Integrated Medicine; the latest trend in health?

Hi all,

As we roll into summer (hopefully a rock n’ roll summer according to Rog) a few developments in the strange world of “integrated medicine” caught my eye. Firstly, I am not really sure what “integrated medicine” is, as none of its proponents seem to be able to come up with a good definition, other than being a “holistic approach.” Frankly, it seems to be a conflation of medicine and stuff that isn’t evidence based and probably doesn’t work but has a strong following of folks who believe in it.

Naming and dividing up pseudoscientific or quasi-scientific practices as a form of medicine is rather an old trick of alternative practitioners. The classic examples being “Western medicine,” “Eastern medicine” or “alternative medicine” to emphasize different philosophical world views behind medical treatments and therapies. In reality, this is of course nonsense, and modern medicine is an evidence based endeavour, and there is simply “medicine” (i.e things that are based on scientific evidence and well-tested theories and actually do work; some better than others granted), and non-medicine (which generally doesn’t work, at least no better than placebo, but sounds hip and cool). Science-based healthcare doesn’t care if therapeutic interventions come from Brighton, Washington, Bejing or Bankok; as long as they work. Integrated medicine does look like the latest in this long line of different terms used to try and make pseudo-scientific practices sound credible.

There is big money behind these endeavours too (and I suspect big profits). A mail-out landed in my mailbox the other day for the Natural Standard website, which looks very well organized and professional when you visit.  It looks like a site dedicated to providing sound and good scientific evidence on complementary as well as established medications.

However, upon closer inspection it seems to present far less than rigerous scientific standards are applied in their recommendations. For example one cited paper suggests that the extract of pulsatilla (a purple flower beloved by homeopaths) may be able to reverse cognitive impairment and be beneficial in the treatment of Alzheimer’s disease. This astounding statement is based on reported research from no-less an authority than the Life Science R&D Center of SK Chemicals in Korea, from it’s laboratory studies. Needless to say lab studies are at the bottom of the evidence pyramid for Evidence Based Practice, and the suggestion at this stage that this may help reverse Alzheimer’s is completely bonkers. Maybe after a wide range of succesful clinical trials you could start to make such a claim, but try getting that one published in the BMJ on the basis of lab studies.

In a similar vein, it looks like things are hotting up for homeopaths in the UK.  A consolidation of existing regulations by the Medicines and Healthcare products Regulatory Agency (MHRA) in the UK will come into force on 1st July 2012 despite a campaign by supporters of homeopathy to try and prevent it.­The problem for homeopaths is that under the new regulations there are only 5 appropriately qualified pharmacies which can now dispense the four dozen or so formally registered potions that can be legally sold in the UK. All other homeopathic prescribing and supply not involving a face-to-face consultation with a registered homeopath will be unlawful after July 1 2012. Thousands of unregistered homeopathic remedies that are not included in the regulations will no longer be legal for sale. Even for the handful of legal preparations, supply without a face-to-face consultation will cease and all online or telephone sales will be illegal. I am not sure what Prince Charles thinks of this, but looks like the stage is set for a rapid change in the black drugs market. One can imagine shady looking characters approaching you in the pub and saying “Psst, want to score some good argentum nictrium in a 5C dilution, I have a good deal going…”

This may pose a problem for the The Royal London Hospital for Integrated Medicine  which is advertising for a pharmacist who specializes in (yes you guessed it) “integrated medicine.” The job requires a trained pharmacist with a minimum of 10 years of experience able to deliver clinical pharmacy services, and requires some sort of integrated medicine training (sadly it seems that the NHS is now getting into IM too) but it doesn’t say what that experience should be (maybe trifling with voodoo as a teenager would qualify)? The position would involve dispensing both regular medical medications and ones that probably don’t work too. Your tax dollars (sorry pounds) hard at work. Well at least Obama’s health reform’s went through this side of the Atlantic, so there is cause to celebrate here. Thanks to Andy Lewis of the Le Canard Noir who flagged this story, and also Scott Gavura’s excellent Science Based Pharmacy site.

Anyhow, as Roger noted the summer is upon us and I am off to Vancouver Island (Sooke) on my holidays for a while. Roger will be away for a bit too, so things may be a little quiet over the summer, but we will try and post when we can. We will of course, be back in full swing in the fall with more scientific quandaries for you (and us) to puzzle over.

Onwards and upwards scientists! Have great summer,

Bernie

 

 

The Science of Rock and Roll: You’re never too old to…

I came across an interesting book this week called “Guitar Zero – The Science of Learning to be Musical” by Gary Marcus. He is a Professor in Psychology but I won’t hold that against him, as it’s an interesting read!

Without spoiling it too much the book concerns his decision, in his late 30’s, to learn to play a musical instrument. This is in the context of having been entirely useless at any form of music since an early age. In fact, every effort to learn to play or sing had ended in complete disaster, he simply had no sense of rhythm or pitch and was constantly told this by his teachers and latterly by his more musical friends.

It’s a fun read, but there is a serious point here as well. In education we often talk about ‘critical periods of learning’, these are periods in our lives when we are more receptive to learning new ideas, concepts and complex skills. Normally such periods of development are associated with childhood. In environmental education for example, Cornell argues that there is a critical period between the ages of about 7 to 12 when children are at their most receptive to environmental learning. The area that is normally dragged out to support this idea is that of learning languages. If you don’t learn a language as a kid, you’ll find it increasingly difficult as you get older. We probably all have personal stories of this. My humiliating experience and eventual dropping out of “Spanish for Beginners” a couple of years ago is mine.

However, if you actually look for any evidence for critical periods of learning, you’ll find that there isn’t much and in fact the research that has been done in this area questions the concept. Children and adults don’t learn at different rates and there is no point after which it becomes more difficult to learn. We appear (as I did in the last paragraph) to ‘retrofit’ experiences to support this idea. Mind you, understanding that I’d have been just as rubbish at Spanish as a kid is hardly cheering news!

Anyway, getting back to the book, Marcus decides to learn a musical instrument and eventually settles on the guitar. He decides to approach this in a ‘scientific way’ so starts with a literature review on how people learn music. He identifies that while there is quite a literature on how children learn, that there is hardly anything on adult learning (actually, no surprise to us educationalists there). His research eventually throws up a number of interesting ideas; not least of which is that perfect pitch isn’t necessary to learn music, what does appear to be key is practice. Everything else is just simply not supported by research. This suggests that children will learn a musical instrument simply because they practice at school and at home. Teenagers will learn at school and in their bedrooms at weekends. Adults simply don’t have the time.

Now this is really interesting and he talks quite a bit about the work of Anders Ericsson whose area is that of ‘expertise’. Ericsson suggests that it takes around 10 years (or 10,000 hours) of practice to develop real expertise in areas as diverse as chess to playing the violin. It may not be entirely linear and perhaps hardly ground breaking but there is a correlation between practice and learning. Of course, it’s not as simple as that. When Bernie and I were graduate students we had a friend called Marc who was a fantastic guitarist. I have now played the guitar for longer than Marc had been alive when we were students, yet I still haven’t got anywhere near his grad student proficiency. So it can’t be practice alone.

Ericsson suggests that you need ‘deliberate practice’. In a nutshell, he means that you practice what you’re bad at. You don’t improve by just playing what you can play over and over again (anything that involves the chords G, C and D in my case) but rather you need to concentrate on the stuff that’s difficult to you (Any bar chord, or those B chords that involve six fingers).

As Marcus points out, actually this is not a million miles away from something that the educational theorist Lev Vygotski (who seems dead fashionable at the moment – so drop the name into conversations for extra kudos) called ‘the Zone of Proximal Development”. Briefly (and here over simplistically) he argued that you only learn if you set (or are set) goals that go slightly beyond what you’re comfortable with. Children and adults need to be pushed, or push themselves. If it’s too easy, you get bored, if too difficult you’ll give up. This holds for any type of learning at any age. The problem here is that if you find a subject comes easy to you (say Maths) it’s tempting to think ‘well I won’t concentrate on Maths, because I can do that, I’ll concentrate on a subject I’m rubbish at like Spanish’. Actually, it would probably be more productive to really push yourself in areas of Maths that you find most difficult.

So, the trick is loads and loads of practice, but always concentrate on the areas that you find the most problematic. This applies not only to acquisition of new skills, such as playing a musical instrument, but also holds for learning generally. It’s how to get a good degree, doctorate, emeritus professorship and Nobel Prize.

Actually, just forget the ‘glittering prizes’. I also agree entirely with Gary Marcos when he says that as we get older we give up on enrichment and as adults we tend to focus on application. We simply stop taking on challenges like learning to draw, sculpt, dance, star-gaze, play the guitar, do calculus, all the stuff that doesn’t add anything that we’d regard as tangible gain, but enriches our lives so much more.

So this week’s message is that the research suggests, practice. Practice what you find difficult and that it’s NEVER to late to learn. By the way after locking himself away for a few weeks to practice 6 – 8 hours a day and continuing to practice most days after his return, Gary Marcos while perhaps not an ‘axe god’ can now play the guitar.

OK I’m off to get my ‘axe’ and smash out some bar chords…Rock on…science dudes.

Roger

Memory, falsity and how we know what isn’t so.

In the week that Totness seems to have become the CAM capital of the UK (apparently it’s twinned with Narnia), my mind turned to the ways in which we can so easily believe in things that are on reflection, obviously not so.

The media certainly has its share of the blame here, often whipping up a sensationalist frenzy of interest in stories that turn out to be untrue. An interesting one this side of the Atlantic was the 2008 case of a reported “pregnancy pact” between 17 teenage girls in Gloucester, MA. This stirred up considerable media interest and has spawned two movies and at least one book I know of. Nevertheless, it was actually not true, and the teenage pregnancy rate in Gloucester was really lower than many other towns in the USA.

However, our own brains can easily mislead us too, as cognitive psychological research frequently tells us. I have also found this area fascinating, and the following example is a great brain twister that illustrates the point.

One area of reasoning can easily give rise to erroneous results is that of memory and illusory inference. The brain uses specific parts of the brain to process and store information (such as the hippocampus for working memory and cerebellum for motor skills). Psychological research has suggested that we can only actually think about seven things at once before we overload our working memory capacity (Miller, 1956). This working or so-called “short-term” memory limits our reasoning ability, but the theory is, has evolved to represent more-than-sufficient working memory for everyday life (Johnson-Laird, 2008).

Indeed. Some people with hippocampus and other brain-injuries have demonstrated short-term memory loss, whilst some “memory athletes’ train to improve their memory capacity for competitions and achieve some remarkable results remembering names, cards, faces and numbers (Foer, 2011). Nevertheless, the memory athletes use techniques that help store information in areas outside of working memory and all appear bounded by the same cognitive processing limitations as the rest of us. We also know there are conscious (declarative) and unconscious (non-declarative) processes that result in memorization, but as yet we still do not fully understand the complex inner workings of memory processing and cognition in the brain.

The limit of about seven things to process at a time seems fairly consistent, and more recent work suggests the human mind also tends to ignore things that are false (also known as falsity).

Falsity involves leaving out or ignoring information in the reasoning process to leave a proposition that is false. Mary Newsome and Philip Johnson-Laird of Princeton University reported in a 2006 experimental study that for certain sorts of premise individuals reliably infer invalid conclusions (Newsome & Johnson-Laird, 2006).  Complex propositions may confuse us into making the wrong decision. Lets take an example, only one of the following statements is true for a hand of two cards:

  1. If there is a king in the hand, then there is an ace
  2. If there is not a king in the hand, then there is an ace

Which is more likely the king or the ace in the hand of cards?  You might want to try and figure out your own answer before reading further.

We generally mentally map out this problem of probability as follows on the basis that we consider each separate statement as true:

  • King & Ace
  • Not King & Ace

So the answer most of us come up with is the ace. It seems we would more likely have a ace in the hand without a king compared to having no king and an ace, as the ace occurs in both sets of statements whereas the king only in the first.  However, this is an illusory response as what we overlook is that when one conditional statement is true, the other must be false i.e. there is an exclusive disjunction in the statements (only one of them can be true). We can see this if we fully map out the problem more explicitly:

EITHER: If “King then Ace” is true, and “Not King then Ace” is false,

OR: If “Not King then Ace” is true and “King then Ace” is false,

Using the mutually exclusive nature of the two statements the two possible models are:

  • Not King & Not Ace  (where the first statement is true and second false)
  • King & Not Ace (where the second statement is true and first false).

In this above rationale we can now see the Ace is not only less likely to occur, but an ace is also logically impossible in the hand given the requirement that the other statement must be false. This is actually the correct solution.

Lastly, let us consider a third option, what if both statements could be true?

This is what is technically known as a bi-conditional interpretation of two conditionals and if we write out all the possible hands using an “and” rule: (that is to say if and only if “king then ace,” and if and only if “no king than ace” we would get these possibilities:

  • King & Ace
  • Not King & Ace
  • Not King and Not Ace
  • King & Not Ace.

In this case there would be an equal chance of holding a king or an ace, but again this answer is also incorrect as it ignores our conditional “either or” statement in the initial premise. In an experiment by Johnson-Laird and Savary experiment in 1996, using this problem administered to students, 79% of participants gave the initial response that an ace was more likely, 13% got the correct answer that the king was more likely, and 8% also incorrectly thought they had an equal chance (Johnson-Laird & Savary, 1996).

They suggested people reason from a mental model that is constructed according to a “principle of truth”, i.e. a model of a possibility representing clauses in the premises only when these clauses are considered true, i.e. we ignore things that are not explicitly stated as false (Johnson-Laird, 2008; Newsome & Johnson-Laird, 2006). This form of reasoning arises from our prior knowledge and experience and reduces the mental processing load, but for this type of problem the consequence is an erroneous result.

Confused yet? Well, that is the point. There are lots of other examples of cognitve and sensory issues that can mislead our brain, but I quite like this one. If you got all this on the first reading I suggest you immediately grab an application form for MENSA and get working on your acceptance speech for an inevitable Nobel prize. However, for the rest of us this serves to indicate why science remains an important epistemological approach.

Anyone can challenge anything in science and the peer review and verification processes (although flawed) are powerful tools in discriminating evidence. Scientists, as much as anyone else, certainly hold things to be true now that will be proven otherwise in future, but the beauty of science is it encourages us to do so. Modern science recognizes the dynamic, and changing nature of our knowledge, and more importantly, our ability to be deceived by our own thinking.

Bernie

References

Foer, J. (2011) Moonwalking with Einstein: The art and science of remembering everything . New York, NY: Penguin Press.

Johnson-Laird, P. N. (2008). How we reason: A view from psychology. The Reasoner, 2, 4-5.

Johnson-Laird, P. N., & Savary, F. (1996). Illusory inferences about probabilities. Acta Psychologica, 93, 69–90.

Miller, G. A. (1956). The magical number seven, plus or minus two: Some limits on our capacity for processing information”. Psychological Review, 63(2), 81-97.

Newsome, M. R., & Johnson-Laird, P. N. (2006). Falsity dispels fallacies. Thinking and Reasoning, 12(2), 214 – 23.