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.

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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

 

 

 

 

 

 

 

 

 

Fishbarrel: making complaints about unscrupulous practice easier

Last month I posted on issues with absolute thinking and the rise of absolutist thinking amongst complementary and alternative medicine practitioners (as opposed to those who claim that their practices are simply complementary to evidence based practice [EBP], or acknowledge they are acting as a placebo).

I got a follow up e-mail from a colleague suggesting the use of a piece of software created by Simon Perry called Fishbarrel. This tool modifies Google’s Chrome web browser to provide a rapid and simple way to complain about or highlight dubious claims, and automatically gather them into a properly formatted complaint to the appropriate agency. The good news is, it supports complaints to the Advertising Standards Canada and the Competition Bureau Canada, as well as agencies in the following countries:

This tool has been around since 2011, but I have only just started using it (yes always behind the times it seems)!  I am very impressed how easy it is to rattle off a complaint about unscrupulous practices. Go to Simon’s original blog post on Fishbarrel  to find details on how to download it and a simple video tutorial on how to use it.

To  my mind this is an excellent way to empower consumers and support EBP. Hats off to Simon Perry for Fishbarrel and support here in Canada.

Cheers Bernie

Absolutism: why people continue to believe what isn’t so

Hello all,

This week’s post was triggered by several things. The brief discussion Roger and I had in the commentary to Roger’s last post, Paul Offit’s excellent new book (Do you Believe in Magic?) and a visit to the pet store. Let me explain…

Following Roger’s posting on science in the UK National Curriculum (and consideration of the possibility jesus rode a dinosaur), we had a short debate on the the issue of when it is and when it isn’t appropriate to challenge beliefs, and of the use of humour to challenge ideas.  Rog made an excellent point with an example from a colleague about guidelines on use of electronic resources. Most of us get this sort of guidance (or similar) from our IT departments:

Users must not knowingly, through use or personal behaviour, cause any annoyance, inconvenience, offence, distress or nuisance to other users of those facilities or individuals within or outside the University.”

As his colleague, Robert, rightly pointed out, this seems to suggest universities are NOT the place for radical thinking that will cause anybody any annoyance or offence!

I find this very pertinent here in Canadian west coast where there is a particularly strong ethos of respect for diversity and plurality. Overall, “dude, its all good” would be an apt summary, but the problem is this neo-liberalsim seems to be taken to such extreme levels now that it has simply become another form of constrained thinking causing more problems than it solves. This reminds me of the time in the UK in the 1990’s when I was told in a diversity seminar that I should not use the term “black coffee” as it was offensive to black people (confused, I actually asked a black colleague if this was so, and he laughed so much he almost fell over).

In the age of Web 2.0 and a variety of blogs of every description we are be seeing some interesting challenges to ideas presented. For example, some opinionated bloggers (such as David Colquhoun,’s Improbable Science, and Ben Goldacre’s Bad Science blogs) have both had complaints and threats to have them closed by opponents, and although I find both rather intolerant at times (and fixated on RCTs as a solution to all) it is good to see they are still running to challenge nonsense and make compelling arguments.

The problem is the division between criticizing an idea and what is seen as a personal attack on an individual. In our view the former should always be open, but the latter is simply bad-form, egregious and uproductive. Nevertheless critiquing and challenging ideas is what science is all about. If ideas become seen as sacrosanct, unchallangable and absolute then it becomes impossible to move forward. Science has long ago abandoned the notion of absolute truths and modern post-positivist science recognizes that our current ideas seem a good approximation of a truthful explanation of a phenomenon, but are flawed by a) our limited understanding of the universe at this point, and b) that the human mind’s understanding of the world is itself a particular interpretation. However, that does not equate to a position that ergo: anything goes. In science, any idea or theory is seen as fair game, as long as you can argue a better theory and demonstrate it represents a better explanation.

However, it seems overall the human mind has a predisposition for absolutes, and concrete thinking and that is where the problem arises. We see it a lot with criticism of religious ideas, which in some countries results in the death penalty, but also in science and my field, nursing. As we know, medicine has dumped many unsatisfactory theories over the years, such as blood letting, putting infants on their front to sleep, or the use of frontal-lobotomies to cure mental illness. The advent of evidence-based practice (EBP) has accelerated this progress; as one theory is shown to be at fault, another one that better explains the phenomenon arises, and supplants it.

This is far from the case in the world of complementary and alternative medicine (CAM) though, where debunked theories are still advocated. Before I go on, I should point out that I have been trying to avoid spending a lot of time on CAM issues in this blog, as numerous others do it so much better (see the links section on the right of the blog main page for good examples) and in nursing here it is like putting a stick in a veritable hornets nest resulting in being labelled as an allopathic dinosaur or similar. Nevertheless,  it is  it is difficult to get around the fact that paradoxically it is from some CAM practitioners (the latest term for which seems to be “Integrated/IntegrativeMedicine”)  that the most extreme forms of absolutist thinking arise.

Firstly let us be clear, there are complementary therapies that make excellent adjuncts to modern medicine, such as massage, exercise-based therapies (such as Yoga) and meditation for relaxation and mental health. On the other hand, if we think about it “alternative medicine” does not really exist. There is simply medicine (things that have been demonstrated to be the most effective treatments/interventions) and the alternative, belief-based health practices: things that currently have no-evidence of efficacy, or even evidence they do not work. Herbs and remedies that are shown to have efficacy become medicine (such as folic acid, to prevent birth defects). As Joe Schwarecz, Director of the Office for Science and Society at McGill University put’s it: “there is a name for alternative medicines that work: it’s called ‘Medicine’ (Offit, 2003).”

Yet people (including intelligent individuals) continue to believe in the absolute ideas of many CAM therapies that have clearly been demonstrated to be nonsense, and CAM practitioners refuse to amend or update their positions, instead claiming the same theories are misunderstood, conspired against by big-pharma, or worse beyond scientific explanation. That brings me to my visit to the pet store. My cat Holmes, has been rather ill over the last few weeks (probably on her last legs poor thing, as she is now 19 years old) and I went to the pet store to pick up some cat snacks. Whilst in aisle with worming remedies I came across the following:

Homeopet, homeopathic pet remedies at $18 a box no less! This raised my ire, as it is basically as clear a case of exploiting peoples health concerns as you will find (admittedly with pets). This is a problem that underpins the whole industry (and make no mistake CAM is a multi-million dollar industry).

Firstly homeopathic theory is barking-mad (sorry could’t resist the pun). The idea that a single molecule of a substance in a volume of material that stretches from the earth to the sun could have therapeutic benefit makes no sense at all. Consider that drinking water from your tap probably has more homeopathic properties than anything costing $18 a pack. Secondly numerous studies over the years have shown no benefits with homeopathic remedies compared to placebo. And yet, homeopaths and naturopaths swear that the theory is sound, and their remedies work, despite clear evidence and theoretical argument to the contrary. Nevertheless, they represent a growing segment of the health care sector here in BC.

The principles behind homeopathy (like cures like) actually arise from medieval belief that there was a causal metaphysical link between a weapon and the wound it caused that persisted after the injury. Even Francis Bacon wrote of it, describing how a salve applied to the weapon, could cure a wound made by it; “bind the wound and grease the nail.” This seems like nonsense now, but the practice of applying weapon salve persisted up until the beginning of the last century with the reported case in the British Medical Journal of a woman, Matilda Henry in 1902 using it for a nail injury (from which she died shortly afterwards from tetanus). Most of the educated world abandoned those beliefs, but a version of the theory persists in homeopathy despite no good theoretical basis, or evidence it works.

Likewise in Chiropractic, there is a battle going on between Chiropractors who simply use spinal manipulation to relieve back and muscle pain (which can be effective in some cases), and those that claim the theory of subluxation works and spinal manipulation can help cure any number of diseases from diabetes to heart disease. There is no evidence (despite numerous studies) to support the theory of subluxation, and yet again practitioners defend the theory as an absolute truth, with no thought of throwing it out or even amending it.

The most extreme example of belief-based heath practice is of course the faith-healer. Recently a very earnest RN sent me a link to this guy (Adam McLeod – the dreamhealer) who claims to be the real thing. She was keen I should attend his show, to see for myself. Now, I admit to a certain degree of skepticism here despite having never seen him work, as these practitioners have been shown to be bogus charlatans over and over again, and he is obviously doing big-business . The usual website testimonials  are present (of the “I was healed by the dreamhealer” variety as well as some from people with postgraduate qualifications). None of this really help dispel the image of quackery. Again this looks like a classic case of exploiting people’s beliefs, particularly when they are in a vulnerable state. Personally, I find this kind of thing highly offensive, and although it is of course possible that  he actually believes he has a gift, I have to consider; what are the odds he really does? The image presented is one of a new-age health guru (complete with mandatory picture with a stethoscope round the neck – to affirm scientific validity). If you were a real believer in your own magical healing powers, why wouldn’t you want to subject this to some empirical trials to show the world this miracle rather than performing private shows at $169 a shot?

Even established nursing organizations condone some of this. An Australian RN colleague Joanne Benhamu, recently tweeted it was embarrassing that North-American Nursing Diagnosis Association (NANDA) still supported the nursing diagnosis of “disturbed energy field” in the latest NANDA diagnostic terms handbook (2012-14). Quite frankly, I find that astonishing and it makes nurses look ridiculous, devaluing the public image of nurses as evidence-based practitioners. That aside from the fact that such a diagnosis is as practically useful to a nurse as the proverbial chocolate teapot. It makes as much sense as diagnosing the patient is “feeling under the weather” or maybe “a bit peaky.” Maybe NANDA would like to add those to its diagnostic statements too? I dispair.

I could go on, but to be frank, it get’s boring, and has no effect on those who believe in this sort of thing despite all the evidence to the contrary. So why do people continue to believe in this sort of thing despite all of the evidence? Worse still why are people happy to be exploited by these sort of shenanigans? It has been going on for centuries, and these folks are still doing big-business. Well, I can understand why the public want these services. As Paul Offit points out in his book, modern technological medical healthcare is far from perfect.  There are many things modern medicine cannot cure, and it is particularly ineffective at helping with many chronic conditions (such as acne, or tendonitis). It is also a victim of its own success. Most patients now receive very depersonalized care with rapid visits for screening, to see physicians or nurses, or for medical and surgical procedures. Also, modern medicine is usually very unpleasant, and as the predominant form of healthcare has rather a significant error rate. Procedures go wrong, people are frequently misdiagnosed, and sometimes people are injured or die as a result of medical practice.

CAM practitioners, on the other hand operate primarily as primary healthcare providers, rarely deal with acute or emergency care, spend considerable time with patients and develop good working relationships with them over long-consultations. Their practices are generally quite non-invasive, often pleasant, and to paraphrase Douglas Adams “mostly harmless.” Likewise contemporary postmodern nursing approaches taught in many Canadian universities are generally supportive of CAM practices so nurses graduate with the notion that these are generally harmless practices, and we should support this plurality. However, we should be clear, accepting a fashionable anti-science agenda and adopting constructivist philosophical arguments about the nature of evidence also has implications for our professional status.  Both homeopathy and opposition to vaccination (naturopaths) are in clear conflict with current EBP, and whilst homeopathy is pretty harmless, opposition to vaccination is certainly not. The “dude, its all good” approach in healthcare can actually result in real suffering, ill-health or worse. That is what academic discrimination is for.

Overall, I think we all want some certainty in our lives, and most practices that support absolute fundamental belief (from religious fundamentalism and cults to modern day magical health practitioners) provide this. Science on the other hand doesn’t provide this or teach us what to think, but focuses on how to think, and sometimes the results can be threatening to our own beliefs and values. Maybe others have some ideas why despite several hundred years of scientific development people still choose faith-based solutions over evidence-based ones, especially with healthcare. I welcome your thoughts.

That wraps up our last post before the summer break as Roger and I are off on various travels for the next few weeks,  but we will be back in September. Have a great summer all (in the northern hemisphere) and a good winter to all you folks down-under: surfs up!

Bernie

References

NANDA (2012) Nursing Diagnoses: Definitions and Classification 2012-14. Available from: http://www.nanda.org/nanda-international-nursing-diagnoses-definitions-and-classification.html 

Offit P.A. (2010) Do you Believe in Magic The sense and nonsense of Alternative Medicine? New York, Harper Collins