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.

 

Neuromyths in Education: Why do they persist?

In a post last year we discussed issues with the lack of evidence-based education, and during some recent professional development sessions and conversations at my university, this came to mind again, as some of the ideas that seem to be taken for granted in higher education seem to have very little supporting evidence. Indeed, education does seem an area where some of the so called “neuromyths” persist, and are even championed.

I came up against this when challenging some of the constructivists and postmodern educational ideas being discussed by a PhD student and a senior member of faculty in education. I was told “I didn’t realize people actually still thought that sort of thing” as if I was some sort of ludite dinosaur. Sadly, I have found members of nursing faculty are often patronized in such ways by academics from other disciplines, which usually signals to me an inability to make any useful counter-argument to a point, and possibly also a rather closed mind!

Neuromyths are really ideas about neurological/cognitive processes that have been repeated often enough to become considered as fact. Unfortunately some misconceptions about the brain persist in the classroom and beyond. Let us consider a few of these established ideas that pervade higher education that have mainly arisen from dubious educational psychology and persist as contemporary wisdom.

Left Brain – Right Brain

The idea is often suggested that people are predominately left or right brained in terms of their skills and aptitudes. E.g. left-brain predominant = logical and mathematically skilled, more organized and systematic whilst right brain predominant = artistic and creative. Just google “left-brain right brain” for many examples. Current research suggests regardless of personality or skill set, you use both the right and left hemispheres of your brain together to perform everyday tasks. Although certain functions, such as speech production, handedness, and facial recognition, tend to be dominated by one side of the brain in the great majority of people, most tasks require parallel processing from both hemispheres. The integration of input is made possible by the fibre connections between right and left sides of the brain called the corpus callosum. Unless an entire hemisphere is completely removed or damaged, no one should really be considered to be “right”- or “left”-brained

The Utility of Learning and Teaching Styles 

As educator James Atherton notes: most teachers would not argue with the proposition that people learn or teach in different ways. This has given rise to a whole host of theories of learning (and teaching) styles. There are at least 71 different learning styles inventories published. However, the assumptions of the “styles” adherents in education are that it is possible to develop a relatively simple typology of learning or teaching styles and then develop test instruments to ascertain where individuals fit, teach to address them, and (more worryingly)  assess the quality of teaching with reference to this.

The evidence to support this is unfortunately weak at best. The research does not support the notion that there are hard-wired styles, and many of the theories conflate learning styles with learning strategies, cognitive theories, or personality type theories. Certainly, students may well have learning preferences but they are not as clear-cut as these various inventories suggest, and motivation would appear to over-ride them every time (Pashler et al. 2008; Scott, 2010). Nevertheless, if you look at many university education and professional development sites they continue to be taught at sage wisdom, and many commercial enterprises exist who are happy to sell you a test.

The Learning Pyramid

The following diagram (or versions of it) appears in around 15,000 web sites (if you do a reverse image search on google – or simply search “learning pyramid”), and yet the evidence that supports it is very vague. It purportedly depicts the degree of retention of material with various teaching methods.

ntl_learning_pyramid

 

 

 

 

 

 

 

It may come from early work by Dale (1946/1969) but even the US based National Training Laboratories Institute for Applied Behavioural Science (who cite it) admit: “NTL believes it to be accurate” but says that they “can no longer trace the original research that supports the numbers” Magennis and Farrell (2005:48). It is also often conflated with the notion of the “cone of experience” in education and the Washington Post also did a nice article on the flaws with it in 2013. Again, there is probably some use and truth in the notion that some teaching methods will work better for some subjects and in some situations. However, the idea that there is a strong validated theoretical model with clearly defined categories is far from the truth.

Multiple Intelligences and Thinking Hats

Howard Gardner’s multiple intelligences model and Edward de Bono’s thinking hats are other good examples of theories I often hear discussed or quoted to support pedagogic approaches. Yet both are also good examples of modern neuromyths. Gardner first proposed his theory of different types of intelligence in 1983. Since then, it has undergone incremental changes, including the addition of one additional intelligence (bringing the total to eight). These different forms of intelligence have been advocated as a basis for changing the way in which we teach. But, repeated research and meta-analysis has found no evidence that individuals actually conform to Gardner’s theoretical categories. Also, according to a 2006 study many of Gardner’s “intelligences” correlate with the g factor, supporting the idea of a single dominant type of intelligence. 

Indeed, even intelligence quotient (IQ) theory itself is commonly misinterpreted. The first IQ test was made by French psychologist Alfred Binet in 1905, and since then the IQ test has become the most recognized tool for predicting academic and professional success. However, although well validated as a psychometric measure there are a number of myths about it that persist, such as:

  • It measures intelligence
  • IQ cant change
  • IQ is genetic

Lastly as a predictive factor for success, it would seem rather simplistic, and although generally a good predicator of performance, does not explain the many confounding examples of successful people who have lower IQ scores than those less successful.

The Thinking Hats site www.debonoforschools.com reads like rather a satire on the subject. It was originally proposed by Edward de Bono in 1985. The premise of the method is that the human brain thinks in a number of distinct ways which can be deliberately challenged, and hence planned for use in a structured way allowing one to develop tactics for thinking about particular issues. However,there is virtually no empirical evidence supporting the model, and it has often been parodied.

In the end, Gardner’s theory or de Bono’s thinking hats interesting ideas but probably not all that helpful for adoption in formal education.

 You Only Use 10% of Your Brain

Again this seems a a widespread common belief, but though the 10-percent myth is widespread, recent neuro-imaging technology has conclusively destroyed this. While not all of the brain is active all at once, functional magnetic resonance images (fMRI) show several brain areas are at work for any given activity, depending on what function is needed, and that we use the majority of our brain matter daily.

Lack of Theoretical Development and Testing?

Overall, I fear part of the problem here is the trend towards accepting postmodern constructivist epistemologies, over thorough scientific investigation, or what I might call the “its all good” syndrome. I worry that this ambivalence towards good evidence in academic inquiry is actually gathering steam, rather than diminishing with key examples being the current rise of so-called integrative science and quackademic medicine. Good scientific practice involves developing ideas into theories, and testing them repeatedly to identify the best of a set of competing hypotheses or explanations. That does not mean we have found the truth but the best explanation given our current understanding. An approach that accepts them all as equally valid explanations of the world offers little in practical value, apart from the ongoing generation of even more unsubstantiated theory.

Enough Already!

The call that we need more research into these theories is often suggested, but we should also recognize the comes a point when it is reasonable to say we have enough evidence, and move on to something new. It is not so much that these neuromyths are wrong, but that the evidence base and/or research methodology is flaky at best, and they have often been misinterpreted and generalized beyond their legitimate use, and make little sense in the real world of education. So, time to move educational theory on towards more productive areas where student performance can actually be shown to improve, such as with the use of improved feedback/formative assessment strategies.

There is an excellent balanced chapter on “neuromyths” from a recent book by the co-ordinator of the Neuroeducational.net site Howard-Jones, that is well worth a look.

Onwards and Upwards

Bernie

References

Atherton J. Read more on misrepresentation, myths and misleading ideas on James Atherton’s site at:http://www.learningandteaching.info/learning/myths.htm#ixzz33zAJEO7S

Dale, E. (1969) Audiovisual methods in teaching, third edition.  New York: The Dryden Press; Holt, Rinehart and Winston.

Doidge, N. The Brain That Changes Itself: Stories of Personal Triumph from the Frontiers of Brain Science. Penguin Books, 2007

Howard-Jones P (2009) Introducing Neuroeducational Research London; Routledge.

Jarrett C. Why the Left-Brain Right-Brain Myth Will Probably Never DiePsychology Today, June 27, 2012

Magennis S and Farrell A (2005) “Teaching and Learning Activities: expanding the repertoire to support student learning” in G O’Neill, S Moore and B McMullin Emerging Issues in the Practice of University Learning and Teaching, Dublin; All Ireland Society for Higher Education/Higher Education Authority

Pashler H, McDaniel M, Rohrer D and Bjork R (2008) “Learning Styles; concepts and evidence” Psychological Science in the Public Interest vol. 9 no.3; available on-line at http://www.psychologicalscience.org/journals/pspi/PSPI_9_3.pdf accessed 21 May 2014.

Scott, C. (2010) The Enduring Appeal of ‘Learning Styles’ Australian Journal of Education 2010 54: 5 DOI: 10.1177/000494411005400102

Visser, Beth A.; Ashton, Michael C.; Vernon, Philip A. (2006), “g and the measurement of Multiple Intelligences: A response to Gardner”, Intelligence 34 (5): 507–510,