Integrative medicine – cat herding for the uninitiated

I confess to having quite a bit of fun by writing letters to medical and scientific journals. The web of course has opened up huge opportunities for this – indeed it was originally designed for scientists to exchange information. One online journal I rather like is MedScape, edited by George Lundberg who previously edited the prestigious Journal of the American Medical Association (JAMA). MedScape has recently carried a number of articles about CAM, and seems to be scrupulously fair in giving all sides a crack of the whip. A recent topic has been `integrative medicine’, which triggered two letters which epitomised the intellectual gulf that exists between the evidence based approach and most CAM supporters. So I bashed in a letter highlighting this. There was a reply from one of the authors of those letters, predictably from the CAM proponent, and I have permission from Dr Lundberg to reproduce that letter here, with my annotations.

Western medicine’s arena is the material “visible” world, meaning what we detect with our senses and our technologies. However, our technologies have also measured the invisible world, such as electromagnetic fields in the retina, heart, brain, and muscles. Is it possible that these fields have more significance than providing Western medicine with diagnostic convenience? And for Les Rose’s (BSc, CBiol, FIBiol, FICR, MAPM) information, even meridians have been measured!! (Meridian-measuring instruments have existed for at least 50 years.) Current software using microcurrent is available through several companies, including Miridia Technology (www.acugraph.com).

While I am flattered by the reproduction of my post-nominals, I am not sure what this paragraph means. Firstly we hear about the `visible’ world, where poor Western doctors dwell, yet scientists can also detect the `invisible’ world. I thought one of the criticisms of Western medicine was its reliance on science. But the key point emerging from this paragraph is that when I asked for evidence of meridians, I was directed to the website of a manufacturer of equipment, rather than to a peer reviewed article. Indeed the manufacturers decline to provide a single item of evidence to support their claims, despite describing the device as `evidence based’. I tried to find some decent articles on PubMed to provide this evidence, but sadly it is so swamped with papers from Chinese journals that such an exercise will take weeks to achieve. If any readers know of any papers showing that meridians exist please let me know.

In other words, we use the same electromagnetic fields for diagnosis that the ancient Chinese, Japanese, Indian, etc, used for both diagnosis and treatment. Is it possible they knew them with an intimacy that is currently beyond us? They didn’t have or apparently need our instruments.

Ah, the usual appeal to `ancient wisdom’. Sorry, but a question is not an answer. I really don’t know what the ancients knew about this, so if you do and have the evidence, do tell.

Many eloquent and brilliant physician-writers, such as Larry Dossey, MD; Deepak Chopra, MD; and Michael Greenwood, MD, have dealt with the limitations of our “evidence-based medicine.” My version is not nearly so learned.

As appeals to authority go this one is not very effective. Do I really need to say much about Deepak Chopra? He who appeared on UK TV last year discussing the essential `rockness’ of a rock? Or about Larry Dossey who writes extensively about the healing effects of prayer (there’s no evidence – look it up). Michael Greenwood apparently writes about “post-modern healing research based on ancient perennial wisdom and the science of quantum physics.” It is curious that we keep hearing about quantum physics in the context of CAM, only in books and in speculative flights of fancy in CAM journals. Do we have even the slightest hint of experimental evidence to back this up? Post modern? Does anyone have the nerve to use this term any more, after the Social Text Affair?

Several years ago, a colleague (neurologist) lamented to me, “Yes, if only we were a fleet of Toyotas.” What he meant, of course, was that practicing medicine would be so much easier if we were all the same, came in with problems that usually reflected only one part’s dysfunction, and could easily get a replacement for the part and drive away “fixed.” However, we aren’t. This model “body as a machine” too often proves less than useful in the medical office, yet we use it, not fully aware that it provides the foundation for what we think of as modern medicine.

The truth is that the mechanistic approach to medicine has been more successful than any other. How else did we render smallpox extinct in the wild? Of course the body is more than the sum of its parts. It is a complex system, with functions that emerge from hugely complex interactions between those parts. This doesn’t mean that studying those parts is a waste of time. I well remember asking Steve Jones about the revolt against `reductionism’. His reply was “Science is reductionism. We can’t try to understand the whole without understanding the parts”.

However, its limitations are most apparent in universities where the “gold standard of double-blind testing” takes place. Studies, intended to discover truths that are based on this model are too often unproductive or yield truths that have been accepted as clinical wisdom for years. That’s because the rarely mentioned simplistic assumptions that support this model fly in the face of common sense.

Do they? Wearily I have to repeat yet again that double blind testing is the bedrock of science itself, not just medicine. What do such studies seek to discover? The homeopath claims that ultra-dilute solutions have therapeutic effects. Is this too simplistic? It’s what the homeopaths claim so ask them. So we conduct a trial that tests the claim. That’s what science is. We don’t detect any effect, so the homeopath says it’s not an appropriate test. It is appropriate for the rest of the universe, so where does that place the homeopath?

These implicit assumptions first include that illnesses are separate entities, all the same. (The word “spectrum” acknowledges the obvious differences of “an” illness without letting go of this assumption.) More assaulting to common sense is that the people who “get” these illnesses are all the same. The gross demographic matches feasible for medication trials do not begin to address the profound emotional, physical, and spiritual differences in how people “handle” disease. Although not “studied,” my impression is that the majority of clinicians would see these differences as significant enough to effect outcome.

These are staggeringly inaccurate assertions. If clinical trials assumed that all diseases and all patients were the same, we would not need to calculate sample sizes or randomise patients to treatments. We do these things because we don’t know everything about the patients or about their disease, but we do know they are highly variable, so we have to compensate for unknown confounding effects.

Double-blind studies also assume that all doctors are the same. Only the treatment “tool,” read drug, counts. One only needs to have a serious health issue to “know,” in more than the intellect, that some physicians are superb, whereas others aren’t. For the former, each patient presents a unique challenge requiring thinking about what processes are contributing to the disease. Other physicians don’t think so much as seek a coded label and follow approved formulas called algorithms. If the formula is not effective, some of these doctors may even get unhappy, either with themselves or the patients. (Like some patients, some doctors believe that when “things go wrong” someone must be at fault.)

Again totally wrong, as anyone (like me) who manages major global clinical trials will know. We have to write protocols to test the hypothesis that the treatment works. Therefore we do the best we can to eliminate other effects. We do this because we know extremely well that physicians vary widely in what they do with patients. We do not dismiss non-specific effects (eg the benefit from the consultation itself), but we are not testing that. We are testing what’s claimed, the effect of the medicine. If someone claims other effects, we can test those and indeed have done in many published clinical trials.

Probably most limiting about this “body as machine” model and its companion gold standard is the unspoken intent of how it has been used. Evidenced-based medicine is a lofty label for a closed system, one that seeks to validate itself by only acknowledging realities that fit within it. That is why those doctors who identify with it can so easily overlook or dismiss the significance of the placebo effect. More than 30% of people get better with a sham treatment — but by a real doctor.

These statements depart progressively further from reality. Evidence based medicine is what it says on the tin. It’s as open a system as anyone wants. If someone makes a claim, we test it. We don’t refuse to test certain claims, we can test anything. Some are more difficult to test than others, but the interesting thing is that, as we get better at testing, the effect sizes of CAM get smaller not bigger. Anyone doing a clinical trial knows about the placebo effect, which is exactly why we do controlled trials. What point is being made here? You don’t need a doctor’s attention, or anyone else’s, to get a placebo effect.

What does this tell us?

Successful treatment involves more than the tool. The doctor’s potential impact may go way beyond the drug or treatment she prescribes. Although that established fact does not fit into this current model, it is a reality that deserves study and not disparagement. Also, many people get better on their own. That also does not fit with the current model. Alas, the essential truths about medicine are not how the body is like a machine, but how it isn’t. Any 5-year-old has discovered that we are mostly self-healing creatures. Someone, way smarter than us, figured out how to make us this way. Maybe we should be studying how we heal.

This is increasingly bizarre. Of course we know about specific and non-specific effects, hence the established methodology of clinical trials. Of course we know that people often recover spontaneously. What is remarkable about this? Life on this planet would not have got very far without such a property. These facts are totally compatible with scientific medicine, because they are science. The mechanisms might not be fully known, but they are not unknowable. The penultimate sentence seems to shed more light on the author’s thought processes than anything else, claiming as it does the existence of an intelligent designer. Such a concept is about as far from science as one can get, with not a jot of evidence to support it.

Finally, are we not already studying how we heal? Medical research is doing just that.

Let me conclude with a message. It’s this – stand up for science. Science is not all there is in life, but it is responsible for most of the material benefits of modern life. If you are a scientist, do what I do and write to journals to correct the sort of wildly inaccurate statements that I have reproduced here. When I do this, I am pleasantly surprised at how much support I get. However you don’t need to be a practising scientist to support science. Contribute to the international web-based community by arguing in favour of critical thinking and positive scepticism. Write to your political representatives in support of real science. You owe it to your children.

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3 Responses

  1. I love your arguments. One of the best examples to me is the modern treatment of Leprosy. Once an incurable disease associated with the wrath of god (His to give and His to take away, according to the Bible – see Chronicles, where King Uzziah was said to have been “Smitten by God with leprosy”). Today we know it is a bacterial disease caused by Mycobacterium leprae and can be treated with a multiple antibiotic regimen. For millennia all the CAM and religion in the world failed to make one iota’s worth of difference to this disease. Today a few little magic beads (antibiotic capsules) and good-bye micro-organism. It is interesting to speculate that if one could go back in time with some antibiotics and cure a few lepers, would you be hailed as the Messiah or burned as a witch?

  2. Thanks – but it’s not rocket science. The arguments are not at all difficult. What I would really like is if no pseudoscientist could publish a letter like that without someone shooting them down in flames. We outnumber them many times over, but the tragedy is that most good scientists can’t be bothered. One of my professional bodies is now awarding Fellowships to chiropractors, and you would not believe how hard it is to get other Fellows to protest.

  3. I’ve written a few eLetters myself, but sometimes the arguments actually are quite difficult: http://ecam.oxfordjournals.org/cgi/eletters/4/1/7

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