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

 

 

 

 

 

 

 

 

 

Why do Gravity Waves Matter?

The first recording of gravity waves by the physicists at the Laser Interferometer Gravitational-Wave Observatory (LIGO), using a pair of gigantic instruments in Hanford, Washington, and Livingston, Louisiana has been hailed as a major scientific breakthrough.

The result of two massive black holes drawing together about 1.3 billion years ago, when they finally merged sent a ripple through the universe in the fabric of space and time called gravitational waves. Five months ago, they washed past Earth. And, for the first time, physicists detected the waves, fulfilling a forty-year quest to demonstrate their existence. Their discovery marks a triumph for the 1000 physicists with the Laser Interferometer Gravitational-Wave Observatory (LIGO), a pair of gigantic instruments in Hanford, Washington, and Livingston, Louisiana who made the discovery.

There is a great little video explaining what occurred here: https://youtu.be/OBybywdPa8U

LIGO

 

 

 

 

 

First there is the question of “proof.” Did the LIGO experiment prove the existence of gravity waves? Science never proves anything to be true, it simply demonstrates a theory or model of our universe seems to work.  If our theories and models agree with real data, it demonstrates we probably on the right track to explaining how and why things happen, but it doesn’t necessarily prove the model is true. Likewise, if you find data that doesn’t agree with your model then it doesn’t necessarily prove that the model is wrong, but tends to suggest there is a problem with it. So if LIGO didn’t prove the existence of gravitational waves, why is it so important?

The project was the first to collect evidence to support the gravitational wave model. Well, except that Russell A. Hulse and Joseph H. Taylor, Jr received the Nobel Prize in physics for their discovery of a binary pulsar with a changing orbital period in 1993. According to Einstein’s theory of general relativity, these pulsars should radiate gravitational waves and decrease their orbital period in the exact same manner as detected by Hulse and Taylor. So, technically they were the first to give convincing evidence of gravitational waves.

However, the advanced LIGO enables us to collect more data on this phenomena to substantiate our theory. Without the Advanced LIGO, you would need a gravitational event (like colliding neutron stars) much closer to Earth, and it seems these events are fairly rare, so we might have to wait a long time for that to happen. By increasing the observational distance we can measure these phenomena, LIGO has given us a much greater chance of detecting future events.

Generally, what this all means is, that a century of scientific innovation, testing, questioning and hard work we have finally started to tap into and explore the deepest register of physical reality, a century after Einstein imagined it. This, is very exciting stuff, and and understanding the nature of gravity is a massively important research area for all of us. Not because it will help us build anti-gravity machines or warp drives but because it can help us understand our world better.  The expansion of our knowledge is fundamental to us making new technologies, and often we can’t even conceive what these will be when they are first discovered (e.g. James Clerk Maxwell’s work on electromagenetic waves in 1865 was thought to be of mainly academic value when initially reported)!

This is also a great example of how science moves in small but important steps in helping us better understand the universe. To my mind, it also illustrates another important aspect of science vs pseudoscience. The scientific process rarely results in simple explanatory solutions to complex problems, but is an evolutionary (and occasionally revolutionary) process involving teams of researchers leading to progress.  Pseudoscience on the other hand, usually involves simple explanations, shortcuts to knowledge acquisition through claims of massive intuitive leaps in knowledge, and proponents with celebrity/guru status, and that tends to do just the opposite.

Onwards and upwards

Bernie

 

NANDA Disturbed Energy Field RIP at last

Hi folks,

Interesting to note that the North American Nursing Diagnosis Association (NANDA) has finally removed “Disturbed energy field” from  its books as a valid nursing diagnostic term. Although, the qualification for its removal was a rather vague:

 “All literature support currently provided for this diagnosis is regarding intervention rather than for the nursing diagnosis itself.”

That sounds a little tautological, and maybe politically phrased to avoid offense to the many nurse therapeutic touch (TT) practitioners. I am not sure how evidence would pertain to a diagnosis rather than a practice? Maybe they mean’t that the nonscientific, and bad scientific work quoted in support of it only referred to the therapeutic use of TT rather than an energy field disturbance? Who knows, but at least its gone.

However, it was on the books for 22 years, and this speaks to the power of the anti-science agenda in North American nursing, that still pervades much of the profession, and especially in nursing academia. It was only really due to the public outcry and work of more high profile skeptics opposing this sort of nonsense (such as  James Randi, Rob Glickman, Brian Hart), and registered nurses as discussed here:

http://www.nanda.org/defining-the-knowledge-of-nursing-priorities-for-terminology-development-_b_7.html

… that this issue was ever taken seriously by NANDA at all.

The California Board of RNs actually issued continuing education credits (CEUs) for nurses undertaking TT courses until they were spoofed by a skeptics organization and their board terminated (sorry couldn’t resist) from office by Governor Schwarzenegger in 2009 http://www.iigwest.com/investigations/cbrn/. It is still amazing to think that a class teaching Feng Shui, Anthropomancy, and TT was actually approved as a valid source of education development for qualified nurses, sigh…

However, this return to clear thinking about the role of magical therapies in healthcare and scientific evidence has yet to cross the border it seems. The Canadian Nurse publication has had two articles in it promoting TT in the last few years,  and the College of Registered Nurses of British Columbia (CRNBC) still allows nurses who practice TT to use their RN title to promote it and sell TT services, supports it as a nursing intervention, and has stated it is within the scope of RN practice (with training in the methods). TT is also still taught here at Langara College locally. http://langara.ca/continuing-studies/programs-and-courses/programs/therapeutic-touch/index.html (although not in the School of Nursing there). I wrote to the head of the department (Contiinuing Ed.) and the President at Langara earlier this year about my concerns in teaching non-evidence based magical health therapies in a public educational institution. I have yet to receive a reply from either. The standard for its justification here is hearsay, the usual “other ways of knowing” argument and bad-science/pseudoscience, which I find very odd. We would not accept that sort of justification for support of blood letting or animal sacrifice as valuable healthcare practices. So why allow this level of evidence to justify TT? I can only summize it is a profitable endeavour.

Plenty of work to do it seems. In light of this I would be very interested to hear from any Canadian Nurses who have attended continuing education sessions, or courses recently that taught magical content. Especially those who would be prepared to share handouts from such session (anonymised please).

In the meantime I wonder if I should pull together a course on anthropomancy, I know of a local college that just might be interested…

Happy Halloween all,

Bernie