Say it ain’t so, Dr. Pho! Credulity towards alternative medicine on KevinMD

Say it ain’t so, Dr. Pho!

Back when I first started blogging over six years ago, one of the first medical blogs I came across was KevinMD, the weblog of one Dr. Kevin Pho. Back then, of course, Dr. Pho’s blog wasn’t anywhere near the medblogging juggernaut that it is now, a part of Medpage Today. Indeed, Kevin was one of my early influences, although, as you can see, I never managed to get the whole brevity in writing thing down. Or the whole commercial savvy thing, either. Or the team blogging thing, either. Respectful Insolence was and remains a one man operation (or one Plexiglass box of multicolored blinking lights operation).

In any case, I always thought that Dr. Pho was one of us, at least when it comes to opposing the pseudoscience in medicine that goes under the name of “complementary and alternative medicine” (i.e., CAM) or “integrative medicine” (i.e., “integrating” quackery with science-based medicine). Yet lately the inimitable Dr. Pho seems not to be guarding the chicken coop. There have been some posts by guest bloggers that not only show a disturbing credulity towards pseudoscience in medicine but pretty fuzzy “reasoning.” For example, in this post by Roberta Bivins, we find this pearl:

For example, in contemporary biomedicine, it is conventional to separate the mind and the body when designing a medical experiment: hence the rise of the double-blinded random controlled trial as medicine’s ‘gold-standard’ of proof. Yet physicians and researchers simultaneously acknowledge the impact of the mind on bodily processes. They call it the ‘placebo effect’. As understandings of the mind-body relationship become more sophisticated, it is possible that the blinded RCT will fall from favor, as a limited test of therapeutic activity which obscures an important variable.

Uh, no. The rationale for using placebo controls is not because we “separate the mind and the body.” What utter twaddle! Indeed, this is the same sort of nonsense that Mike Adams regularly parrots. The rationale for using placebo controls is because there is a large body of evidence supporting the existence of placebo effects and nonspecific effects that need to be controlled for. It is not necessary to posit that there is a separation between the “mind” and the body to accept and control for placebo effects in randomized clinical trials. Far from it! After all, recent advances in brain imaging and functional MRI have allowed neuroscientists to visualize the regions of the brain that are involved in placebo effects with no need to invoke mind-body dualism at all to account for them. Let’s just put it this way. Double-blind, randomized clinical trials are not likely to be going anywhere any time soon.

I also note that Bivins is known for being very sympathetic to unscientific medical modalities. Indeed, a recent NEJM review of Bivins’ book concluded that Bivins characterizes “Western” physicians past and present as “mostly predatory and misguided” and “questions why researchers continue to assess treatments from other cultures in a Western framework.” Silly me! I always thought that there was no “Eastern” or “Western” medicine; there’s just science.

For shame, Dr. Pho, for letting such a person blog for you!

Unfortunately, last week, I saw the worst example in a long time of a post utterly lacking in skepticism towards CAM in the form of a post by guest blogger Dr. Peter J. Weiss entitled Why alternative care seems to work. Of course, this could be the topic of a very good post. In fact, I’ve written about this very topic many times before. Confirmation bias, confusing correlation with causation, regression to the mean, all these things lead to a mistaken impression that CAM modalities such as homeopathy “work.” If Dr. Weiss could have concisely explained these factors and how they can contribute to the illusion that CAM “works,” then he would have done Dr. Pho’s readers a service. He didn’t. What he did instead is to invoke some of the hoariest pro-CAM canards out there. In essence, his article is based on the all-too-often used premise of CAMsters that just because we don’t understand the mechanism by which various CAM modalities “work” does not mean that they aren’t valid. It’s kind of sad, because Dr. Weiss starts out reasonably:

Suppose I believe that light is a liquid, and it travels in pipes in the wall. And I believe that when you turn on the light switch, the light travels up the pipes in the wall, over the ceiling, and comes out of the light bulb and radiates/evaporates light into the air. Is that true? Is that a good explanation of light? Probably not! But that doesn’t mean that the light switch doesn’t work for me. If I turn on a light switch it’s going to work no matter what I believe about how the light comes out of the fixture in the ceiling.

And it’s true. Scientific medicine works whether you believe in it or not. the prototypical example of this is the observation that antibiotics will treat infections quite effectively even in comatose patients. They’ll also work in patients who believe that their infection is a result of evil humors or miasmas. That’s because antibiotics have a defined mechanism of action. We understand it. We know how antibiotics work. We know which bugs they kill. We know what proteins or molecules in the bugs they target. In brief, science, it works, bitches! Unfortunately, Dr. Weiss draws precisely the wrong conclusions:

The same is true, I think, of acupuncture, which is another common modality — increasingly common in the western world — that was really developed in ancient China in a prescientific era. The Chinese developed these theories of energy flow (or Ch’i) in the body, along channels related to meridians; and all of that define the practice of acupuncture.

There’s no scientific basis for any that. None of it can be measured as far as we know, in our scientific world today. That’s a totally separate question than, “Will the practice of acupuncture help my pain get better?” or help me feel better, or help me with my problem. And many, many people are accepting that acupuncture works for them. It doesn’t mean necessarily that it works in the way that it has been traditionally explained for thousands of years.

Except that acupuncture, as it is practiced today, is not really thousands of years old or steeped in antiquity. More importantly, Dr. Weiss puts the cart before the horse. Yes, there are a number of science-based medical interventions for which we don’t know the mechanism of action. However, in general, before seeking out a mechanism of activity for an effect of an intervention we first make sure that there actually is an effect due to that intervention. For acupuncture, as I’ve described time and time again, the better the clinical trial, the more rigorously controlled it is, the smaller the apparent effect is, until that effect disappears in the largest, best-controlled acupuncture trials. After all, it doesn’t matter where you put the needles or even if you put them in at all. In fact, you can even twirl toothpicks against the skin, and acupuncture “works.” In other words, acupuncture is placebo medicine.

Dr. Weiss takes this gambit to an annoying extreme when he mentions the drug Lunesta and how at the end of Lunesta commercials there is one of these disclaimers: “The mechanism of action of Lunesta is unknown” or “How Lunesta actually works is unknown.” He then likens this to acupuncture:

Or, “We just don’t know how this stuff works basically.” So, this is a widely prescribed drug, market leading drug, many many doctors are writing for it, the drug company is making it, the FDA has approved it, and no one knows how it really works! We just know it helps people sleeps. That’s okay.

Transfer that theory into alternative care. We don’t know how all those practices work either but they seem to work to help people. So free up your mind a little bit. Don’t get hung up by explanations that don’t make sense to you. If you think the practices are safe and they might help you, open your mind a little bit give them a try. Leave the explanation behind and do what works for you.

I suppose I should be grateful for small favors in that Dr. Weiss spared me the the usual example preferred by CAMsters, namely aspirin. The usual story goes that doctors knew that aspirin worked to relieve pain and decrease fever but didn’t know the mechanism, which wasn’t worked out until long after aspirin use had become widespread. The Lunesta spin is a different one than the ones I’ve heard. In any case, here’s the difference. Even when we don’t know the exact mechanism, in general we know that there is a plausible scientific mechanism for drugs like Lunesta. They are, after all, chemicals and presumably they bind to some receptor or other protein or intracellular molecule and thereby exert their effects. Also, we aren’t entirely in the dark about the mechanism of Lunesta, even if ewe don’t know the exact mechanism, and we do know that they work.

In marked contrast, for the vast majority of CAM modalities, including acupuncture, the mechanism proposed is, as Dr. Weiss points out, completely unfounded in any science. Homeopathy, for instance, violates numerous well-established principles of physics and chemistry, and, for it to work, science would have to be not just wrong but spectacularly wrong about much of what we understand about physics and chemistry. In other words, for drugs like Lunesta there are scientifically plausible mechanisms by which they work. For something like homeopathy or acupuncture, not so much, and likening highly implausible CAM modalities to science-based medical interventions in terms of a lack of a known mechanism is fundamentally deceptive. His argument is, in essence, “We don’t know exactly how Lunesta works. We have no idea how acupuncture ‘works.’ They’re alike! So let’s use both of them!”

Moreover, Dr. Weiss seems completely oblivious to something as obvious as placebo effects. In essence, he is advocating placebo medicine. Who cares whether acupuncture or other CAM really works or not, as long as it appears to work? He is also advocating “opening your mind” to the point where your brains fall out.

I have to say, I never would have expected to find a post like this on KevinMD. I had always thought that Dr. Pho was a proponent of science-based medicine (or at least evidence-based medicine), and it’s exceedingly disappointing to see this sort of nonsense on his blog. Normally, I view KevinMD as a reliable source of medical information and a good place to go for medical commentary. I have to wonder if, in his expansion to a multi-blogger medical social media juggernaut, Dr. Pho isn’t minding the store the way he should. The result are posts like those by Weiss and Bivins.

ADDENDUM: Kevin has responded in a comment.

I posted a response, but thought of a little more after I hit “submit,” so I expand slightly here:

Post pieces you don’t necessarily agree with myself to promote discussion and debate? Give me a break! I didn’t want to believe it, but one of my readers commented that it looks like you’ve become all about the page views, traffic, and advertising. Your comment makes me think he might well have been correct.

You appear to have lost your way from way back when six years ago. Whether or not CAM modalities are scientific or whether patients should be encouraged to be “open minded” (i.e., to try them even though they are pseudoscience) goes beyond being something that you just “disagree with.” It goes to the heart of practicing science- and evidence-based medicine, which you apparently have forgotten or abandoned in your search for ad revenue.

As a result, sadly, I can no longer recommend your blog to my readers as a source of reliable medical information and will be removing it from my blogroll the next time I revamp it (soon).

Perhaps some additional opinions from my readers would persuade Dr. Pho that he has strayed into dubious territory.