Note added 6/16/2011: The author of the target–I mean subject–of this piece of insolence has responded in the comments.
Note added 6/17/2011: Steve Novella has also commented. He is unusually harsh (for him).
What is it with The Atlantic lately? It used to be one of my favorite magazines. In fact, I was a subscriber for something like 20 or 25 years. Then, back in 2009 at the height of the H1N1 frenzy, The Atlantic published what can only be described as an execrable bit of journalism lionizing the brave maverick doctor Tom Jefferson and arguing, in essence, that vaccinating against H1N1 was a horrendous waste of time and effort. The article was so bad that I applied a characteristic dose of my not-so-Respectful Insolence, while the ever-inimitable Mark Crislip did a complete annotated rebuttal. Even revere (who is, alas, no longer on ScienceBlogs) was most definitely not pleased.
I also let my subscription to The Atlantic lapse and have not to this day renewed it.
Then, last year, The Atlantic published an article that wasn’t nearly as bad but was nonetheless pretty darned annoying to anyone who takes the perspective of a science-based physician. Entitled Lies, Damned Lies, and Medical Science, it was an article lionizing John Ioannidis (whom I greatly admire) while largely mangling the context behind his work. It was written by David H. Freedman, a writer who, it should be noted, also got it so wrong that he wasn’t even wrong, so to speak, about Andrew Wakefield. Basically To him the discovery of Andrew Wakefield’s scientific fraud was nothing compared to what he saw as the corruption and level of error present in the current medical literature. To Freedman, Wakefield is representative of the system. The bottom line is that the article featuring Ioannidis seemed to confuse what is the strength of science-based medicine with a weakness and garbled a lot of the significance of Ioannidis’ work along the way. Freedman’s article ended up being depressing to read, because it could have been so much better. Instead, it was a mess.
Now, Freedman’s back again, this time with a much, much, much worse story in The Atlantic in the July/August 2011 issue under the heading “Ideas” and entitled The Triumph of New Age Medicine. Yes, I suppose that’s an idea. A bad idea. An awful idea. A terrible idea. But it is an idea nonetheless.
Speaking of bad ideas, in contrast to his previous article, in which he managed at least to get the gist of what Ioannidis teaches but merely spun it in what I considered to be an annoying fashion, the entire idea behind Freedman’s new article channels the worst fallacies of apologists for alternative medicine. The whole idea behind the article appears to be that, even if most of alternative medicine is quackery (which it is, by the way), it’s making patients better because its practitioners take the time to talk to patients and doctors do not. In other words, it’s a massive “What’s the harm?” argument. Yes, that’s basically the entire idea of the article boiled down into a couple of sentences. Deepak Chopra couldn’t have said it better. Tacked on to that bad idea is a massive argumentum ad populum that portrays alternative medicine (or, as purveyors of quackademic medicine like to call it, “complementary and alternative medicine” or “integrative medicine”) as the wave of the future, a wave that’s washing over medicine and teaching us cold, reductionistic doctors to care again about patients and thus make them better. Freedman even contrasts this to what he calls the “failure” of scientific medicine. I kid you not. Worse, Freedman makes this argument after having actually interviewed some prominent skeptics, including Steve Salzberg and Steve Novella, in essence, missing the point.
Let’s dig in, shall we?
You know the article’s going to be dubious when it starts out with a sympathetic profile of Brian Berman. Regular readers of this blog might remember Dr. Berman, who is what I like to call the head of quackademic medicine at the University of Maryland. In fact, I just wrote about him a mere week ago because of an announcement that he had been appointed to the advisory council for the National Center for Complementary and Alternative Medicine. Less than a year ago, I wrote about him in the context of his having managed to infiltrate the pseudoscience of acupuncture into the hallowed pages of the New England Journal of Medicine.
Then, not unlike the vast majority of the evidence that CAM practitioners prefer over basic science and clinical trials, Freedman segues right into an anecdote about a man named Frank Corasaniti, a 60-year-old retired firefighter who had injured his back falling down a steel staircase at a firehouse some 20 years earlier and had subsequently injured both shoulders and his neck in the line of duty. Corasaniti was suffering from chronic pain due to his old injuries and at the urging of his wife tried acupuncture at Dr. Berman’s clinic under the direction of an acupuncturist named Lixing Lao:
His wife, a nurse, urged him to try acupuncture, and in February, with the blessing of his doctor, he finally met with Lao, who had trained in his native China as an acupuncturist. Their first visit had lasted well over an hour, Corasaniti says, time mostly spent discussing every aspect of his injuries and what seemed to ease or exacerbate them, and also other aspects of his health–he had been gaining weight, he was constipated, he was developing urinary problems. They talked at length about his diet, his physical activity, his responsibilities and how they weighed on him. Lao focused in on stress–what was causing it in Corasaniti’s life, and how did it aggravate the pain?–and they discussed the importance of finding ways to relax in everyday life.
Then Lao had explained how acupuncture would open blocked “energy pathways” in his body, allowing a more normal flow of energy that would lessen his pain and help restore general health. While soothing music played, Lao placed needles in and around the areas where Corasaniti felt pain, and also in his hands and legs, explaining that the energy pathways affecting him ran throughout his body. The needle emplacement itself took only about three minutes. Lao then asked Corasaniti to lie quietly for a while, and Corasaniti promptly fell asleep, awakening about 20 minutes later when Lao gently roused him. Corasaniti continued to come in for 40-minute sessions twice a week for six weeks, and since then had been coming in once a week.
In other words, acupuncture works because Mr. Corasaniti feels better now.
I wonder how closely Lao is supervised by Dr. Berman or what the formal arrangement is, because, quite frankly, from the description I see here it sure sounds as though Lao is practicing medicine without a license. What are his qualifications in nutrition? Is he a dietician? What are his qualifications as a counselor? In the article, Lao is described as a physiologist with Dr. Berman’s center, which to me sounds as though he has zero legitimate qualifications to be discussing diet and counseling Corasaniti how to deal with his injuries. Yet there he is, practicing what sounds like dietetics, counseling, and even medicine without a license at a major academic medical center.
Truly, Freedman strikes me as obliviously out of touch when he pontificates, “Concerns of outright malpractice or naked hucksterism seem grossly misplaced when applied to a clinic like Berman’s.” Really? I wouldn’t so blithely dismiss the possibility when practitioners at Berman’s clinic, by Freedman’s own report, are telling patients that there is a magical life force whose flow acupuncturists can rearrange by sticking little sharp objects into their bodies and thus heal them. If you start with a completely unscientific premise like that, it infects everything else. Indeed, if there’s one thing I’ve found about alt-med, it’s that the supposedly “sensible,” science-based advice about diet and exercise that it’s co-opted as somehow “alternative” and pointed to as being better than what physicians offer often turns out not to be so sensible or science-based when you look at it more closely. Fad diets, supplements, various “detox” diets are all par for the course. I’ve pointed out numerous examples right here on this very blog of pure pseudoscience in medical schools and academic medical centers. What makes Freedman think that nutritional advice given out by “integrative medicine” centers affiliated with such institutions is somehow immune from pseudoscience?
Freedman then delves into what he apparently views as the failure of scientific medicine (or what he has imbibed from the promoters of quackademic medicine whom he interviewed as the failure of scientific medicine), beginning by proclaiming that “on balance, the medical community seems to be growing more open to alternative medicine’s possibilities, not less.” Unfortunately, I can’t actually argue with this assessment; thanks to the infiltration of unscientific CAM into former bastions of science-based medicine like the University of Maryland, quackademic medicine is indeed coming to the fore, but Freedman seems to be arguing that this is a good thing rather than a bad thing because somehow, some way to him scientific medicine has “failed.” This leaves Freedman making this argument as to why quackademic medicine is so popular:
That’s in large part because mainstream medicine itself is failing. “Modern medicine was formed around successes in fighting infectious disease,” says Elizabeth Blackburn, a biologist at the University of California at San Francisco and a Nobel laureate. “Infectious agents were the big sources of disease and mortality, up until the last century. We could find out what the agent was in a sick patient and attack the agent medically.” To a large degree, the medical infrastructure we have today was designed with infectious agents in mind. Physician training and practices, hospitals, the pharmaceutical industry, and health insurance all were built around the model of running tests on sick patients to determine which drug or surgical procedure would best deal with some discrete offending agent. The system works very well for that original purpose, against even the most challenging of these agents–as the taming of the AIDS virus attests.
But medicine’s triumph over infectious disease brought to the fore the so-called chronic, complex diseases–heart disease, cancer, diabetes, Alzheimer’s, and other illnesses without a clear causal agent. Now that we live longer, these typically late-developing diseases have become by far our biggest killers. Heart disease, prostate cancer, breast cancer, diabetes, obesity, and other chronic diseases now account for three-quarters of our health-care spending. “We face an entirely different set of big medical challenges today,” says Blackburn. “But we haven’t rethought the way we fight illness.” That is, the medical establishment still waits for us to develop some sign of one of these illnesses, then seeks to treat us with drugs and surgery.
This is pure piffle. Note how Elizabeth Blackburn’s Nobel Laureate status is touted. Note that what she won her Nobel Prize for (shared it with Carol Greider at Johns Hopkins and Jack Szostak Harvard, actually) for the discovery of telomeres. That’s great and was a very important discovery, particularly for cancer research. Believe it or not, however, a Nobel Prize doesn’t give Blackburn any particular insight into how medicine is practiced that is any greater than that of any other prominent basic scientist, although she does appear to have been palling around a bit too much with the CAMsters at UCSF Osher Center. Basically, when you boil it all down, her assessment is nothing more than the same old complaint against “reductionistic Western medicine” that CAM supporters trot out again and again. It’s just tarted up with a “just so” story about how modern medicine supposedly evolved. It’s also presented as though physicians haven’t advocated healthy lifestyle interventions for many decades now, and I don’t mean the radical low fat diets of the sort touted by Dean Ornish, whom Blackburn’s teamed up with. In Freedman’s narrative, cribbed from Blackburn, and placed on steroids by Freedman, in come CAM and “integrative medicine” to deal with chronic disease, after, of course, cherry picking examples of conditions against which current treatments have disappointed and reiterating a favorite CAM trope about how the U.S. spends more on health care and has worse outcomes:
All of these shortcomings add up to a grim reality: as a prominent 2000 study showed, America spends vastly more on health as a percentage of gross domestic product than every other country–40 percent more than France, the fourth-biggest payer. Yet while France was ranked No. 1 in health-care effectiveness and other major measures, the United States ranked 37th, near the bottom of all industrialized countries.
This observation is utterly irrelevant to the central thesis of the article implying that CAM can somehow improve health care in the U.S. The reason is that France, just as much as the U.S., uses science-based medicine, not CAM, as its preferred system of health care, nor does France, as far as I can tell, “integrate” quackery with its science-based medicine any more than the U.S. does. Rather, France is just apparently better at providing its science-based care at a lower cost than we are here in the U.S. CAM has nothing to do with it. Yet Freedman deceptively conflates two unrelated issues to imply that CAM can show us the way out of the “failure” of science-based medicine because of its emphasis on “prevention” and the closer, more caring relationship between provider and patient.
The one part of the article that comes closest to making sense is when Steven Novella is quoted thusly:
Steven Novella calls the notion that alternative care’s benefits are rooted in closer practitioner-patient interactions the “touchy-feely defense.” Novella is a highly respected Yale neurologist, and the editor of Science-Based Medicine, an influential blog that has tirelessly gone after alternative medicine. I met with him in his home outside New Haven, Connecticut, where he argued that claims about the practitioner-patient relationship are only intended to draw attention away from the fact that randomized trials have by and large failed to show that alternative treatments work better than placebos. And while he concedes that sham treatments can give patients a more positive attitude, which can confer real health benefits, he is adamant that providing sham treatments at all–essentially fooling patients into believing they’re being helped–is highly unethical. “Alternative practitioners have a big advantage,” says Novella. “They can lie to patients. I can’t.”
And lie to patients they do, such as telling them that sticking little tiny needles into their skin will “unblock” the flow of their life energy, that diluting a remedy containing a substance that causes a symptom will make it stronger at relieving that symptom, or that they can manipulate energy from the “universal source” to make them feel better. But apparently to Freedman it’s all good because of placebo effects, which he proceeds to use and abuse in the same way that Mike Adams did when he was seemingly amazed enough to discover that there are placebo effects in medicine that he tried to argue in a massive tu quoque argument that “Western medicine” is every bit as much a placebo as alt-med. He even pulls out an argument that I like to call, “Your Western science can’t study my woo because it’s ‘individualized,'” which is much favored by woo-meisters:
Randomized controlled trials, the medical world’s gold standard for assessing the efficacy of treatments, cannot really test for this effect. Such studies are perfect for testing pills and other physically administered treatments that either have a direct physical benefit or don’t. (In its simplest form, a controlled study randomly assigns patients to receive either a drug or the equivalent of a sugar pill. If the real thing doesn’t bring on more improvement than the placebo does, the drug is a washout.) But what is it that ought to be tested in a study of alternative medicine? To date, the focus has mostly been on testing the physical remedies by themselves–divorced from any other portion of a typical alternative-care visit–with studies clearly showing that the exact emplacement of needles or the undetectable presence of special ingredients in homeopathic water isn’t really having any significant physical effect on the patient.
But what’s the sham treatment for being a caring practitioner, focused on getting a patient to adopt healthier attitudes and behaviors? You can get every practitioner in each of the study groups to try to interact in exactly the same way with every patient and to say the exact same things–but that wouldn’t come close to replicating what actually goes on in alternative medicine, where one of the main points is to customize the experience to each patient and create unique bonds.
This is, of course, utter nonsense, as I and others have pointed out time and time again. For example, I blogged about just such a study that studied the practitioner interaction with the patient compared to the actual acupuncture, and this was published over two years ago. The bottom line is that science-based medicine can and does study the question of how much of an effect is due to the actual intervention and how much is due to nonspecific effects, placebo effects, and practitioner interaction with the patient. If Freedman couldn’t find at least a few of these studies, he wasn’t looking very hard. Of course, the CAM practitioners he interviewed wouldn’t be very likely to point him to them because they are very strong evidence that the vast majority of CAM relies on nonspecific and placebo effects.
The bottom line is that Freedman’s article is built on a false dichotomy. Basically, he seems to be arguing that because conventional doctors are constrained by the system of reimbursement from spending a lot of time with patients to get to know them better, empathize with them more, and deal with psychosocial issues we should cede that aspect of patient care to quacks, letting them step into the breach, so to speak. No, that’s not a straw man position; that’s really what one can reasonably conclude from Freedman’s article. He just wouldn’t call it “quackery.” I would in many (but not all) cases. The reason I would is because what comes in with all the caring attention to patients is often pure pseudoscience based on prescientific vitalism. That’s what homeopathy, acupuncture, reiki, and various forms of “energy healing” popular today are. There has to be another way to bring back the “personal touch” and more attentiveness to patients besides telling them that if they want that personal attentiveness they have to go to a quack.
Finishing his article, Freedman looks to the future, proclaiming that the next generation of physicians will determine whether alternative medicine takes hold. Unfortunately, he is probably correct about that. There’s a reason why promoters of unscientific medicine are focusing so heavily on medical education, particularly at the medical school level. They’re playing for the long term; there’s no doubt about that. Right now, they’re succeeding, too. The infrastructure is rapidly being built to subvert science in the bastions of academia and replace it with quackademic medicine. The difference between Freedman and me is that he appears to view this mostly as a good thing. I do not.