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Dilemmas at the heart of alternative medicine

All forms of ineffective treatment, ‘alternative’ or otherwise, pose real dilemmas that are usually neglected. I use here the term ‘alternative medicine’, rather than CAM (complementary and alternative medicine), because things that don’t work are not medicine at all and can’t be ‘complementary’ to anything.

The only distinction that matters is the distinction between things that work and things that don’t work. The term ‘alternative’ tends to be used for things that have not been shown to work, so it is better to avoid words like ‘complementary’ and ‘integrative’ which (quite deliberately) are designed to give the impression that they known to be effective.

The definition dilemma

  • Once any treatment is shown beyond doubt to be effective, it ceases to be ‘alternative’ and becomes just like any other part of medical knowledge. That means that alternative medicine’ must consist entirely of unproven treatments.

The lying dilemma

  • Suppose that a treatment owes all its effectiveness to the placebo effect, e,g. homeopathy (even Peter Fisher almost admitted as much). But in some people, at least, the placebo effect is quite real. It may be a genuine physical response, though one that does not depend on any activity of the drug, or other treatment.
  • If the placebo effect is real, it would be wrong to deprive patients of them, if there is nothing more effective available. For example, if terminal cancer patients say they feel better after having their feet tickled by a ‘reflexologist’, why should they not have that small pleasure?
  • If the foregoing argument is granted, then it follows that it would be our duty to maximise the placebo effect. In the absence of specific research, it seems reasonable to suppose that individuals who are susceptible to placebo effects, will get the best results if their treatment is surrounded by as much impressive mumbo jumbo as possible.
  • This suggests that, in order to maximixe the placebo effect, it will be important to lie to the patient as much as possible, and certainly to disguise from them the fact that, for example, their homeopathic pill contains nothing but lactose.
  • Therein lies the dilemma. The whole trend in medicine has been to be more open with the patient and to tell them the truth. To maximise the benefit of alternative medicine, it is necessary to lie to the patient as much as possible.

As if telling lies to patients were not enough, the dilemma has another aspect, which is also almost always overlooked. Who trains CAM practitioners? Are the trainers expected to tell their students the same lies? Certainly that is the normal practice at the moment. Consider some examples.

The training dilemma

  • If feet tickling makes patients feel better, it might be thought necessary to hire professional feet ticklers who have been trained in ‘reflexology’. But who does the training? It cannot be expected that universities will provide a course that preaches the mumbo jumbo of meridians, energy lines and so on.
  • A good example is acupuncture. It is often stated that one of the best documented forms of ‘alternative medicine’ is acupuncture (though actually it doesn’t work). Certainly the act of pushing needles into to your body elicits real physiological responses. But recent experiments suggest that it matters very little where the needles are inserted. There are no ‘key’ points: it is the pricking that does it. But its advocates try to ‘explain’ the effects, along these lines.
    • “There are 14 major avenues of energy flowing through the body. These are known as meridians”.
    • The energy that moves through the meridians is called Qi.
    • Think of Qi as “The Force”. It is the energy that makes a clear distinction between life and death.
    • Acupuncture needles are gently placed through the skin along various key points along the meridians. This helps rebalance the Qi so the body systems work harmoniously.

    I suppose, to the uneducated, the language sounds a bit like that of physics. But it is not.

    The words have no discernible meaning whatsoever. They are pure gobbledygook.

    Can any serious university be expected to teach such nonsense as though the words meant something?

    Of course not. Well so you’d think, though a few ‘universities’ have fallen for this, to their eternal shame (e.g, Westminster, Thames Valley, Salford, Central Lancashire, Lincoln: see here for more).

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65 Comments

65 responses so far ↓

  • 1 Epidermoid // Aug 1, 2007 at 12:42

    David, I’m an alternative electrician and wonder if you would be interested in having your houses re- wired using my holistic skills? What I do is run my fingers along the wires and so get a measure of the ‘energy’ flowing beneath them (with the switch on of course!) I used to do this by holding wires and pushing them into the sockets but I now realise that this is a silly thing to do. When I detect ‘negative energy fluxes’ in the wire, or find that the people in the house eat dairy products, then I channel my healing positive forces down through what is left of my fingers into the circuitry of the house so that it forces out the bad and cleanses in much the same way as one is detoxed with regular colonic irrigations. You can see that what I am offering is much quicker than all that nasty conventional mess that so called ‘electricians’ make in your home. I’m also an extremely caring person so if that doesn’t clinch it then my remarkably reasonable rates of £1000 per house will certainly impress.

    By the way, I also do kinesiology, homeopathy, reflexology and aromatherapy all at the same time, in isolation, or even combined with the electrical work.

    Makes sense? You know it does.

  • 2 Acupuncture is sham: and more bad reporting // Oct 14, 2007 at 19:07

    [...] is allegedly based is just so much bunk. A typical statement of these was reproduced in the Dilemmas of Alternative Medicine. . . . its advocates try to ‘explain’ the effects, along these [...]

  • 3 It’s Evidence Jim, But Not As We Know It! « A canna’ change the laws of physics // Nov 8, 2007 at 20:52

    [...] Perhaps the author would be better occupied devoting her philosophical skill to overcoming the ethical impediments to this [...]

  • 4 mugsandmoney // Jan 1, 2008 at 22:03

    The term “traditional” is often compounded with “alternative” and this has further dilemmas, since therapies such as acupuncture and herbalism have drastically changed their techniques and terminology in order to stay a) legal and b) trendy.

    I would challenge any traditional therapy to demonstrate any meaningful similarity with the way it was practiced (say) a century ago.

  • 5 mugsandmoney // Jan 3, 2008 at 13:50

    Second comment – I can’t go along with your assertion “That means that alternative medicine’ must consist entirely of unproven treatments.”
    Two examples:
    a) Massage, meditation, stress therapy, etc. Generally classed as “alternative” although sometimes available in mainstream.
    b) MMR. Separate jabs are equally effective but higher risk. This might be classified as “alternative”, mightn’t it?

  • 6 David Colquhoun // Jan 3, 2008 at 14:07

    Sure, the borderline is fuzzy, I wouldn’t say, though, that massage, meditation, stress therapy were “proven”. Indeed most physiotherapy isn’t either. All of these, proven or not, seem more acceptable to me than acupuncture or homeopathy, perhaps simply because they are’t accompamied by a lot of mystical balderdash about meridians an miasms.

    I wouldn’t class separate MMR injections as alternative in any sense of the word. Just unnecessary.

  • 7 Laying on of hands: just tick the box // Jan 4, 2008 at 13:34

    [...] Spiritual healing clearly comes under the heading of  “œdishonest placebo effects”. Nobody is disputing the value to some patients of palliative treatments. The placebo effect can be quite powerful. But is seems the proponents of laying-on-of hands have not considered adequately the lying dilemma [...]

  • 8 Integrative baloney @ Yale // May 16, 2008 at 14:17

    [...] Katz asks, as one must, what should we do if there is no treatment that is known to help a patient. That is only too frequent a problem. The reasonable thing to say is “there is no treatment that is known to help”. But Dr Katz thinks it’s better to guess an answer. There is nothing wrong with placebo effects but there is everything wrong with trying to pretend that you are doing more than give placebos. Perhaps he should consider the dilemmas of alternative medicine. [...]

  • 9 DavidShipley // Sep 5, 2008 at 18:17

    Where are you on psychology? Any science in Freud? I notice the Central Lancashire psychology department had the cheek to line up with the established scientists against the CAM people.

    These quacks seem to get a much easier ride from the “bad science” ranters than the acupuncturists, even though both use theories without biochemical supporting evidence, and the acupuncturists probably have the edge in experimental support, improbable as the ideas about Qi and meridians may seem. Mind you, acupuncturists should distance themselves from some of the real freaks.

    Anyway, I’ll bet you a grand that something will be found in the next 50 years that bears some relation to the whole meridian stuff – we can leave it to each other in our wills. Remember that at no point in time does science know everything – there is a tendency to assume that today is the culmination of the whole of history.

  • 10 David Colquhoun // Sep 5, 2008 at 18:57

    I’m no expert on psychology but I do know that most of those that I meet would be happy to agree that Freudian psychoanalysis is junk pseudo-science.

    A lot of psychologists seem to do perfectly sensible experimental work, and I certainly can’t be classed as quacks There is, though, often a lot of armwaving in the way they try to connect their observations to hard neuroscience.

    One thing I can’t quite forgive psychologists for is their claim to be able to assess the potential of children by a single number. Or, more recently, those who use their knowledge to work for the advertising industry, or even at Guantanamo.

  • 11 Mike Eslea // Sep 5, 2008 at 20:38

    Oh dear, I feel I have to defend Psychology. AFAIK most of the woo has been purged from academic Psychology in recent years. There are few Unis who teach Freud as anything other than a historical curiosity (take a bow, MMU) and most are at pains to try to separate the science of psych from its more dubious applications. I accept we do have a big image problem – few non-psychs really know what psychology is, and even our own students often seem surprised that they have to learn research design and stats rather than just saying “tell me about your relationship with your mother”. But in my cheeky department we have people studying all sorts of useful practical stuff. My main interest (apart from quackery) is school bullying, and what schools can do to reduce it and minimise its effects. Across the corridor is a friend who puts gas rig workers through simulated helicopter crashes, to try to ensure they will survive if they ever have a real one. Down the way, another colleague is working on photofit techniques to improve the likelihood of the police catching and convicting criminals. Another studies the long term effects of illegal drug use, while another is looking at the effects of the pub smoking ban: are people smoking less, and what effect is it having on children whose parents are now smoking and drinking more at home? We have ed psychs improving school life for children with dyslexia, disabilities or mental health problems. We have sport psychs working with elite rowers, golfers and cyclists, to improve their performance. We have health psychs working on eating disorders, occupational psychs studying the effects of stress in the workplace, forensic psychs working on adjustment in prison and how to make rehabilitation more effective. We also have cognitive psychs studying all manner of weird shit just because it’s interesting!

    We are all trying to be scientific but human behaviour is simply MESSY, which makes it much harder to tease out cause and effect. But that is precisely why a good psychologist will tend to be sceptical of woo: we know how easy it is for people to fool themselves, to succumb to biases and prejudice and cognitive dissonance and so on. The psych dept is the proper home for complementary medicine research simply because only psychologists really understand the placebo effect and how to study it.

    Psych is often accused of “physics envy”, because we are supposed to be so desperate to put our dodgy human science on sound theoretical foundations. But if you want to find quacks, try talking to some physicists! I am sure all that cosmology does funny things to the mind…

    But DC is right about Guantanamo. I dearly hope the APA will vote for anti-torture presidential candidate Steve Reisner, and support the anti-torture resolution at their convention later this month.

  • 12 Ben Goldacre’s Bad Science. “Let me tell you how bad things have become // Sep 11, 2008 at 12:00

    [...] bad consequences flow being over-tolerant of lies if you take it too far (he doesn’t).  The lying dilemma and the training dilemma are among them. Some unthinking doctors will refer troublesome patients to a reflexologist.  That [...]

  • 13 BBC2 and the Open University on Alternative Medicine // Oct 27, 2008 at 15:39

    [...] are the central dilemmas of sCAM, as listed at the top of this page. The programme did nothing to solve them, or even to draw attention to [...]

  • 14 pajamapaati // Dec 5, 2008 at 23:22

    “”””””””””””””””””””””””””””””””””””””””””””
    Mike Eslea // Sep 5, 2008 at 8:38 pm

    Oh dear, I feel I have to defend Psychology

    a good psychologist will tend to be sceptical of woo: we know how easy it is for people to fool themselves …
    “”””””””””””””””””””””””””””””””””””””””””””

    Indeed: over in another thread
    http://dcscience.net/?p=258#comment-4694
    David C referred to some work of the late Barry Beyerstein, Professor of Psychology at Simon Fraser University (who they?).

    Some of Beyerstein’s work can still be found in the Internet Archive / Wayback Machine
    http://web.archive.org/web/*/http://www.sfu.ca/~beyerste/
    including an autobiographical sketch here:
    http://web.archive.org/web/20060115042020/www.sfu.ca/psyc/faculty/beyerstein/bio_sketch.htm

    If you’re not already acquainted with Beyerstein’s work I think you’ll be glad to become so.

  • 15 angua // Dec 23, 2008 at 11:34

    mugsandmoney says above re MMR: “Separate jabs are equally effective but higher risk. This might be classified as “alternative”, mightn’t it?”

    A perfect example of the dangers of alternative therapies ;-). Separate jabs are actually potentially harmful compared to the single shot – six separate visits to the doctor may prevent parents from completed the full course for their children, not through badness but through sheer forgetfulness. Also, there is a risk of infection in the interim between shots.

    In fact, the entire premise for separate shots is flawed, and relies on fake science and scare-mongering. Wow! The latest alternative therapy has been discovered!

  • 16 Medicines that contain no medicine and other follies // Dec 30, 2008 at 08:26

    [...] It is sometimes asked, what is wrong with placebo effects as long as the patient feels better? First it must be said that much of the apparent benefit of placebos like homeopathy isn’t a placebo effect, but merely spontaneous recovery. Echinacea cures your cold in only seven days when otherwise it would have taken a week.  But when there is a genuine psychosomatic placebo effect, it can be a real benefit.   As always, though, one must consider the cost as well as the benefit. [...]

  • 17 BMJ Group blogs: HeadtoHead » Blog Archive » The Holistic Prince and Mental Health // Feb 24, 2009 at 09:52

    [...] (so it’s free to access). For a slightly more jaundiced view of alternative medicine in general David Colquhoun’s blog is well worth a look. Posted in EBMH notebook, alternative, complementary. Email This Post [...]

  • 18 rustum // Apr 15, 2009 at 06:26

    Alfred North Whitehead, Britan’s greatest mathematician and philosopher said:

    Nothing is more curious than the self satisfied dogmatism with which mankind cherishes the dlusion of its existing modes of knowledge…

    ..Skeptics and believers are all alike. At this moment scientists and skeptics are the leading dogmatists.

    Advance in detail is admitted, fundamental novelty is banned!

    Look up Roy Rustum PhD of Penn University a scientists, on the web and you will understand what Whitehead really meant. You will be surprised to learn that Rustum does believe and prove that water can be changed with highly diluted remedies beyond the avogadro point.

  • 19 David Colquhoun // Apr 15, 2009 at 07:18

    Oh dear, I don’t think that you have been following the arguments about the work of Rustum Roy, Did you actually read critically his work? It is a sorry tale of duplicated graphs, among other problems.

    I suggest that you should look at
    http://forums.randi.org/showpost.php?p=2909440&postcount=205

    or here
    http://apgaylard.wordpress.com/2007/12/21/deconstructing-a-fallen-star/

    You also neglect that fact that his work can’t be replicated.

  • 20 Lindy // Apr 15, 2009 at 11:06

    @rustum

    Please could you post the reference for your A.N.Whitehead quoataion?

  • 21 andrew // Apr 15, 2009 at 23:42

    “I have suffered a great deal from writers who have quoted this or that sentence of mine either out of its context or in juxtaposition to some incongruous matter which quite distorted my meaning , or destroyed it altogether” A.N. Whitehead, quoted in Michael Moncur’s Cynical quotations #26758, cited on the quotations page http://www.quotationspage.com/quotes/Alfred_North_Whitehead/

  • 22 David Colquhoun // Apr 16, 2009 at 07:33

    Andrew -thanks -that quotation is a real gem.

  • 23 NICE falls for Bait and Switch by acupuncturists and chiropractors: it has let down the public and itself // May 25, 2009 at 16:49

    [...] Once again, we see the consequences of paying insufficient attention to the Dilemmas of Alternative Medicine. [...]

  • 24 Americans spend $33.9 billion a year on alternative medicine | Online Blogging | Web of Blogs // Aug 4, 2009 at 12:14

    [...] Colquhoun. He says that one of the main problems with complementary and alternative medicine is the definition dilemma. It goes like this. Once a treatment is shown to work, it stops being alternative, and becomes part [...]

  • 25 The Faculty of Homeopathy Offer Flawed Answers To Criticisms « Stuff And Nonsense // Sep 6, 2009 at 21:18

    [...] dimension to this – David Colquhoun has written about the “lying dilemma”. Here, Colquhoun writes that: “The whole trend in medicine has been to be more open with the [...]

  • 26 OldNils // Nov 7, 2009 at 08:27

    Paris on a beautiful fall day;

    Dear specialists

    There might be another way of understanding so-called “alternative practices”.

    If we consider the working of living entities, not only from the point of view of their anatomy and physiology but as an information system, then some practices apparently absurd could make sense.

    If our body, our “me” is comparable to an information system, or uses an information system to regulate itself, then it does not matter much how the information is acquired.

    It would also help in understanding why some classical medical procedure that should not have failed have failed.

    The understanding of the working of the NET does help us in understanding the working of the information system of our body.

    If tickling the sole of the feet does provide the system with an information for which it has a response program, then possibly we could use it? I am not sure why I chose that example, possibly because the tickling of the sole of the feet is so essential to us to stabilize our position and inform us about our “position”.

    The one fallacy that my students make is to assume that the information is analysed at the level of the brain, as they tend to make an analogy between a computer and a human being. Of course this is not the case, we do not have a chip ( a brain) that does all the intelligent work and electric cables that bring the information to the chip.

    Most of us remember that very old impressive experiment when a volunteer under slight hypnosis was informed that he had been burned on the arm and consequently developed scar tissues at that place.

    Please log of as from here, as I am going to be rather crude.

    Let a man (not capital M) alone on a bed and he will fantasize about the nearest non available woman, and his body will take that fantasy as a reality and react accordingly, preparing itself for the mating process.

    Our Information Processing System does not have any firm boundary between reality and fantasy. Information if information, and treated at the same level.

    For those of you old enough to have read books in the fifties, a forgotten French writer named Veraldi, wrote a book about a scientist penetrating his own information system to try and cure a cancer inside his body. In those days it was great fun, but there might be something that could be used in that approach.

    Sorry for the length of the comment, put the blame on my old information system which does not tell me when the wine poured into the glass has gone over the rim of the glass.

    OldNils, found by typing “MPR”

  • 27 A Beginner’s Guide To Homeopathy « Stuff And Nonsense // Dec 5, 2009 at 16:55

    [...] to the ethics of prescribing alternative medicine such as homeopathy for its placebo effect, here, David Colquhoun writes that: “The whole trend in medicine has been to be more open with the [...]

  • 28 pohiggins // Dec 31, 2009 at 12:45

    I am curious that this website and that of Ben Goldacre (Bad Science) seem to make little or no mention and no critical mention at all of Psychoanalysis. I wonder why this is. In my opinion it is essentailly a secular religion, with cult like characteristics and no evidence or science base whatsoever. I am not alone:

    http://www.csulb.edu/~kmacd/paper-CrewsFreud.html

    Despite this, it is provided on the NHS, has a base at UCL, why is this difernt from e.g homeopathy? Am wrong? Is there actually some basis for its practice and evidence for effcicacy? I’d like to hear views.

  • 29 David Colquhoun // Dec 31, 2009 at 14:40

    pohiggins

    Thanks for that comment. I expect you are quite right, and it’s an interesting case because always been a bit more academically-respectable than things like homeopathy.

    One of my predecessors in the AJ Clark chair at UCL fought long and hard to stop its introduction at UCL, but sadly he failed.

    I simply don’t know if any of it has been tested empirically, Somehow I doubt it, but I’d be interested to hear if anyone knows better.

    I do wonder how these things manage to find their way into otherwise respectable universities. It isn’t restricted to post-1992s by any means. Southampton has George Lewith, and York has homoeopathy apologists. My suspicion is that this happens because of quality control procedures, rather than despite them. By reducing quality to a mindless box-ticking procedure just about anything can get anything through a committee,

  • 30 Dr Aust // Dec 31, 2009 at 15:56

    I suspect the reason George L has a Chair at So’ton is that he manages to generate a fair bit of research funding, David. As long as CAM is viewed as something that should legitimately be researched, there will be those who have grants to do it, and VCs happy to give them a home – money talks. Lewith is also a prolific publisher, mostly in Alt.Med journals naturally.

    Of course, the problem with Lewith is that, in common with virtually everyone else who does research on CAM apart from Edzard Ernst, he is at heart an advocate.

    Lewith’s official title:

    “Professor of Health Research within the Department of Primary Care”

    – reminds me that, as you have previously noted, one might question why the College of General Practitioners has been so utterly PC neutral-mealy-mouthed, or just silent, about pretty much all forms of CAM. It seems clear to me that this has given tireless advocates like Lewith and the rest of the FIH fellow-travellers leverage. One suspects that most GPs think CAM is largely claptrap, or placebo if one is being polite, but the Colleges dare not say so. One suspects the dead hand of political correctness, though I also suspect they do not want to say anything clear-cut on the grounds that it would alienate CAM-loving patients.

  • 31 pohiggins // Dec 31, 2009 at 17:09

    Thank you David, I too would like to see this taken up as a point of debate (I have also started a topic on BadScience), not only do apparently sensible Universities promote this ‘science’ but the NHS Actively pays for training in it and then employs analysts! so I certainly do hope there is evidence.

    My search of the web and various journals leaves me very clear that neither does the theory make any sense nor does the practice have any effect beyond other therapies, a proper control being tricky.

    The lack of any decent trial means the psychoanalysts can slip through the critical net ‘we’re as good (or is bad?) as the rest’.

    please someone tell me if I’m wrong.

  • 32 David Colquhoun // Jan 1, 2010 at 00:56

    Dr Aust
    “one might question why the College of General Practitioners has been so utterly PC neutral-mealy-mouthed, or just silent, about pretty much all forms of CAM.”

    Well well, I see that the chair of the RCGP has just been awarded an OBE. How unsurprising.

  • 33 Keir // Feb 5, 2010 at 22:48

    I am a little concerned at the way that ‘proof’ of efficacy for a drug or medical procedure (or absence of such in the case of alternatives) appears to be used as if it is synonymous with treatment.

    Treatment is a very different and complex process that involves many subjective steps each carrying multiple variables and sources of potential error or uncertainty. It starts with a particular patient with a number of primary and secondary symptoms, a detailed medical and genetic history, presenting at a particular time and place, being assessed by a particular medic (practitioner) who spends a certain amount of time listening to the patient, examining and thinking about the case, differentially diagnosing before deciding on one or more related or separate pathologies, then attempting to select the treatment strategy that may be most efficacious in this case, prescribing from a range of medications.

    In the case of ‘evidence based drugs’ (as opposed to other treatments, just to keep the point simple for now), it is only at this point in the entire treatment that the ‘scientific trial’ can have any relevance (i.e. that the drug is more efficaceous than placebo).

    Any ‘errors’ in the preceeding steps could render the ‘scientific evidence’ of the efficaciousness of the drug valueless, and at worst it could lead to the reverse effect – harm. (For example where asprin to reduce the risk of heart attack leads to a stroke)

    How many clinical trials check for even a small percentage of the permutations that correspond to the real life scenarios patients in the health care system may pass through?

    Even at this stage treatment has not finished as patient compliance, drug interactions, follow ups, repeat prescriptions, changes to dose or medication all have an effect on outcome.

    Unless each and every stage in the treatment process has been individually trialled for efficacy how can the efficacy of that one step (the drug) be given such prominance? The cumulative effects of small variations in the other treatment steps would surely reduce the statistical significance of the drug study markedly.

    Furthermore, it may well be that some of these steps have the potential for improving patient outcome more reliably and to a greater degree than that ascribable to the drug. For example the hour consultation time given by some alternative practitioners, followed by a ‘no better than plaebo’ medicine, or needles, may (for some people with some conditions I grant) contribute more to recovery than a 10 minute GP intervention where a poor diagnosis may simply be ineffective or harmful.

    I realise it cuts both ways, and I really only want to flag up that continually saying ‘we work with evidence based medicine’ may mask the truth of how complex treatment procedures pan out in terms of real patient experiences and outcomes.

  • 34 David Colquhoun // Feb 5, 2010 at 23:46

    @Keir
    Thanks for your comment, but I’m not quite sure what point you are making.
    It’s clear that much diagnosis is crude in the extreme (specially, but not exclusively, in the central nervous system). Nobody believes that there is a single, well-defined condition called bipolar disorder, or depression.

    One consequence of this is that the reaction to any treatment is not likely to be homogeneous. This is well-recognised but we just don’t know enough to do much about it yet. That doesn’t seem to alter the idea that it is undesirable to use treatments that have not been shown to work under any conditions. I don’t believe that anyone thinks that because something has been shown to work under one set of conditions means that it is universally effective. We know that is not true,

    So are you not perhaps destroying a straw man? I suppose that really just saying that evaluation of treatments is very difficult, but I think we knew that.

  • 35 Keir // Feb 6, 2010 at 18:57

    No I am not just saying that evaluation of treatments is very difficult, I am arguing that evidence based medicine is to some degree an illusion. That it increases the sense of certainty in a treatment and blinds adherents to both its limitations and the possible value of those aspects of treatment that do not have an evidence base.

    Basically, I am trying to reconcile the facts that there is such a high level of iatrogenic illness among evidence based medicine yet such a high level of patient satisfaction from those who use alternatives.

    I am making two linked points that have their concern in the way that the ‘evidence based’ mantra is held as the be-all-and-end-all of medical validation and is used to crudely bash alternative practitioners – probably unfailrly in some cases*.

    Firstly, I am suggesting that because treatment evaluation is difficult the part that is evidenced is less significant than it first appears. For example, Statins (which have received massive press support as the wonder drug) may well lower colesterol in x% of cases by an average of y mmol/L. But following heart attack they only lower the chances of dying from heart attack over 6 years from 8% to 6 or 7%. All this time there are the side effects which are difficult to quantify or even identify. The amount of good and harm being done is unknown and unlikely to be represented by the initial evidence on which they are promoted.

    Is there evidence for benefits from statins? Yes – they reduce cholesterol.
    Do they reduce heart attack recurrence? Yes, but only marginally.
    Do they do more good than harm? We don’t know.
    So where is the value in claiming statins are ‘evidence based’?

    On the statin theme Dr Andrew Banji, consultant rheumatologist at Queen Mary’s hospital, Sidcup, discovered than many of the patients he was treating were actually suffering the side effects of statins, not a primary joint pathology. Once taken off them they reovered. This only came to light when he suffered the same fate himself and took himself off his statins. His patients had suffered a second course of treatment as a result of the undiagnosed statin-induced-arthropathies. Both treatments were ‘evidence based’ and both would have appeared successful when measured against their narrow success criteria (lowering cholesterol & reducing inflamation) but these treatments did not make the patients better – they made them worse.

    My second point is that the aspects of treatment that are not currently evidence based may play a much more significant role. For example in the case of Dr Banji it was pure anecdotal evidence that led to him effecting real benefit for his patients, not the evidence-based statins and arthrhitis drugs. Do you agree that he was being a good practitioner? His methods were not evidence based in these cases. Also, horror of horrors he took his patients off a ‘life saving drug’

    If you are going to attack, say herbalists for working with medicines and methods on the basis of their and their patients’ anecdotal evidence should you not also attack Dr Banji for doing the same?

    To clarify my second point – the reported patient satisfaction with alternatives is often dismissed as simply being a ‘placebo effect’ of simply making the patient feel better or listened to. Such dismissive remarks may be overlooking a very real therapeutic effect, however, and as I suggested in my previous post their effect on patient outcome may be higher than the questionable/marginal evidence based effects of the drug (e.g. statins). Hence it is not impossible that an accupuncturist could have better actual patient outcomes following heart attack over 6 years, compared with the ‘evidence based’ statin treatment. That their ‘Chi-energy’ theories are gobbledegook (as I tend to agree, but not dismissively) would be a moot point, not just because outcomes should speak louder than words, but because from the patients perspective the biochemical explanation of the action of statins is equally meaningless.

    *Medical herbalists, as it happens, claim excellent outcomes for cardiovascular conditions, and always have. The recent evidence of hawthornes efficacy by E. Ernst will not make them any better at what they do, but I suspect it lends them a small berry of credibility in the current evidence-based climate. However, I suggest it is their whole approach to care and patient attention that makes the real difference as it was in the case of Dr Banji.

  • 36 David Colquhoun // Feb 7, 2010 at 00:01

    @Keir
    I really don’t see your point. The fact that evidence is hard to get doesn’t mean that you are free to invent stuff to fill in the gaps. The only alternative to evidence is guesswork.

    I’m the first to deplore commercial pressures to over-prescribe statins, but the current NICE advice seems quite sensible. I don’t take them myself despite my age (73 dammit), because I have never had heart problems and am at fairly low risk. If I’d already had MI I’d probably would take them if the side effects were minimal.

    People have gone to a lot of effort to get evidence in this field and it’s slowly becoming clear. On the other hand the evidence for herbal treatment is infinitely thinner (and yes, I know all the arguments about funding).

    Of course acupuncture etc could be better but there is the slightest reason to think that it actually is, You really should stop inventing things to fill the (enormous) gaps in knowledge. It endangers patients.

  • 37 Keir // Feb 7, 2010 at 22:09

    I am not sure why you don’t get my point.

    I am saying that (some) alternative medicine has been shown to have significant benefit in terms of patient outcome and satisfaction, and that this may be due to the overall care (‘treatment package’) as a whole. (These ideas are well summarised by Paolo Bellavite et al, 2006 in the discussion*).

    That there is little formal evidence base for these alternatives, and that double blind controlled studies are often only weakly supporting at best is partly due to lack of trials, funding and/or appropriate methodology, and partly because controlled trials tend to exclude the real life patient/practitioner interaction at the heart of these practices.

    I am also saying that the ‘evidence base’ for much (not all) of mainstream medicine is far less significant than you imply. Often drugs (like statins) have only a marginal benefit, but an unknown range of side effects (as illustrated in the story of Dr Banji). In some applications statins have an NNT of 100, so 99 patients get the risks/harm for each 1 that benefits. Hence it is reasonable to say they may do more harm than good, despite being ‘evidence based’.

    You say that people have ‘gone to a lot of trouble to gain evidence in this field’ (statins) and that ‘it is becoming clear’. I disagree with the thrust of your argument: There is a great deal of debate around these drugs with many authorities considering they are worse than useless. (e.g. BBC radio 4’s, The Investigation, 03/04/08)

    Furthermore, it is likely that ‘evidenced based’ medicines can lull practitioners into a false sense of security/complacency and lead to a lack of patient care – for example, through a lack of consideration of whether the intervention is really necessary (my father was placed on statins following a heart attack, despite having normal cholesterol levels), and side effects are often under-acknowledged (my father became withdrawn and depressed as a result – the doctor insited that it was nothing to do with the statins. He decided to stop taking them and recovered fully, with no change to cholesterol levels throughout).

    Practitioners without an evidence base tend to take more care and pay more attention to their patients needs, responses and reactions. I am saying that “the best way to care for the patient is to care for the patient” .

    Dr B Golomb of UCSD school of Medicine is highly critical of the supposed gold standard of the double blind placebo controlled trial saying that they are being systematically manipulated under the influence of the pharmaceutical sponsors, with collaboration from the medical profession.**

    Ben Goldacre’s piece in the Guardian makes a similar point about the unacceptable influence of a pharmaceutical company on the labellng of side effects for statins***

    So can we stop the dogma and false posturing that “evidence based” medicine is so superior? It’s far more complicated than that.

    References/links:
    *http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1697745/?tool=pubmed

    **http://video.google.com/videoplay?docid=-7758662442132419447&ei=8f9gSae3HI62iAL-i6naBw&q=Beatrice+Golomb.&hl=en#)

    ***http://www.guardian.co.uk/commentisfree/2009/nov/21/statins-side-effects-ben-goldacre

  • 38 David Colquhoun // Feb 8, 2010 at 11:58

    @Keir
    I think you protest too much. I don’t think many people advocate treatmenst with NNT of 99.

    Neither does anyone I know try to defend the bad practices of some Pharma companies, Quite on the contrary, it is something that I. like Goldacre, have written quite a lot (check my miniblog).

    In other words, Your arguments are largely straw men.

    They seem to me to be unrelated to your bottom line. You say

    “So can we stop the dogma and false posturing that “evidence based” medicine is so superior?”

    My response to that is, if you don’t like evidence, what do you propose to base your judgements on? Guesswork?

    Nonbody pretends that the evidence is complete, Of course it isn’t, but what else can you do but hope to improve it? Efforts to improve it are only hindered by arguments like yours.

    I also find another of your statements quite outrageous

    “Practitioners without an evidence base tend to take more care and pay more attention to their patients needs, responses and reactions. I am saying that “the best way to care for the patient is to care for the patient” ”

    I don’t even know if your premise is true anyway. The physyicians and surgeons with whom I’ve come in contact have been sympathetic and caring as well as well-informed. But if you have something serious wrong you care less about sympathetic care, and more about being cured. When I recently had a ‘small renal mass’ that turned out to be malignant, I wanted it removed as quickly as possible, The fact that the surgeon was sympathetic and caring was an added bonus. What i really cared about was his surgical skills.

    To suggest that all people want or need is tea and sympathy is dangerous and absurd. They want to get better above all.

  • 39 Keir // Feb 9, 2010 at 00:46

    First, the NNT 100 figure for statin use was associated with the USA proposal to treat otherwise healthy individuals as a preventative for CVD, on the grounds of its ‘evidence base’ and we in the UK had a similar proposal that was in the media for weeks in early 2008. Do you remember the medics popping up all over the media to support this proposal on the grounds of statin evidence?

    Business weekly, Jan 2008, ‘Do chloesterol drugs do any good':
    “The drugs are thought to be so essential that, according to the official government guidelines from the National Cholesterol Education Program (NCEP), 40 million Americans should be taking them. Some researchers have even suggested—half-jokingly—that the medications should be put in the water supply, like fluoride for teeth. …And it’s almost impossible to avoid reminders from the industry that the drugs are vital. A current TV and newspaper campaign by Pfizer, for instance, stars artificial heart inventor and Lipitor user Dr. Robert Jarvik. The printed ad proclaims that “Lipitor reduces the risk of heart attack by 36%…in patients with multiple risk factors for heart disease.
    The second crucial point is hiding in plain sight in Pfizer’s own Lipitor newspaper ad. The dramatic 36% figure has an asterisk. Read the smaller type. It says: “That means in a large clinical study, 3% of patients taking a sugar pill or placebo had a heart attack compared to 2% of patients taking Lipitor.”
    Now do some simple math. The numbers in that sentence mean that for every 100 people in the trial, which lasted 3 1/3 years, three people on placebos and two people on Lipitor had heart attacks. The difference credited to the drug? One fewer heart attack per 100 people. So to spare one person a heart attack, 100 people had to take Lipitor for more than three years. The other 99 got no measurable benefit. Or to put it in terms of a little-known but useful statistic, the number needed to treat (or NNT) for one person to benefit is 100.”

    You say “if you don’t like evidence, what do you propose to base your judgements on? Guesswork?”, but who said I don’t like evidence? I don’t think I have said that anywhere! My point throughout has been simply that the evidence you seem to rely on is not as sound as you imply, and that the absence of evidence for the alternatives is not proof of no benefit, for reasons I have outlined. I do not think that you have the right to treat me like some kind of soft-sympathiser simply because you find my points hard to grasp, I am a rational scientist and hope to debate with another rational scientist based on the merit of the arguments.

    PCTs are not the only valid medical evidence. All medics use personal experience and anecdotal evidence from their patients to modify their practice. Are they wrong to do so? How do unexpected drug interactions or novel side effects come to light? – by individual observations in many cases – not 100% reliable sure, but not 0% reliable either. Why then do you dismiss the anecdotal and patient satisfaction evidence for some alternative therapies? You see I am NOT against evidence, just against the demand that only certain evidence counts.

    Didn’t you watch the video link I gave above of the highly respected Prof. Beatrice Golum, presenting damning evidence aginst the ‘gold standard’ of medical research? Or perhaps you might read the New Scientist article by Stuart parkinson et al ‘Stop selling out science to commerce’ (issue2733, 09/11/09)which describes the dire state of funding bias affecting many branches of scientific research, not just medicine. Are you sure that you are not basing YOUR ‘evidence’ on straw men??

    It seems to me that you are willing to accept the current NICE guidelines on evidence for the benefits of statins, but do not seem to care that they offer no comparable analysis of the side effects. Hence you do not know if they do more harm than good! Why are you not shouting for this evidence? Without it the evidence for the benefits cannot be evaluated (=meaningless?). Why are you happy to accept the stautus quo? The fact is that whilst you applaud the gold standard of ‘evidence of efficacy’ you are happy to rely on ‘anecdotal’ evidence for the side effects (yellow card reporting etc) – this is double standards! Where are the PCTs designed to measure the ability of statins to cause joint-pain, or measure the depression or memory loss? How do you accept inflicting these unquantified risks on patients that will not benefit? (even accepting an NNT closer to 10 in most current clinical situations that’s 9 lots of unnecessary and unquantified side effects for each patient that benefits).

    And we are only mentioning statins because this has become a sub-theme in this conversation, however, there are plenty of other examples of dubious evidence based drugs: antipsychotics, NSAIDs, the vast array of high blood pressure drugs, antidepressants (many no better than placebo, and St John’s Wort more effective than many – when was the last time you recommended that herb with its good evidence base?). In the case of antibiotics, how do we quantify the harm caused in terms of creating MRSA?

    As I understand it, in the USA, the FDA will accept drug efficacy based on two positive trials, no matter how many trials show NO effect above placebo! For example in 6 out of 10 clinical trials for prozac no benefit above placebo was detectable, (Moore 1999). Hence, if only a few studies have been carried out for a herb or homeopathic medicine and they show no effect above placebo, you have to accept that more research is needed or damn prozac too!

    Now please don’t think I am saying something other than what I am saying. Of course there is much convincing evidence for medical drugs (e.g. antibiotics for H.pylori with a NNT of 1.1 – that’s much more like it). But much of what you call evidence is partial. Is it better than no evidence at all? Sometimes yes, sometimes no – for example unless the side effects of NSAIDS are fully quantified we can’t say that they are better or worse than nothing. Am I saying that evidence is not good? NO! – I just don’t think that what you accept as evidence is good enough, complete enough, clear enough or free enough from commercial bias to give you the right go around damning minority groups that do not have the resources to participate at this level of play. Question them yes, as I do – I can’t stand unexamined ‘theories’ being speiled off as if that explains everything I need to know about a subject – but you are being dogmatic when you do not have your own house in order. The fact is that you do not have ‘evidence’ that alternatives do not work, you only have evidence that they MIGHT not. Just as you only have evidence that statins MIGHT do more good than harm. This is science. It is always contingent lest we fall into the very dogma we try to denounce. You have to keep the door open. Close the door and you are just another believer, not a scientist.

    If you are really interested in evidence why don’t you use your enviable and priviledged position to encourage real research into the alternative therapies. Instead, because you have a ‘belief’ that they MUST be wrong, that they MUST be unscientific, you point the finger and damn them.

    You seem to deliberately take a distorted and extreme interpretation of my comments, instead of seeing the thrust of my argument which is much more in the middle ground.

    If we are to have a purposeful discussion, which I hope we can, it may be helpful to avoid the extremes. So let me make it absolutely clear that

    (1) I am not opposed to orthodox medicine – it clearly is the primary health care option for many medical conditions and has every reason to be proud of its wonderful achievements.

    (2) I am not naive enough to believe that surgery or most life threatening conditions should be treated by alternative practitioners (except as adjuncts).

    (3) I would prefer all alternative practitioners to be sufficently trained in the medical sciences and skills to diagnose and recognise serious underlying medical conditions, be able to understand a patients prescription and know how to communicate with a patients GP. (Many western medical herbalists fit in to this catagory as do those MDs who practice alternative medicine)

    (4) I do not take all alternatives to be equal, either in their scope or potential.

    So may I correct the charicature you introduced in claiming that I am recommending ‘tea and sympathy': I meant nothing of the sort, and do not think anything I said deserves to be treated as if I did.

    By ‘care’ I am referring to the intelligent and sensitive application of history taking, differential diagnosis and follow up. You know as well as I do that many patients complain that their doctor did not listen to them, or that they feel their NHS experience was like being passed through the mill. You also know that there are very high incidents of misprescription and avoidable injury in the NHS. I am saying that where there is over-reliance on the ‘proven benefit’ of an intervention that this can lead to complacency and fragmentation of care. I could show you hundreds of cases of inappropriate interventions where there was a clear lack of clinical attention, as could any honest medical practitioner.

    The surgeon that treated me when I had a hernia operation phoned me personally when I had an adverse reaction to the analgesics, and monitored me by phone for several days until I was over the problem. He made suggestions of ways I could improve the situation, adjust the dose, try other painkillers. That is care. It helped achieve a better outcome (cure). Not just because it made me feel better, but because he was constantly reevaluating whether a different course of action would be better. I am not talking about tea and sympathy!

    Now, there are many MDs that are homeopaths, and several that are medical herbalists. Others have referred patients to herbalists or homeopaths. Their patient-centred approaches require extended consultation times and careful diagnosis with regular follow ups to adjust the prescriptions. My point is that just because you can’t find convincing evidence for the efficacy of, say, homeopathy in a PCT does not mean that they do not ‘cure’ patients. I am not asking you to believe an unbelievable explanation (‘water memory’ etc) but you must reconcile the very real benefits reported by patients and practitioners. In dismissing these peoples experience you further alienate ordinary people and insult them by treating them as gullible fools. Of course there are real charlatans in every field, but you are being simplistic if you dismiss the entire discipline.

    p.s. I appologise for the vulgarity of using capitals for emphasis, but the comment box on your blog does not offer an alternative!

  • 40 Keir // Mar 3, 2010 at 18:16

    As another example of the ‘dodgy’ evidence base of many conventional medicines, I see that the papers report today on a study that finds aspirin as a preventative ‘may do more harm than good’ – not what we have been advised for the last 20 years! If the last 20 years of evidence were wrong why should we trust the next 20?

    (http://www.telegraph.co.uk/health/healthnews/7351739/Healthy-people-should-not-take-aspirin-to-ward-off-heart-attack-research-shows.html)

    I am pleased to see that Ben Goldacre is honest enough to admit that the problems of conventional medicine are like the submerged part of the iceberg compared to homeopathy.

    (http://www.guardian.co.uk/science/2010/feb/26/bad-science-homeopathy-trials-drugs?showallcomments=true)

  • 41 David Colquhoun // Mar 3, 2010 at 19:41

    @Keir

    You alternative people don’t really get the idea of evidence. The finding that aspirin is valuable for secondary prevention but not primary is a result of large and painstaking trials over a long period, Knowledge increases that way. In alternative medicine you have, in most cases, no decent trials and no evidence, just blind faith.

    Goldacre’s article was excellent I thought. He was talking about advertising, not efficacy of course. He found that 30 – 60% of claims made in advertisements for conventional medicines were not justified by evidence. That is a disgrace. But not quite as disgraceful as alternative medicines where the fraction of claims not justified by evidence is alarmingly close to 100 percent.

  • 42 Keir // Mar 4, 2010 at 23:53

    Thank you David for your persistence in bringing me back to the point again and again.

    I have to say that being involved in this debate on your blog and numerous news article comments over the last few weeks has made me far more aware of the significance of the issues you are raising. The arguments you and Mr Goldacre present have definitely moved me towards accepting the need to look more carefully at the evidence base for all treatment claims.

    I do not consider myself an ‘alternative’ type, though you may, I am just aware that my personal experience as well as that of many people I know tends to support the view that conventional medicine is often crude, crass and impersonal, dangerous, rushed and narrrow minded. This common experience of the HNS vs a visit to one of the better alternative practitioners is compelling, and I think with reason.

    Your attack of alternatives therefore appears to be inflated, and the demand for evidence suggests a bias. However, I do increasingly see what you are saying, and am becoming less and less happy with the wishy-washy arguments of many supporters of alternatives.

    However, it still seems to me that it is not credible to dismiss all the claims of benefit as simply being placebo effects. Even if that is a significant percentage I do not believe you have evidence to dismiss millions of peoples experience so casually – that would require far more proof than a simple ‘paucity of evidence’.

    Of all the alternatives I am most familiar with medical herbalists. The benefits their patients report are certainly real for them. For some the effect is so striking, and in such contrast to their experiences in the NHS that it is little short of a revelation. Many have stories of ineffective drug treatments that have caused them terrible side effects, dismissive GPs who tell them it is all in their mind, botches, accidents and terrible breaches of trust. A proper consultation with a good herbalist and (in a significant number of cases) ‘poof’ they are cured – no more drugs – no more problems. Sometimes they see this repeated for secondary conditions, other family members etc. If you are saying that this is all placebo, then they would say ‘screw you – what do I care? It worked for me, the NHS didn’t – it nearly killed me!’.

    We are not talking about allieviating minor subjective symptoms here, but real palpable ones, verifiabled by their (sometimes astonished) GPs. I can introduce you to individuals who have been cured (rendered symptom free) by a herbalist of moluscum contageosum (all over their body), chichenpox (3 days cleared), odeoma, high blood pressure, arrhythmia, conjunctivitis, eczema, psoriosis, arthrhitis, pneumonia, quinsey, migraines, gastritis, hiatus hernia, kidney stones, rampant cellulitis, leg ulcers & bedsores, benign breast lumps, period pains, deep splinters, lymphoedema, side effects of statins, toothache, glue ear, cramps, infertility, kidney infections, cystitis, foot pain (now off tramadol), insomnia (now off diazepam – withdrawal treated), cholecystitis, pancreatitis, asthma, extensive wart clusters all over body, athletes foot, head lice.

    These are not mere ‘anecdotes’ to the individuals cured – they are the best thing that has happened to them medically in years. They are not ‘lacking an evidence base’ they are 100% evidenced by the person it matters to most.

    If an evidence based drug therapy works in, say, 60% of cases, why shouldn’t the other 40% try an alternative? (That is why it’s called an ‘alternative’ surely?); and what about the numerous conditions for which there are no standard therapies anyway? After all, what percentage of presenting conditions are GPs faced with for which there is no name, treatment or evidence? Why shouldn’t alternatives be tried by individuals in these cases? What gives GPs the monopoly in such circumstances? What about when they say ‘there is nothing more we can do’? If an alternative treatment works in such cases then that has to be better does it not?

    In terms of the patient experience, the bit of the treatment that is ‘evidence based’ in the NHS is often swamped by misdiagnosis, misprescribing, side effects and incompetence. I could write a book detailing hundreds of appaling cases of incompetence and ignorance meated out by NHS practitioners, and I’m sure it would chime true with millions of people across the country who have experienced similar. For these people the ‘evidence base’ of the drug is hardly the issue.

  • 43 Antares42 // Mar 9, 2010 at 18:02

    Dear Keir,

    none of the conditions you mentioned are incurable, in fact many of them are transient anyway. So going on and picking those patients that got better is severely biased at best and disingenuous cherry-picking at worst.

    Don’t understand me wrong – anecdotes are valuable and can point research to interesting questions and they are a necessary part of monitoring established drugs and treatments for side-effects. Anecdotes are one of the sources of the Hey-wait-a-minute moments of research. But they can never be the last word.

    Almost any treatment can be placebo- and sham-controlled, blinded and randomized, including the most intimate patient-practitioner relationship.

    Not doing rigorous research is saying “well, patients are happy, let’s rather not look closely.”

    That said, I am aware that herbal medicine, unlike many if not most other alternative treatments, does have a plausible mode of action.

    It just badly needs to be backed up with better evidence.

    Two more notes: On the ethical implications of administering placebo (drugs or treatments), I am torn between the desire to help people feel better and the conviction that it would be wrong to lie to patients.

    And: If the heart of the problem is the patient-practitioner relationship and the level of personal care, then… why are we not willing to spend more on health insurance (to give our doctors more time) while we at the same time shell out hard earned cash for un- or disproven alternative therapies?

    Deeply intriguing.
    Daniel

  • 44 Dangerous Conventional // Mar 11, 2010 at 09:44

    Some excellent comments Keir. You sound like someone whose looked at both the conventional and natural sides of medicine. Your conclusions are very similar to my own.

  • 45 Eric the half // Mar 11, 2010 at 14:22

    @Antares
    “It just badly needs to be backed up with better evidence.”

    Exactly. Where is all the low-hanging fruit?

  • 46 peterdeadman // Mar 18, 2010 at 22:11

    David C. says “In alternative medicine you have, in most cases, no decent trials and no evidence, just blind faith.”
    I can only speak with any knowledge of Chinese medicine but it seems to me to embody the very best of scientific development. Surely 99% of scientific and practical knowledge derives from observation, experimentation and the intelligent assessment and refinement of results – preferably over a long period of time. Most modern medicine results from this process as does everything from the development of aeroplanes and computers to parachutes (never subject to randomised controlled trials) and just about everything we ever use in daily life. Chinese science has been much neglected in the West but as Joseph Needham has shown, the Chinese pioneered numerous scientific discoveries (and inventions) often many centuries before they were discovered by or adopted in the West. When we encounter ideas unfamiliar to us, or couched in terms/concepts that are unfamiliar and which we do not understand, a good starting point is to look and see who is saying it rather than just scoff and betray one’s own prejudices and ignorance. Many of the greatest minds in China’s impressive intellectual history devoted themselves, over nearly two millennia, to the development and refinement of Chinese medicine. This means that it should be approached with a measure of respect and genuine curiosity. It is an extraordinarily sophisticated and refined medical system, one of the treasures of human knowledge. For those who believe only in evidence-based medicine, acupuncture is well on the road to demonstrating efficacy (see http://www.jcm.co.uk/catalogue.php?catID=691&opener=0-691) for example, while Chinese herbal medicine – a much vaster field than acupuncture – has barely been tested.

  • 47 David Colquhoun // Mar 18, 2010 at 22:26

    You quote me

    David C. says “In alternative medicine you have, in most cases, no decent trials and no evidence, just blind faith.”

    And you say

    Chinese herbal medicine – a much vaster field than acupuncture – has barely been tested.

    So not much disagreement there!

    The point is that observations lead to hypotheses, but until the hypotheses have been tested properly there is no good reason to believe them. Most hypotheses turn out to be wrong.

    We do disagree on acupuncture though. That has been thoroughly tested and turns out to be a rather theatrical placebo in most well controlled experiments. I suggest that you read Barker Bausell’s book.

  • 48 peterdeadman // Mar 19, 2010 at 10:24

    Chinese herbal medicine has been tested through nearly two thousand years of carefully observed use, on hundreds of millions of patients by hundreds of thousands of doctors. Much of that experience has been carefully recorded and handed down through teaching, apprenticeship, textbooks, and – in recent times – hundreds of thousands of articles in Chinese medicine journals. There is absolutely nothing comparable to this kind of medical lineage in the European world. Chinese medicine is extensively used today throughout the modern Chinese medical system, alongside Western medicine. It is only in the context of randomised controlled trials that it has barely been tested, as my comments made clear. Frankly it is just cultural and intellectual arrogance to dismiss it in its entirety without knowing anything about it.
    I also think you are on a losing wicket with regards to acupuncture as clinical studies accumulate on an almost weekly basis Many – though not all – show significant differences between true and sham needling.

  • 49 David Colquhoun // Mar 19, 2010 at 12:48

    All I can do is repeat what I said in a comment in the BMJ

    In view of the well-known fact that 99% of evaluations from China are positive: “No trial published in China or Russia/USSR found a test treatment to be ineffective” [5]. He must surely realise that medicine in China is a branch of politics. In fact the whole resurgence in Chinese medicine and acupuncture in post-war times has less to do with ancient traditions than with Chinese nationalsim, in particular the wish of Mao Tse-Tung to provide the appearance of health care for the masses (though it is reported that he himself preferred Western Medicine).

    5. Vickers, Niraj, Goyal, Harland and Rees (1998, Controlled Clinical Trials, 19, 159-166) “Do Certain Countries Produce Only Positive Results? A Systematic Review of Controlled Trials”. [pdf file]

  • 50 peterdeadman // Mar 19, 2010 at 21:03

    I agree with you about the dubious nature of Chinese studies – though I think that at last they are changing. But I was referring to studies published outside China. And while the publication of unremittingly positive studies in China may well be political, I think that is only one element in the use of Chinese medicine in China. I have worked in Chinese hospitals and my observation is that Chinese people use traditional medicine because it works – often for conditions for which Western medicine has proved ineffective. The simple fact is that Chinese medicine is a vast system that you know little about. Why should you? You haven’t studied it. But you act as though you know everything about it – or rather that having taken a quick look you have cast your opinion and are now trying to persuade everyone to agree with you. You meddle and try and influence opinion on the basis of what authority exactly? Your view is narrow and limited and you model the kind of certainty that most genuine scientists would find appalling – knowing as they do that the certainties of today may be seen as mistaken prejudices just a few years later. I ran a natural foods business in the 1970s and regularly heard the same tone of voice from medical authorities who asserted that diet had nothing to do with disease in general and cancer in particular.

  • 51 redjsteel // Mar 24, 2010 at 01:47

    @peterdeadman
    You show ignorance by speaking about “Chinese medicine” and “Western medicine”. What does Chinese medicine actually entail? Is it medication method developed within the current borders of the PRC? On what ground do you project back political boundaries to cultural developments? If not, then which provinces are you talking about? Or are you talking about Han medicine? Do you really think that different medicines developed in isolation? How do you oppose this to “Western medicine” (whatever it means)? Why don’t you contrast it with Indian, Japanese, Arabic, Maya, whatever medicine (I doubt if any of these have any meaning – they don’t of course)? You are creating an ideological (but not political-ideological) confrontation between two abstract, non-existent polars – to create an irrelevant argument.

    You seem to know very little about “Chinese medicine” when you claim that it is a system. Is it a closed system or an open system? What larger system is it a component of? Would you like to explain the inherent changes in this system? You cannot, because what is called “Chinese medicine” is not a system, but independently assumed elements connected by external and arbitrary assumptions. Hence the contradictions between its recommendations. It is mechanistic.

    It is impossible to say anything about your claim “it works – often for conditions”. What is the mechanism in which it works? What does often mean? What do these two claim mean to prove? You state only the predicate – where’s the rest of the proposition?

    Indeed science starts with observation. And observation is very valuable. But observation also include theoretisation – even at an elementary level. They are separate only in mechanistic fantasies. Human activity is teleological, it needs theoretical assumptions, which also include mechanisms. So, in two thousand years (if we take your word for this – are you suggesting that it grew from nothing? Why do not we go back to the neolithic? Or further? Nothing shows more the mechanistic thinking than saying that an observation based method is two thousan years old) this medicine has not managed to eliminate theoretical contradictions and conflicting predictions (medical recommendations) through the many millions of cases – what does it tell you?

    For me – the burden of proof is on those who make the claim. Until then it is sufficient to me that no theoretical/practical framework is proposed in which the mechanism works, hence it is protoscience at the best – considering the length of time and the number of cases you suggested, it is unlikely to progress from this stage.

    As to the last sentence – I really don’t know what to say. Relationship between “the” diet, “the” disease, in particular “the” cancer…

  • 52 peterdeadman // Mar 29, 2010 at 11:28

    redjsteel

    I find your response very metaphysical and often opaque. It reminds me of the one about what do you get when you cross a French philosopher with an Italian mafioso. Answer: you get an offer you can’t understand.

    A few comments:

    Yes I think there is such a thing as Chinese medicine which is distinct from all other forms of medicine (though it may share similarities with many, partly through cross-fertilisation). Just as there is in fact Indian medicine (ayurveda) and Tibetan medicine and Japanese medicine (mostly being a variant of classical Chinese medicine). I don’t think Chinese medicine is uniform or monolithic but is expressed in different theories, techniques, treatments that depend on place and time in its history. But there are certain underlying principles and theories common to all these different forms – yin-yang, the five phases, jing-qi-shen and their different manifestations in the body and the universe, pathogenic evils, the use of herbs – mostly in formal prescriptions etc. etc.

    Whilst knowing the mechanism (whatever you might mean by that) of how Chinese works is important, it is not necessary, any more than knowing the mechanism of oxygen exchange is essential for breathing. You seem to question whether Chinese medicine has theorisation. Of course it does. It’s just that its theories are different from those of Western medicine/science.

  • 53 David Colquhoun // Apr 1, 2010 at 11:33

    @peterdedman
    Your last comment is as good an illustration as any of the problems of the alternative world. It says, in effect, that it is quite OK to believe several mutually incompatible things at the same time. A perfect illustration of the “parallel universe” school of thought.

  • 54 redjsteel // Apr 7, 2010 at 01:04

    @peterdedman

    It’s not very nice to accuse me with an opaque comment, when in your comment you paraphrased Hegel (“he can digest without studying physiology” – Encyclopedia, Preliminary, II) without referencing ot, especially as this unjustifiably unfashionable gentleman would have been horrified with the logic that you presented, even though he wrote probably the most opaque philosophical works ever.

    TCM as you described is not a medical artifact, but a philosophical (or if you want, cultural) one, thus my points were perfectly adequate. I tried to show that the arguments that you presented are non-scientific, non-logical once they are removed from a very contextualised frame that appeals to feelings (prejudices) rather than reflections. However, I try to present the argument in a much simpler form:

    Firstly, traditional medicines, being Chinese or whatever, attempt to identify treatment from symptoms, as they cannot identify causes (unfortunately it happens with modern medicines too, however, crucially, it is a problem and not a virtue in modern medicine) – just think of extremely different illnesses (by etiology, for example) with quasi-identical symptoms. Secondly, they bring in irrelevant factors, e.g. the particular herb is harvested at the Xth full moon after the spring equinox is useful for… (in contrast with theoretical approaches that abstract from the accidental influences). While the maturity of the plant may have an impact, but the full moon is a simple optical phenomenon. Third, they have competing recommendations for relatively simple collection of symptoms in terms of the type of active ingredients or treatments, which full moon after the spring equinox, etc without an attempt to critically engage with the competing treatments. (The critical engagement with competing explanations is a sine qua non of not simply scientific, but theoretical arguments). In modern medicine we are not discussing alternative (disproved) treatments for certain illnesses because the practice based on theory deselected them, while in TCM completely incompatible alternatives to identical health problems remain the norm. Fourth, traditional medicines (as your comment shows) are based on the separation of theory and practice. As a result, TCM’s practice has to rely on inductions based on isolated observations that may or may not be correct and may only occur once, while its theory has to become more and more dogmatic and irrelevant to practice. From the point of view of TCM the success or failure of a particular treatment is completely irrelevant. It cannot change the “theory” and it cannot verify itself. It is modern medicines (science) that can do this by ignoring the “theory” of TCM and subject the practice of TCM to its own critique. Through this criticism it can lift out from the practice of traditional medicine what is useful and de-contextualise it – hence make these parts: medicine. TCM cannot do this, because it is not a system (therefore it is not science and it has no theory): it is different bits brought together by arbitrary assumptions, while explicitly excluding the critique of these assumptions.

  • 55 Homeopathy Awareness Week 2010 « Stuff And Nonsense // Apr 11, 2010 at 19:57

    [...] Dilemmas at the heart of alternative medicine. [...]

  • 56 It’s Evidence Jim, But Not As We Know It! | CAMcheck // Jun 25, 2010 at 20:56

    [...] Perhaps the author would be better occupied devoting her philosophical skill to overcoming the ethical impediments to this [...]

  • 57 ivandominique // Feb 9, 2012 at 09:16

    I think that your argument is incomplete and biased. A placebo,by definition, doesn’t have any effect on the condition being treated. A placebo effect then is a psychological phenomenon. If a less understood psychological phenomenon can produce a beneficial effect on a condition, it means that our knowledge about the condition and its varied contributing factors is incomplete. This creates a dilemma even in conventional medicine. The dilemma here is that of denying patients undergoing conventional treatment,a possibility of recovery as we don’t understand how placebo effect works. We have the knowledge that at times placebo effect works. So when we deny patients of this possibility, we are in effect cheating on patients. Hence the dilemma that you have mentioned applies to the whole field of medicine, where placebo effect seems to work.

    Therefore the dilemma should be framed in a different way. The same ethical dilemma is encountered in medical research that actually provides placebos in place of medicines being tested to participants. We don’t inform the participants whether we are giving placebos or actual medicines.

    Hence, i find your argument incomplete and biased.

  • 58 David Colquhoun // Feb 9, 2012 at 11:06

    @ivandominique
    I agree entirely that the ethical dilemma about what to do about the placebo effect applies equally in (real) medicine. In fact I”m not sure what you are criticising,

    There is no ethical dilemma in using placebos in trials, as long as the procedure has been explained properly to the patients. If it were not possible to use placebos in trials, we’d never know whether anything worked or not.

    Is your comment advocating the view that RCTs are unethical (that’s a common argument used by people who advocate treatments that fail RCTs)?

    If the treatment works better than placebo, then, of course you get the placebo effect too, as a sort of free bonus. The problem arises when the treatment does not work better than placebo. In that case, are you justified in concealing that fact from the patient? I maintain not, but there is room for argument about this point.

    Recent developments may make these arguments less important than at the time this was written. First, it seems that patients can get benefit even when they are told the pill is a placebo. Second, and far more important, it seems to be emerging that the placebo effect is smaller and more transient than originally believed. Most of the apparent benefit of ineffective treatments seems to be regression to the mean, rather than a placebo effect. For example, a recent non-blind trial of acupuncture showed that acupuncture ineffective, and didn’t even elicit any worthwhile placebo effect.

    Insofar as placebo effects are small and transient, the whole argument goes away. It leaves no justification whatsoever for using ineffective treatments.

  • 59 ivandominique // Feb 9, 2012 at 13:14

    @David Colquhoun:

    My only criticism was that the argument sounded as if the dilemma was specific to alternative medicine. There was no acknowledgement of a similar dilemma that arises with placebo effects in conventional medicine.

    No, I’m not against RCT. In blind-RCT, we do conceal some information from the participants and leave them in the dark as to the constituents of the treatment. I sensed a similarity to the way some alternative medicines work in real settings (& not in trials).

    And I’m also not quite sure what you mean by the training dilemma. It is a dilemma only for people who don’t believe in it. If you take the view point of some one who believes in it, they are only teaching what they believe in. To them, it is not a lie. It is the same thing creationist complain about the evolutionary world view and vice versa. The only way out of this is through open dialogue between the factions that allows constant growth. And the principle of liberty demands that every man finds his own truth. So what we can demand of educational institutions is to develop critical thinking abilities that will allow a person to find his own truth.

  • 60 David Colquhoun // Feb 9, 2012 at 17:29

    @ivandominique
    Again, I agree up to a point. The word “lie” implies that somebody is deliberately telling untruths. My experience of talking to homeopaths is that most of them seem to believe quite genuinely in their own brands of magic, however batty those ideas seem to the rational world. In fact that’s precisely why, on this blog, I aim much more at vice-chancellors who allow BSc degrees to be awarded for learning things that aren’t true, than I go for the practitioners themselves.

    When it comes to high powered supplement salesmen, I’m often a lot less sure that their motives are honest, but their facts are, only too often, equally wrong.

    I don’t want to make homeopathy, or creationism illegal. If people wish to ignore all the principles that have, over the last 400 years, brought us out of the dark ages, they are free to do so. I just object to universities, of all places, being complicit in such daft ideas, just because a handful of vice-chancellors value bums on seats more than they value science.

  • 61 RB // Feb 9, 2012 at 17:30

    “To maximise the benefit of alternative (also read) and allopathic medicine, it is necessary to lie to the patient as much as possible.” I certainly have been “lied” to many times by doctors, healthcare professionals and surgeons.

    My opening thought is that for many years science derided yogis, mystics and occultists, all “kings of woo” who taught that matter could exist in two places at once and that the observer affected the experiment, they were derided and laughed at by “scientists” until scientists caught up and learnt through physics that actually what we have taught for thousands of years was true. We will wait for you to catch up with our latest thoughts when you are ready.

    A number of other things things occur to me here.

    1 Who decides what is “truth” and what is a “lie”.

    2 Given the subsequent dubious history of some previously “respectable” clinical trials and treatments the testing regime is clearly subject to corruption or is sometimes deliberately skewed to give the answer the researchers seek in all types of science, therefore it is also suspect.

    3 Given the fact that many existing allopathic treatments have had a treatment record as dismal as “alternative” medicine over the years. (Stomach ulcers comes to mind where the treatment for decades from science based consultants was “drink milk” and take antacids, also the Thalidomide scandal) tells me that many august medicinal practitioners and consultants and their ilk have often been practising “woo” for decades.

    4 Following the discoveries in recent years of the failures in some parts of conventional medicine then it to has been practising much “woo” for many years at very high salaries and rewards. Must not “attack” it though after all it is based on good scientific practice at taxpayers expense is it not ?.

    5 For someone who is ill there is not alternative or non alternative medicine their is only what works, if allopathic medicine was so brilliant and had all the answers there would never have been a market for CAM.

    6 This site does not create a collegiate atmosphere where all sides can discuss the whole subject of health and science in a positive atmosphere it just “attacks” and “derides” different points of view and interpretations of “science” to its own.

    7There is a respectable debate taking place with regard to what constitutes scientific proof and the nature of trials and testing that the tone of this site does not serve well nor seriously acknowledge.

    8 Given the failure to equally acknowledge the above in allopathic medicine it appears to be a site for the venting of personal viewpoints and much vitriol against science that is deemed “unacceptable” or is just “woo” by its backers/creator. Given the tone and style of language used it certainly shuts down debate and generates fear or at best an anticipation of scorn and derision levelled at some people and in those it seeks to discredit. This is clearly thought to be a very humane, mature and grown up attribute by those who use it and which I have seen used by those who are convinced they are “right” many times in polemic debates.

    9 This site is clearly one sided and the truth always lies in between two sides so I don`t expect to find or anticipate finding a balanced argument or mature debate here of the pro`s and cons of both sides.

    10 It is a useful tool for me as a Healer, I do insist my students to visit this site, it is part of the curriculum to examine its style, approach, arguments, content and rigorousness of its arguments, along with many other anti, neutral and pro science based research sites. This is so that when they start to learn and practice they can discern between the different types and styles of scientific debate and research and that which dresses up as science and “psuedoscience”. Given that many of my students have had high level scientific degrees I trust them to be able to discern what is good science and what is not, after all one must first research the researchers before designing ones own research trials.

    11 This will be my only contribution I don`t have the resources to rebut or research much of what is claimed and written on here.

    12 Being a practitioner of “woo” I also don`t anticipate my opinions being treated with any respect or politeness, after all I am clearly mistaken, delusional, defective, mentally inferior, academically flawed and not very intelligent. That after all is how I am likely to feel given the thrust, tone, language and inference of the arguments presented here.

    Fortunately I am able to understand that all of the above site is just your / a “point of view”. Many of those sincerely working to help people through the use of “woo” may not be able to see that and are likely to be offended, feel attacked and disrespected. Very positive that is. Good luck in your work and approach you will drive CAM underground if you succeed in driving it out of mainstream life and the your version of “woo” will reign supreme. Truth has eternal patience.

    RB

  • 62 David Colquhoun // Feb 9, 2012 at 18:08

    I don’t like censorship, so I’ve posted another long comment from “RB”, despite his being on the moderation list.

    It can sometimes be useful to debate things with, say, herbalists or nutritional therapists.

    But people such as you, who advocate astrology, psychics and clairvoyance, are so far from any sort of science or rationality that it scarcely seems worth debating. The vast majority of the population (including me) regards those subjects as more suitable for stage acts and fairgrounds that as serious topics.

    Most of your arguments are, as always, straw men, or based on simple misunderstanding of physics (as in “two places at once”). One example will do. You talk about stomach ulcers. Yes, of course, for many years, the true cause was not known. Then, as a result of serious research, by serious scientists, it was eventually discovered. The result was so surprising that it wasn’t universally believed at first. But they produced good evidence, and as the evidence built up, they were believed, and ended up getting a Nobel prize.

    It is a superb example of how science works. It changes, develops and improves. It is the fact that the alternative world doesn’t care about evidence that keeps it trapped in the dark ages.

  • 63 dbdouble // Nov 18, 2012 at 13:45

    The trouble is that too much of modern scientific medicine is also “effective” because of the placebo response.

  • 64 mhammer // Aug 2, 2014 at 08:48

    While I appreciate all the contributions and patient sacrifices made to improve allopathic medicine, I don’t see in this body, equal attempts to really understand and grasp what Chinese medicine brings to the table. I know its frustrating to grasp a holistic knowledge that has been around more than 2000 years, as well as sift through all of Chinese medicine’s explorative processes in an attempt to find the truth. However, I ask you all to be patient for the nuggets to come forward from the more scientific brethren who will show evidence that the practice works. As you may know the first wave of English speaking practitioners who learned from the Chinese masters are just coming forward to reveal their findings. The way Chinese medicine is taught in many of the American and European schools is not the same Chinese medicine taught in China. For instance, In China, students are not taught that acupuncture is the primary lead regimen. In fact, it is one of the last remedies provided.

    Traditional Chinese medicine leads, after an assessment is done, with appropriate diet that counters their underlying imbalance, the 2nd tier is to provide exercise that meets their capability (TaiChi, QiGong), 3rd, is the use of herb formula, not just single, simple herbs which usually are ineffective by themselves but formulas which practitioners in the past and continue to find, daily, to be impactful. There are many formulas which have been given up on just like pharmaceuticals that were found not as beneficial. However, there are the select 10% of formula that work. And then there are the 5% which are incredibly effective and most in this group show corrective results in 90 minutes. In the billion$ research done, I did not see those experimented with and I really wonder who they were talking to about their choices.

    When I look at the research coming through now, I am beginning to see some of the effectiveness shine through. Its, also, heartening to see that when we combine allopathic and traditional Chinese medicine, great outcomes can be found. Below, is one example of many, where both camps work together in harmony. While I think there are more effective Chinese medicine for hypoglycemia, its at least, a start.

    http://www.ncbi.nlm.nih.gov/pubmed/23460810

    Efficacy and safety of traditional chinese medicine for diabetes: a double-blind, randomised, controlled trial.Ji L1, Tong X, Wang H, Tian H, Zhou H, Zhang L, Li Q, Wang Y, Li H, Liu M, Yang H, Gao Y, Li Y, Li Q, Guo X, Yang G, Zhang Z, Zhou Z, Ning G, Chen Y, Paul S; Evidence-Based Medical Research of Xiaoke Pill Study Group.Author information

    AbstractBACKGROUND:

    Treatment of diabetes mellitus with Traditional Chinese Medicine has a long history. The aim of this study is to establish the safety and efficacy of traditional Chinese medicine combined with glibenclamide to treat type 2 diabetes mellitus.

    METHODS:

    In a controlled, double blind, multicentre non-inferiority trial, 800 patients with unsatisfactory glycemic control (fasting glucose 7-13 mmol/L and HbA1c 7-11%) were randomly assigned to receive Xiaoke Pill, a compound of Chinese herbs combined with glibenclamide, or Glibenclamide in two study groups – drug naive group, and patients previously treated with metformin monotherapy (metformin group). Outcome measures at 48 weeks were the incidence and rate of hypoglycemia, mean difference in HbA1c, and proportion of patients with HbA1c<6.5%.

    FINDINGS:

    In drug naïve group, the total hypoglycemia rate and the mild hypoglycemic episode in the Xiaoke Pill arm were 38% (p = 0.024) and 41% (p = 0.002) less compared to Glibenclamide arm; in Metformin group, the average annual rate of hypoglycemia was 62% lower in Xiaoke Pill arm (p = 0.003). Respective mean changes in HbA1c from baseline were -0.70% and -0.66% for Xiaoke Pill and Glibenclamide, with a between-group difference (95% CI) of -0.04% (-0.20, 0.12) in the drug naïve group, and those in metformin group were -0.45% and -0.59%, 0.14% (-0.12, 0.39) respectively. The respective proportions of patients with a HbA1c level <6.5% were 26.6% and 23.4% in the drug naïve group and 20.1% and 18.9% in the metformin group.

    INTERPRETATION:

    In patients with type 2 diabetes and inadequate glycaemic control, treatment with Xiaoke Pill led to significant reduction in risk of hypoglycemia and similar improvements in glycemic control after 48 weeks compared to Glibenclamide.

    PMID:

    23460810
    [PubMed - indexed for MEDLINE]
    PMCID:
    PMC3584095

      

  • 65 David Colquhoun // Aug 3, 2014 at 20:54

    @mhammer

    You make a brave attempt to defend Chinese medicine, but the sad fact is that 100 percent of trials that are published in China (and in Russia) come out positive [download pdf].  That carries the strong suggestion that the results are more to do with politics than with truth.  

    Of course it’s true that a few useful compounds have been found in Chinese herbs, as in other plants.  Ephedrine was one, though that is now thought too dangerous to be used, even in a controlled dose, never mind the unknown dose that you get from a plant.  The only real success is the anti-malarial, artemesinin.  But to give that as a herb would be disastrous. because there is no control of the dose when given in the way used by TCM practitioners.  A sub-optimal dose would guarantee the rapid development of resistance.  It became useful only after the active principles had been isolated and purified so the dose could be controlled.

    You can find more details at http://www.dcscience.net/?p=169

    I’m afraid that your assertion that 10% of Chinese herbs work well is entirely made up. I’m not aware of any evidence at all for such an assertion.  The appeal to tradition doesn’t work either. If western medicine had developed that way, we’d still be using blood-letting. Both western and Chinese medicine had their origins long before anything whatsoever was known  about physiology, and even longer before anything was known about how to conduct fair tests of efficacy.  It’s not surprising that very few of the early ideas worked.  But western medicine moved on and developed things that do work. Traditional Chinese medicine remained traditional, and largely untested.  It makes as much sense to advocate TCM in the 21st century as it would to advocate mediaeval western medicine.

    Neither is it fair to China to suggest that they are stuck in the dark ages.  China has produced excellent science and scientists. Chinese people who can afford it naturally prefer medicines that work rather than ill-defined mixtures of untested herbs.  I can see no reason to change my definition 

    • Herbal medicine: giving patients an unknown dose of an ill-defined drug, of unknown effectiveness and unknown safety.

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