The Anatomy of Deception: a deconstruction

Hi folks,

I recently came across this advertisement from a naturopath and found it to be an excellent example of the use of  a variety of advertising techniques based upon targeting what psychologists have identified as people’s susceptibility to persuasion.

To be fair and not target one specific individual I have anonymised it, and to
be honest it could be an advertisment for any new age alternative therapist, but as it contains so many examples of these techniques in a single advertisement I thought it worthy of exploration here.

So lets take a look in detail and simply deconstruct this advertisement:

  1. Prominent use of the words “natural” and “science.” This is designed to establish a link between the belief-based practices advertised as scientific, and natural. This exploits peoples assumptions that natural products are good and somehow associated with health, morality and being trusted (naturalistic fallacy). Also, this represents an attempt to establish a notion of postmodern pluralism in that the practitioner is open-minded, trustworthy and accepts both scientific and alternative worldly explanations as valued non-binary viewpoints. Additionally, this also cleverly implies that scientific medicine is somehow focused on non-natural and single-minded practices.
  2. Identification of qualification from a reputable university. Identifying that the practitioner completed a degree in a subject from a good university establishes an appeal to authority, with a genuine academic credential, but followed by:
  3. Conflation of a quackademic qualification from a non-university accredited private college with an authentic academic qualification (see #2). Again, exhibiting an appeal to authority in that the secondary qualification is presented as more advanced than the earlier one. In this case, the award is through a Canadian College but actually accreditation is through a US-based private self-interest group. A bit like an Academy of Wizards conferring a Wizardry qualification after several years of study. Sounds impressive, but in reality is not an independently validated  academic qualification.
  4. Prominent use of the word “interdisciplinary” or “multidisciplinary.”This establishes two things. Firstly, that the practitioner is a team player, and that they work with other health professionals. This seeks to impress professional authentication, but carefully avoids stating which disciplines the practitioner is associated with. In this case new-age disciplines involved here are Therapeutic Touch, Nutrition (n.b. nutritionists not dieticians) and Bowen therapy. I had to look that last one up – but it’s another manipulative therapy supposed to have more generalized health effects (sheesh, Peter Parker, where do all these guys come from)!
  5. A list of generalised and vague health issues cited as key areas of impact. This is a key feature of alternative health practitioners advertising. Being careful to avoid stated efficacy over any specific medical condition is important not to fall foul of advertising and competitive business standards/laws. However, by stating a wide range of (usually) complex chronic conditions that are not well controlled with contemporary medical treatments they have staked a territory where they can make money selling unproven and non-science based therapies. Basically, this is stating they have a cure for non-wellness.
  6. Out of house lab testing implies they use modern scientific practices. Again an appeal to science by faith-based practitioners. In reality many official lab testing services will not accept tests ordered by naturopaths, so many resort to in house testing in which they have very little expertise. Often, they will emphasise this by standing in front of a microscope or other diagnostic equipment in promotional material (also see #13).
  7. Use of a  list of alternative therapeutic practices presenting them all as equally valid therapeutic options.There is often conflation of scientific therapeutics with magical ones, and E.g. vitamins (science based nutrition) and homeopathy (faith based magic). These are usually a list of therapies that are not available from scientific medical practitioners or health services as they are not evidence-based, and have no demonstrable efficacy. Hence, their practice by alternative purveyors. Where scientific evidence is used (e.g. the importance of good nutrition and vitamins) it is usually accentuated with a completely unevidenced implementation; e.g. IV megadose vitamins, or the notion of homeopathic vaccination (actually a contradiction in terms).
  8. A recognition of status by a claim to provide education, at vaguely described educational institutions. Again, an appeal to authority.
  9. Another appeal to authority and status through the use of accolades and awards. Usually these awards will be from the practitioner’s own discipline, and therefore once again of questionable value. If you receive an award for promoting magic, does it make the magic real?  For the public these convey the air of respectability and status.
  10. Prominent use of the word “collaboration” implying as in #4 that the practitioner is a team player, and that they work with other health professionals. Also, this serves to imply that science-based medical health professionals are somehow not collaborative.
  11. Conflating alternative professional awards with another from a respected institution. In this case the award is implied by the use of the term “recognized.” This represents another appeal to authority in the practitioners presentation of their recognized status as a health professional.
  12. Collaboration emphasised once again, but this time in terms of “medical collaboration” firmly linking the notion that this practitioner works alongside physicians on an equal footing. I.e that the practitioner is a medical practitioner. Also, promoting social inclusivity.
  13. Prominent use of a stethoscope in the promotional picture. This is a frequently used method to establish scientific authenticity. Expertise in the use of this diagnostic tool is widespread (our nurses are taught how to auscultate in their first term). Nevertheless, it has a powerful symbolic significance, and once again is used here to imply technical expertise.

Overall the advertisement is very cleverly designed to imply that the practitioner is a science-based professional with authentic qualifications and experience comparable to a qualified physician or nurse. They are not, but this sort of thing has even managed to convince some academic institutions to include non-science based therapeutics in integrative medicine programs (sadly on the increase). If these folks simply advertised themselves as magical or faith-based practitioners I would have no problem, but implying they are science-based is simply disingenuous, and deceptive (either that or they have no real understanding of what science is).

In reality, this is a modern version of the snake oil salesman, and the this is a new-age practitioner selling unproven and magical therapies as a business. They may or may not believe in them themselves and that is for the reader to judge, but if you want an insider’s view on the education and practice of naturopaths take a look at Britt Marie Hermes blog on the subject. So, now you know what to look for!

Cheers

Bernie

 

 

 

 

A Tale of Two Cultures: Why integrative medicine is fatally flawed.

It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, as Dickens wrote. I thought of those lines when I recently found myself a guest speaker at an Integrative Medicine Conference in Shanghai China.

How on earth did a skeptic like me end up there you may well ask? Well, it’s a long story, but in a nutshell I got an email invite as a guest speaker through a Chinese colleague in IT who asked me at short notice if I was interested in speaking a forthcoming medical conference in Shanghai, all expenses paid. The idea was to present some of our exploratory work on virtual reality (VR) as an adjunctive distraction therapy in pain management. I thought why not, as I happened to be free, it was only for a few days and I had never visited China before. So, a week before I was set to go I finally got sent the official conference literature in Chinese. Using Google Translate I discovered the conference was actually titled the “2016 Design and Implementation of Clinical Trials in Integrative Medicine Conference.” I was somewhat surprised at this to say the least, and wondered if these folks had ever looked at my professional profile or read anything I have written (including this blog)? I could have pulled out at this stage, but thought they had graciously invited me, paid for my flights etc, and I could discuss research techniques to support evidence-based healthcare, and talk about rapid evidence assessments in the context of our work in my presentation. Also, I must admit I was somewhat curious as to what this sort of conference would look like, and am far too past-it in my career these days to worry about negative career impact from attending academically dodgy conferences. So, despite my misgivings, I decided to go for it, and vowed to do my best to give it a fair shake, so to speak.

My hosts were very hospitable, and a day after I arrived I found myself sitting in the front row of the Lecture Room in Shuhang Hospital, Shanghai University of Traditional Chinese Medicine (TCM) ready to deliver my talk. I got a tour of some of the hospital beforehand. I asked several nurses, physicians and other staff how they used TCM here? I was surprised to find they all looked a little uncomfortable discussing it, and several noted that actually all of the hospitals offer science-based medicine with the usual pharmaceutical and surgical treatments found in the west as the primary health care interventions.TCM was used as complementary therapeutics. A few also openly admitted that TCM (which is based on an eclectic collection of a lot of vastly different philosophies and therapeutics, from demonology to acupuncture) was not highly regarded here and was seen as more of a politically sensitive response to health problems by most health professionals.

To those unfamiliar with TCM, although aspects of it have been around for at least 2,000 years or so, it was actually devised by Chairman Mao (see David Gorski’s entertaining summary here), and continues to be promoted by the government. So any critique of it within China is, to say the least, a rather sensitive issue. That is not to say it may have its benefits, as in many rural areas there is no medical care apart from TCM practitioners, so it probably is better than nothing. And, that’s the point really. Whilst much of TCM  appears to have no clinical efficacy, and some is definitely harmful, some of the remedies do actually work, but generally no where near as well as other modern scientifically validated therapies.

The problem I have always had with integrative medicine is that if you throw magical and empirical therapies together with some misplaced notion of “inclusivity,” you end up with  a melange of vacuous nonsense. The scientific medicine that actually works is devalued by being placed on the same platform as magic, whilst the magical treatments supported by pseudoscience and bad science are elevated to academic respectability (but still don’t actually work). Unfortunately, my experience in Shanghai did nothing to divest me of this view.

Before my presentation there was a rather excellent one on the use of electroacupuncture for vagal nerve stimulation by Dr. Luis Ulloa, and its potential to improve outcomes in the treatment of sepsis by reducing the inflammatory response. It was a highly creditable and very well delivered conference presentation of sound scientific work. I was very impressed with the creativity, scholarship and level of work involved; overall typical good science at work. However, to be clear this work’s relationship to TCM and acupuncture was purely in name only. It actually involved the electrical stimulation of the vagus nerve in animal studies through a needle inserted in an identified acupuncture point that corresponded physiologically with the location of the vagus nerve. It used established scientific knowledge of anatomy and neurophysiology, and at no point ever used any reference to meridians to manipulate the flow of life energy (qi) or any other TCM explanations of acupuncture. At this point my hopes were raised. Was this what the future of integrative medicine was to be, replacing mythology and faith-based explanations with sound empirical work? Maybe my misgivings had been premature.

But alas it was not to be, and things went downhill very rapidly from then on. The other presentations stretched credibility beyond belief, and demonstrated surgical ethics that were highly suspect at best. Firstly, the Director spoke proudly of how an open heart surgery operation in 1975 had been performed using acupuncture for anaesthesia, and then a speaker who was one of the  original anesthesiologists in that surgery came on stage to say how they pioneered these techniques. These were even commemorated on this Chinese stamp:

stamp

The hapless patient here was a 15 year old girl, and the reality was that it was later reported, that in addition to acupuncture the patient  also had powerful sedatives and analgesics (midazolam, fentanyl, and droperidol) and also large volumes of local anaesthetic injected into the chest. They also had to be taught abdominal breathing exercises for days before the procedure to maintain ventilation (but they did maintain an endotracheal tube for emergency use – thank goodness).

This added to the mythology of the effectiveness of acupuncture as anesthesia in the west, arising from a 1972 story when journalist James Reston wrote about his emergency appendectomy during American President Nixon’s trip to China. He was initially reportedly as “anaesthetized” by acupuncture needles. But this soon became established as a PR stunt, as again, it turned out he actually had conventional anaesthesia, and acupuncture afterwards to help pain control in the recovery period. if you ever want a patient’s first hand account of the benefits of acupuncture anesthesia I highly recommend professional ballet dancer Li Cunxin‘s autobiography. He is not a fan, having experienced it as a young man.

The presentation went on to outline how they now regularly employed acupuncture anesthesia for open heart surgery as it was shown to save costs considerably both in terms of the costs of anaesthetics and recovery. They also cited a 2011 paper that claimed “during operation, patients were kept on spontaneous breathing.” I took the following picture during the presentation which had some rather gruesome photos of patients they claimed to be undergoing open heart surgery using acupuncture anesthesia.

img_5422

The trouble with all this is it includes some science mixed with half-truths and a large dose of pure propaganda. Firstly, I have no doubt it is possible to do thoracic surgery with minimal conventional anaesthesia and adjunctive pain control measures,but that doesn’t mean it’s a good idea. Scientifically we know pain is multifactor complex neurophysiological and psychosocial phenomenon. Placebo and distractive effects can be very powerful here. In all likelihood a range of alternative placebos together with pharmaceuticals would probably have had similar effects to those claimed for acupuncture here. However, experimenting with these during major surgical procedures is completely unethical by any modern medical standards (and I would suggest borders on medical torture). Some may deconstruct this as an old-colonialist view of a very different culture, but to suggest it is reasonable to use low doses of established  anesthetic drugs with acupuncture and keep the patient conscious to save money is simply morally indefensible, and hardly patient-centred medicine. As a nurse I would have to say that anyone who has witnessed open chest surgery, and thinks it is good for the patient to be conscious during the procedure is either a sadist or has no respect for human suffering.  I’ll leave it to your imagination to think what it would sound and feel like as the surgeon saws through your sternum. Certainly, there is always the: “but what if there is no alternative” argument but the problem here is – there are good alternatives (and that argument really does represent an old-colonialist viewpoint). There are many better proven anesthetic and pain control measures that could be used than this, and this falls far short of the “do no harm” principle.

Secondly, a cursory review of the actual work reveals the whole thing is a politically motivated sham anyhow. Even one of the Chinese doctors I spoke with there thought the whole thing was politically driven nonsense. By mixing ancient chinese magical theories of qi energy, meridians and needles with doses of modern sedatives, local anesthetics and narcotic analgesics it is impossible to determine what effect the actual acupuncture is having compared to the drugs, let alone any placebo effect. Use of sham acupuncture was cited as being inferior in some of the work presented, and the presentations on acupuncture anesthesia all contained copious statistical reports with p values supporting positive outcomes. No one could claim the researchers were not statistically competent. In fact, I have never seen so many P values and positive results presented in a single medical presentation. Nevertheless, apart from the well established problems with P values, statistical inference relies on robust methods and hypotheses to be meaningful. It’s a case of garbage in, garbage out, and I have never seen such demonstrations of overt confirmation bias as I experienced here. If the findings claimed here were actually true and replicable, I guarantee anaesthetists all over the world would be throwing out their Boyle anaesthesia machines and embracing acupuncture as the technique of choice.

Unfortunately, evidence for the basic theory and science of acupuncture in TCM just isn’t there, and by adding multiple confounding variables in studies any possible effect is completely obfuscated. In our own initial work with VR and pain, we are at an exploratory phase and although it looks promising as a distractive therapy, the reasons why it seems to work are unclear. Also, we have found the effect size varies considerably with individuals, and we are far from identifying if it will turn out to be a useful therapeutic adjunctive. This is for a new technique, and yet the results of the first ever well-controlled study of acupuncture (claimed to be over 2000 years old) for back pain were only published in 2007 in the Archives of Internal Medicine. This study found:

  1. Both acupuncture and sham acupuncture appeared to work better than conventional drugs, physical therapy, and exercise alone.
  2.  However, acupuncture worked no better than sham acupuncture.

So, clearly there was some effect but most likely placebo. It well established that pain perception is hugely impacted by psychological factors, but magical theories of qi and meridians have never been independently empirically demonstrated. Following further studies even NICE in the UK has now rejected the use of acupuncture for low back pain.

So overall, the whole conference experience was very dispiriting. Mixing good scientific work with myth-based bad science and pseudoscience is going to get us nowhere fast. From my perspective the experience was akin to me going to an aviation conference and watching a presentation on the latest developments in carbon-fibre technologies to create improved aerofoil designs, followed by one explaining how to weave charmed threads into a magic carpet to gain maximum levitation. At the end of the day only one of these approaches is ever going to get off the ground. Sadly, the whole integrative science/medicine enterprise is academically bankrupt, and the sooner universities here promoting it realize this, the better.

Oh, and how did my presentation go down? Well, it was politely received (probably didn’t state enough P values – even with my small samples – for this audience).  I did find one of the audience kept eying me with a death-ray glare throughout though. So I suspect at least one person had actually looked up my background.

Season’s Greetings to all

Onwards and upwards.

Bernie

 

 

 

 

 

 

 

 

 

Dirk Gently’s Holistic Lawyers are Coming

In a  week where my life seems to have taken on aspects of an absurdist comedy, my university and professional body received a letter of complaint from a self-described holistic lawyer, Geneviève Eliany of Buckley and Company complaining I was teaching against the UBC School of Nursing curriculum by teaching science, rather than practices that “cannot be easily quantified or scientifically supported.” It was unclear if this was a letter from the lawyer herself, or acting on behalf of a client (the BCTTNS).

Quite synchronously, this happened in the week a TV series of Douglas adam’s book Dirk Gently’s Holistic Detective Agency filming here in Vancouver (with Sam Barnett and Elijah Wood). Amazingly, I discovered holistic lawyers are actually a real thing (see: http://www.holisticlawyers.org/holistic-lawyer/) but most seem to prefer the term “holistic” rather than “wholistic.” Apparently, everyday lawyers are acting in some sort of of fragmented way, Who would have thought?

The letter didn’t seem to exhibit any particular holistic qualities I could detect, but was a rather bad quality fax sent to the school that complained I was somehow bullying nurses by using my university position to make a case against therapeutic touch, and using my authority to teach and champion evidence-based practice instead of non-scientific holistic practices.

Fax header

Anyhow, the university gave the expected response that as a matter of academic freedom, professors are quite entitled to express their views regarding therapeutic touch (or other things) as well as claims made in advertising and promoting them.

The letter also contained technical errors, mixing up lateral violence with vertical violence, stating that Advertising Standards Canada was a “false authority” and assuming that nurses are simply taught one  way of thinking (Carper’s ways of knowing). Conversely, in sending it, Ms. Eliany also seemed to be doing exactly what she was complaining about

Most bizarre of all was the fact that in her publicity blurb she states identifies as a “wholistic lawyer, and she uses a “paperless practice.” The fax contained no return e-mail address, and last time I checked, a fax was not a great example of a paperless practice (as well… it requires paper to work). As she supplied no return e-mail address, it also required either a fax or written response from the university!

First time in my career I have ever been complained about for promoting and teaching science, so watch out, it seems the holistic lawyers could be coming for a scientist near you…

Bernie

P.S. Ms Eliany’s Twitter handle is @wholisticlawyer.