learn from many of you.
I appreciate all your advice
Toby
Dr J
Your post with your 10 point advice to Toby is a surprisingly unflattering depiction of scientific medicine.
Thanks for being honest.
Toby, I applaud your attempt to understand the scene of ‘CAM’ (which I term ‘camistry’), but I urge you to be wary.
I too have been interested in how folks think, feel and emote, and have studied anachronistic and outmoded methods along with new trends – but I have found ‘science’ to be the best currently available method for guiding wise practice.
I am also fascinated by deceit and deception, whether by con-artists, quacks or magicians – but as a doctor I seek to protect patients, especially the gullible and vulnerable, from practitioners who lack integrity.
The methods of treatment you quote as being part of modern medicine are indeed methods which have been shown to have a beneficial effect (and not just due to placebo effects which all methods have).
But no, acupuncture has no proven rationale or beneficial effect (beyond being a theatrical placebo), massage is nice, but that is not ‘osteopathy’, hypnotherapy is not a CAM (IMHO). No claims are made about ‘energies’; chakras; meridians or the like. Hypnosis is what the patient experiences, not what is done to them.
I appreciate GPs are struggling (I represent them), but medicine ‘twas ever thus. That is no reason to set reason aside and give credence to non-evidence-based practices, particularly the more bizarre.
As a magician I must counsel that we tell an apparently plausible story and weave a miasma of misinformation to misdirect the spectator from the simple fact – we are trying to take advantage of them.
I should have been a quack!
And profited by inducing folks to attend my ‘training courses’.
Hi Richard,
As above. I genuinely really appreciate the comments and debate.
Hopefully we can meet at some point in the future!
Bw
Toby
Had a really good time reading both the post and comment – there are valid points among many of the arguments. However, I feel there is a difference between view point between CAM modalities and science-based modalities that I have always trouble pin-pointing and resolving.
What is the difference between development of knowledgebase within these modality pairs – naprapathy/chiropractic and physiotherapy? – phytotherapy and pharmacognosy? – homeopathy/anthroposofic and pharmacology? – Freudian psychology and psychiatry?
I believe it is not the concern for the patients well-being, but I do believe mistaking one for the other is bad for patients…
From your examples, I would say that the difference seems to be in where you end up by looking for evidence that fits your theories as opposed to looking for evidence that disproves them.
The essence of the scientific method is the latter approach, and if the data don’t fit your theory then you discard the theory, not the data. Unfortunately most people find this a very unnatural way of doing things.
Evidence based CAM is essentially an oxymoron.
I believe that in an effort to be open-minded and balanced you are in danger of allowing these practitioners to persuade you that these is something of value in their snake-oil. The belief that many of them are sincere and truly believe that they have the welfare of their clients at heart doesn’t make their treatments any more effective – and it makes the practitioners themselves that much more dangerous.
Richard Feynmann famously stated: “Science is a way of trying not to fool yourself. The principle is that you must not fool yourself, and you are the easiest person to fool.” Unfortunately practitioners of sCAM practise belief based medicine rather than science based medicine and it is all but impossible to deal with someone caught up in a religious fervour.
It is a fact that almost no sCAM belief or treatment has been abandoned in the last two hundred years in the light of scientific advances or as a result of research. Rather they have doubled down is spite of such efforts.
sCAM practitioners may seem very reasonable and have all the trappings of science based medical care, even using all the right words, just not in all the right places. There will even be claims of published articles, some in respectable journals that ought to have known better. To an experienced observer however all of this will be seen for what it is – a glossy exterior on an empty vessel, one that makes the most noise.
These are mostly all treatments that are highly implausible at best, have no known mode of action, and have no better response than placebo in well conducted trials. Their proponents all have vested interests in promoting them, and often decry well established and proven healthcare interventions as part of their ideology – e.g. the anti-vaccine crusading of chiropractic and naturopathy. Often it involves individuals practising well outside their sphere of training and competence – e.g. the fad of chiropractors manipulating the spines of infants for supposed birth injuries and subluxations when they receive inadequate training and experience in paediatrics.
You mention myofascial pain syndrome – but from the NIH reference you gave comes this gem: “Interestingly, there is a lack of specific diagnostic criteria for MPS. Electrodiagnostic and morphological findings have been identified; however, they cannot be practically applied in the clinical setting due to cost and time constraints.” So MPS can be just about anything you want to make it – and equally you can unmake it after whatever treatment you apply – kind of convenient huh?
Anyhow it is never wise to build much of a case on one article – and dry needling is just acupuncture by another name. We know acupuncture is just a theatrical placebo – and the theatre makes the placebo more effective. Numerous studies have demonstrated that it doesn’t matter if you use real needles or sham needles, real acupuncture points or fake acupuncture points, that meridians are a myth, and that toothpicks are just as effective as proper needles. Another studies definitively demonstrated that using mirrors and drapes, needles inserted in a fake plastic arm/hand were equally as effective as those inserted in real patients – given this coup de theatre it is hard to imagine the method by which gate theory or endorphins are alleged to somehow transfer from the plastic limb to the brain of the patients who were tricked into believing that they were in reality receiving real acupuncture.
I believe that you also fall into a common trap when you believe that sCAM may have a role for those patients for whom conventional medicine often fails. This group constitutes a very vulnerable set who are easily taken advantage of and in whom because of their often subjective symptoms they are often very liable to placebo responses. Ideal prey for sCAM practitioners. As has been said by Ben Goldacre, the answer to problems in the airline industry is to make aircraft better, not to invest in magic carpets!
The argument that there is such a mountain of sCAM treatments that one of them somewhere sometime must be bound to work is ridiculous. If you throw enough darts at a dartboard on of them is bound to hit the bullseye – what’s your point? The fact that aspirin and artemisinin etc were eventually isolated from natural sources was as a result of science and not homeopathy, herbalism or TCM. People may latch onto the story of foxgloves and digitalis but how many other stories that led absolutely nowhere have had to be forgotten in the process? How many natural cures led to sickness and death nearly all of which are undocumented? (There is after all no sCAM equivalent of such things as the yellow card reporting system for adverse drug reactions and such like, nor is there any equivalent of the PILS product insert advisory leaflets for example.)
There are many systematic and deliberate elaborations and obfuscations involved. For example acupuncture has not been practised in its present form “for millennia” as claimed– ancient needles and descriptions more resemble curettage and blood-letting. It has only been in the last hundred or so that it has been possible to manufacture the steel necessary for the very fine needles used today. Acupuncture and the whole of TCM was heavily promoted and organized by Chairman Mao as part of the cultural revolution in China, partly as a factor in the propaganda war and largely because there were nowhere near enough Western trained doctors to treat the population. The masses had to make do with ineffective ancient nonsense similar to the four humours of pre-scientific Europe, while the communist elite themselves used proper scientific medicine. Mao himself never used TCM. Auricular acupuncture is less than one hundred years old and is a European invention based upon an imagined homunculus seen in the shape of the ear.
You seem convinced by your own experience but admit it has now worn off. Medics are as prone to the placebo effect as anyone else. Regression to the mean explains most of the placebo effect in any case. There are so many effects that can make one believe that a treatment has worked – wishful thinking, confirmation bias, availability heuristic – I could go on. The placebo effect is why we have double blind placebo controlled clinical trials. These are conditions that sCAM artists believe don’t apply to them and they will use all sorts of weasel words to make excuses as to why their pet therapy can’t be used in such conditions. This is all bunkum and ingenious methods have been found to blind for various treatments, to use objective assessments and to use strict criteria. However sCAM practitioners almost always manage to conduct trials in such a way that the results are never going to be anything but inconclusive. Or if in TCM and out of China nearly a statistically highly improbable 98% positive.
There is only two kind of medicine – the kind that works and the kind that doesn’t. The trick is to be able to tell the difference and the trick is called science.
Ultimately it can be summed up in the closing words of a debate between Ken Ham and Bill Nye over Creationism vs Evolution. Nye admitted that there were certain things that if presented as fact could convince him of creationism – whereas Ham averred in no uncertain terms that there was absolutely NOTHING conceivable that could ever convince him of the truth of evolution. When you are dealing with dogmatic certainty in the face of overwhelming contradictory evidence, truth and patients are always the losers.
You have already been pointed in the direction of Barry Beyerstein. May I also recommend the Science Based Medicine Blog and Respectful Insolence? I’m afraid the only treasure likely to be found in the mountains of sCAM will be Fool’s Gold.
I can’t believe that i have read point 5 from Dr JMK’s post- I didn’t expect any Dr to ever admit this.
Too much fraudulent medical research has been presented and accepted by psychopaths in the medical industry ie people with no empathy for patients who serve only themselves.
There is a real SCAM going on here costing lives. People are finding out about this hence the huge forthcoming multi billion $ litigations which will hopefully bring changes fir EBM to actually become truly evidence based.
let me give you some advice: if you want a reasonable debate with anyone, it helps not opening it by using terms like ‘psychopathy’; it reflects badly on your own psyche.
Let me give you some advice Edzard.
Please read the quote from Dr JMK’s post above. I didn’t introduce the word psychopath. He did and I think that many would agree with him. I have pasted it below.
Quote from Dr JMK
5. Don’t just believe somebody because they are charismatic. It might just mean that they are a psychopath (there are a lot of those, too, in medicine, particularly among surgeons).
1. If you discover “evidence-based CAM,” please share with us. This is an ongoing request from us skeptics. We are still waiting.
2. “. . .evidence-based CAM.” Don’t confuse evidence with anecdotes. Acupuncture worked for you? That’s an anecdote.
3. “Cam debate”? Nope. Not a debate.
4. “I irritated a few speakers when I asked about the evidence behind their claims!”
Yes, we get that here a lot. Many have their own reasons for believing in this nonsense. Some do it for the money, some do it because they tried—and failed—to become real doctors and some simply cannot get in touch with that part of the brain that is supposed to help us make good, sound decisions based on facts.
5. I think you need to work on your skeptic’s skills. You seem to be coming down on both sides of the fence. Pick one.
@Ron
Not wanting to speak for Toby, but I imagine the reason he’s not ‘picking a side’ is that he’s open-minded, and wants to explore all possibilities in helping his patients. You only have to take a look at the shambolic state of the current political situation in this country to see how useful ‘us and them’ thinking tends to be.