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.

 

Therapeutic Touch & Misleading Advertising: The power of adding “scientific” to your product

Hello all,

Last month two Therapeutic Touch (TT) outfits here in BC were found culpable of misleading advertising following complaints to Advertising Standards Canada.  They were the BC Therapeutic Touch Network Society (the organization promoting TT in BC), and  a TT Clinic in Delta who had a TT practitioner making unsubstantiated health benefit claims in a local newspaper advertisement.

Clause 1: Accuracy and Clarity
Clause 8: Professional or Scientific Claims

Advertiser: BC Therapeutic Touch Network Society
Industry: Health and beauty services
Region: British Columbia
Media: Digital – Marketer – Owned Websites
Complaint(s): 1
Description: A not-for-profit organization, which publicizes information in support of its members who provide Therapeutic Touch therapy to the public, published information on its website promoting the Therapeutic Touch therapy technique. Claims and statements regarding the efficacy of the technique included:

Therapeutic Touch therapy is a “benefit to the practitioner and the client, proving to be a significant antidote to burnout in healthcare professionals”

Therapeutic Touch therapy is “effectively used on humans, plants and animals”

“By producing a rapid relaxation response…your body will heal and recover faster” (with Therapeutic Touch therapy)

Therapeutic Touch therapy “(may be) used pre- and post-operatively to hasten recovery, to balance emotions, and relieve depression, to assist cancer patients to deal with side effects of therapy and to boost the immune system, to assist in recovery from addictions, to assist in pre and postnatal care, to calm anxiety and aggression in patients suffering from various forms of dementia, and to calm and support palliative care patients and their families”

“Over 50 doctoral and 20 post-doctoral studies are available through the (BC Therapeutic Touch) Network, which have proven the effectiveness of Therapeutic Touch”.

Complaint: The complainant alleged the advertised claims were not currently supported by reliable, science-based evidence.
Decision: It appeared to Council that the efficacy claims regarding Therapeutic Touch therapy were medical treatment outcomes for serious diseases and conditions that readers of the advertisement would associate, in whole or part, with conventional medicine practices and procedures. However, Council found that the studies and research provided by the advertiser were insufficient to support such claims. It concerned Council that the claims and statements could cause readers to believe that Therapeutic Touch therapy was an alternative for medical treatment for some of the identified conditions, rather than as complimentary to traditional medical treatment. The advertiser requested an appeal from Council’s decision.
Appeal: Following a careful review by the Appeal Panel, Council’s original decision was affirmed.
Infraction: Clauses 1 (e) and 8.
Clause 1: Accuracy and Clarity
Clause 8: Professional or Scientific Claims

Advertiser: Healthcare Service Provider
Industry: Health and beauty services
Region: British Columbia
Media: Newspapers
Complaint(s): 1
Description: A natural healthcare clinic advertised various services provided by the clinic’s practitioners. Among the claims made in the advertisement were efficacy claims about one of the procedures identified in the advertising.
Complaint: The complainant alleged the claims were not currently supported by science-based evidence.
Decision: Council found that the studies and research provided by the advertiser were insufficient to support the advertised claims.
Appeal: Council’s original decision was affirmed by an Appeal Panel, acting on the advertiser’s request for appeal. Notwithstanding the fact that the advertiser appealed Council’s original decision, the advertiser had withdrawn the advertising before the original Council hearing. On that basis, the advertiser is not identified in this case summary.
Infraction: Clauses 1 (e) and 8.

Their original advertisements on the web and in the paper made claims that  Therapeutic Touch (TT) was an evidence based practice that could effectively reduce symptoms of stress, anxiety and pain while supporting the immune system, accelerating healing.

After thoroughly deliberating these matters, taking expert advice, and reviewing a 56 page response and appeal by BCTTNS, the ASC panel finally concluded that the advertised claims in question clearly contravened Clauses 1(e) – Accuracy & Clarity, and 8 –  Professional and Scientific Claims, of the Canadian Advertising Code.

Provision 1 of the ASC Code requires that both in principle and practice, all advertising claims and representations must be supportable. If the support on which an advertised claim or representation depends is test or survey data, such data must be reasonably competent and reliable, reflecting accepted principles of research design and execution that characterize the current state of the art. At the same time, however, such research should be economically and technically feasible, with due recognition of the various costs of doing business.

Clause 8 of the Code requires that advertisements must not distort the true meaning of statements made by professionals or scientific authorities. Advertising claims must not imply that they have a scientific basis that they do not truly possess. Any scientific, professional or authoritative claims or statements must be applicable to the Canadian context, unless otherwise clearly stated.

Neither of those standards had been meet by the BCTTNS or the private clinic, but sadly neither saw a problem with their advertising either, as both appealed the original complaint decisions. BCTTNS submitted a summary of numerous TT research papers undertaken over the last 20 years to the ASC as evidence of efficacy. Unfortunately though, the vast majority of these were of very poor quality,and small scale-studies from self-interest journals (such as Holistic Nursing). They also omitted several other critical works from more established journals:

  • Hansen et al. 2006 – A Cochrane systematic review of evidence regarding TT and dementia, which found no evidence of effectiveness to date.
  • O’Mathúna and Ashford 2014 – A Cochrane of evidence regarding TT for healing acute wounds which found no evidence of effectiveness to date.
  • Robinson, Biley and Dolk 2007 – A Cochrane systematic review of evidence regarding TT for anxiety disorders, wounds which found no evidence of effectiveness to date.
  • Smith et al. 2013 – A Cochrane systematic review of evidence regarding TT debridement for surgical wounds which found no evidence of effectiveness to date.

A major problem here is the lack of scientific literacy of those making claims that TT works. I am sure it is not the case that the majority of TT practitioners are trying to deliberately deceive the public, but that, as with several complementary and alternative medicine (CAM) practices these practitioners are unwilling to question their own beliefs critically. Reading their responses, I don’t believe there is actually anything that would dissuade them that TT is most likely nonsense. As it is impossible to prove a negative, this sort of blind faith in TT is likely to continue. Science involves testing our theories and when they don’t work out, considering we got it wrong and moving on; faith-based explanations do not require this.

Scientifically we have very good evidence that the  bioenergy field as postulated by TT practitioners does not appear to exist. Scientific attempts to demonstrate a bio-energy field and quantify how it can be manipulated have actually been pretty been minimal. Instead, proponents have relied on mystical explanations or pseudoscience from supporters, primarily in  CAM journals. In 1999 review of the physics of complementary therapies stated that the existence of a “bio-field” or “bio-energetic field” directly contradicts principles of physics, chemistry, and biology (Stenger, 1999). However, it is possible (although improbable) that there is an energy beyond our abilities to currently detect (although, strangely, those initiated to feel the force in a short TT course, can do so by waving their hands around). However, proving scientifically, it does not exist is impossible. Absence of evidence is not the same as evidence of absence. It is the old Russell’s Cosmic Teapot argument, and yet again we are asked to believe, because we can’t prove it doesn’t exist.

At this point it would seem very clear that TT should  be considered metaphysical/ magical as it is explained in terms that are not able to be addressed by scientific inquiry, and involves ritual rather than demonstrable practical skills. I.e. only those initiated and approved by the professionals can detect and manipulate the bio-field. So why do these practitioners continue to claim its science?

The better quality studies actually demonstrate no effect of TT (or none better than placebo). There are no good-quality Randomized Controlled Trials (RCTs) or other high-quality experimental work that supports TT (which given the volume of pilot work and time this intervention has been practiced would be expected for a truly valuable therapy). All of the quality meta-analysis studies undertaken reveal no effect better than placebo.

It would be relatively simple to test the claims of TT practitioners in being able to detect bio-fields, and yet little work to do this has been undertaken. If they want to fund me to do it, I’d very happily recruit some grad students and do some experiments, and I promise if it is shown to work I’ll be very happy to publicize the results widely. It is of note that there is still a $1,000,000 prize offered by the James Randi Organization for anyone who can demonstrate TT working, and it still remains unclaimed: for over 20 years now.

Nevertheless, TT continues to have quite a following here in BC. The BC Cancer Agency supports its use, and you can do courses to gain qualification in it at Langara College. Canadian Nurse has also published a couple of supportive articles on TT over the last 10 years.

Looking at their website today I see that the BCTTNS continues to make the same claims it was cited against. Whilst a local TT practitioner offers sessions charging the not-inconsiderable fee of $120 for an hour and a half initial “Quantum Healing” session of therapy.

Regrettably, the current state of TT as with much other new-age research relies on very bad-science and pseudoscience and it is clearly not accurate to claim that TT is an evidence-based therapy, or an effective intervention for any of the conditions claimed by these practitioners (at least any better than placebo or simple relaxation techniques). To do so represents a form of deception, and as commercial service providers TT practitioners should not be using such claims in their advertising. It seems the ASC at least, agrees. So why don’t TT practitioners just advertise TT as a mystical/magical therapy and be done with it?  I wouldn’t have a problem with that, but claiming TT is evidence-based science, is at worst disingenuous, and at best simply vacuous nonsense.

Bernie

Reference

Ernst, E. (2003) Distant healing — An “update” of a systematic review. Wiener Klinische Wochenschrift.
115(7), pp 241-245

Hansen NV, Jørgensen T, Ørtenblad L. Massage and touch for dementia. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD004989. DOI: 10.1002/14651858.CD004989.pub2

O’Mathúna, D. N. P.; Ashford, R. L. (2012). O’Mathúna, Dónal P, ed. Cochrane Database of Systematic Reviews (Online) 6: CD002766

Robinson J, Biley FC, Dolk H. Therapeutic touch for anxiety disorders. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD006240. DOI: 10.1002/14651858.CD006240.pub2

Smith F, Dryburgh N, Donaldson J, Mitchell M. Debridement for surgical wounds. Cochrane Database of Systematic Reviews 2013, Issue 9. Art. No.: CD006214. DOI: 10.1002/14651858.CD006214.pub4.

Stenger, Victor (1999). “The Physics of ‘Alternative Medicine’ Bioenergetic Fields”. TheScientific Review of Alternative Medicine. 3(1) 79-84