Our patients don’t practice evidence-based medicine? That doesn’t justify doctors embracing quackery!

ebm-pyramid

One of the most annoying phenomena when it comes to “complementary and alternative medicine” (CAM), which its advocates are more and more insistent on calling “integrative medicine” is how little the average doctor cares that pseudoscience is infiltrating medicine. The reason, of course, is that CAM advocates don’t like the “alternative” part of the term CAM. Come to think of it, they don’t like the “complementary” part, either, because it implies that conventional science-based medicine (what I like to refer to as “real” medicine) is the main treatment and what they do is just “complementary” and therefore not really necessary. The model they prefer and are increasingly getting people to buy is that they are “integrating” their treatments with science-based medicine, the implication being that they are equal and the sales pitch being that they are “integrating” the “best of both worlds.” Of course, to paraphrase my good buddy Mark Crislip, integrating cow pie with apple pie doesn’t make the cow pie better; it makes the apple pie worse. And, yes, the woo of integrative medicine is the cow pie in this analogy.

Worse, however, is how easily physicians buy into the mindset behind “integrative medicine. I found this out yet again when I came across an article by Robert P. Cowan MD, FAAN, a neurologist at Stanford University, entitled CAM in the Real World: You May Practice Evidence-Based Medicine, But Your Patients Don’t. My first thought on reading the title was that he might be discussing how to get one’s patients to accept evidence-based recommendations and how to talk to them about CAM. And it is, sort of. Unfortunately, Dr. Cowan buys into a lot of the tropes about CAM that lead to its acceptance among physicians. Now, I will admit that the abstract, on the surface, doesn’t sound so bad, although I really think Dr. Cowan is exaggerating when he starts out with this background:

Complementary and Alternative Medicine (CAM) approaches are widely used among individuals suffering from headache. The medical literature has focused on the evidence base for such use and has largely ignored the fact that these approaches are in wide use despite that evidence base.

Now, I’m not a neurologist, and I don’t read a lot of the headache literature. However, I do read a lot of the CAM literature, and rarely do I see a paper on CAM that doesn’t mention how such therapies are so popular among patients and that doesn’t mention that the evidence base for such therapies is thin to nonexistent. Even papers by advocates tend to mention these things, although advocates tend to emphasize the popularity and downplay the lack of evidence. So what does Dr. Cowan plan to do? The purpose of this article, apparently, is to suggest strategies for “understanding and addressing this use without referring back to the evidence base,” the rationale pivoting “on the observation that patients are already using these approaches, and for many there are anecdotal and historical bases for use which patients find persuasive in the absence of scientific evidence.” He then concludes that “until such time as the body of scientific literature adequately addresses non-conventional approaches, physicians must acknowledge and understand, as best as possible, CAM approaches which are in common use by patients,” which is about as obvious a conclusion as there is. It’s not the conclusion so much that bothers me. It’s how Dr. Cowan gets there.

He starts off with a a really annoying introduction:

There is a French proverb, dating from the late 13th century that proclaims: “It is the poor craftsman who blames his tools.” But there is a belief in headache medicine (and elsewhere) that, if only we had the proper tools, we could meet all our patients’ expectations.

Similarly, there is another belief, widely held, perhaps not consciously, by many of our patients that the tools to manage their headaches exist, but their doctors, as “Western,” evidence-based practitioners, are unaware, inappropriately skeptical, or simply arrogantly biased when it comes to implementing non-Western approaches. And so they seek these alternatives out, often clandestinely. And why? Because their doctors talk about the “dangers” of using anecdotal “evidence” in making decision treatments or the perils of using treatments that lack scientific foundation? Why do patients turn to folk remedies and other alternative approaches? Should we be trying to dissuade patients from “experimenting” with these nontraditional approaches?

Increasingly, over the last century or so, physicians have been spending more and more time at the altar of evidence-based medicine and implicitly rejecting treatments that lack a “rigorous” and “validated” evidence base. This has occurred despite ongoing discussion of the flaws and deficits in the vetting of and access to the “evidence” in evidence-based medicine.[1] Nonetheless, this approach has become the standard of practice for the doctors. But what about the patients? Do patients accept and practice evidence-based medicine?

Ah, yes. Note the framing. Doctors worship at the “altar of evidence-based medicine” (EBM) and reject treatments that lack a “rigorous” and “validated” evidence base. (Note the scare quotes around “rigorous” and “validated.”) I hate it when doctors who should know better throw around the old trope, beloved of quacks everywhere, that doctors are not practicing based on evidence and science (because, you know, EBM is not perfect) but rather are doing so because EBM has become a religion. And, of course, we’re “arrogantly biased” when it comes to “non-Western” approaches. Does Dr. Cowan know how off-base his use of “Western” medicine as a construct is? As I’ve pointed out before many times, the dichotomy between “Western” and “non-Western” (usually “Eastern”) medicine is a false one—and an implicitly racist one, to boot, although most people who use it don’t realize the racism inherent in the construct. The implication of this dichotomy is that only “Western” medicine is scientific while “Eastern medicine” (or non-Western medicine) is not scientific. Only the West, or so it seems, can claim the mantle of science in medicine, while the West, or so it seems, can’t claim the mantle of “wholism” or understanding that the patient might have other understandings of how to determine what works than EBM. It’s irritating as hell.

It’s also a bit of a straw man to say that proponents of EBM tell patients about the “danger” of relying on anecdotal evidence. What patients are told is that anecdotes are unreliable as a means of determining what does and doesn’t work, which is absolutely true, particularly for subjective symptoms. Placebo effects, regression to the mean, and the form of selective memory known as confirmation bias lead human beings, including doctors, to think they know what works.

After an anecdote about a patient with headaches coming in and telling him of all the various natural treatments that seem to work or the various substances that seem to trigger his headaches, Dr. Cowan does make a reasonable point when he describes what his patients tell him when about reactions of other doctors to their descriptions of what work and don’t work for their headaches:

  • There is no scientific basis for these “so-called” natural cures. Stop them, you’re wasting your money and might even be harming yourself.
  • Have you considered seeing a Pain Psychologist? Generally, when a patient goes to such extremes, there is some underlying psychiatric issue.
  • There is a variety of prescription medications that may be more effective for you, and these other things you are taking might be interfering with the real medicines, making them ineffective.

Dr. Cowan (and I) both think that #1 is the wrong approach. Although I do tell patients when I think that there is no scientific basis for a treatment, I rarely tell them not to use them, at least not bluntly. I’m also very careful to try to remain as nonjudgmental as possible, having learned the hard way from being too blunt in the past. I’d be lying if I said that I don’t occasionally slip up and revert to such bluntness, but such incidents have become so rare that I honestly can’t remember how long ago the last one occurred, although I can remember (and regret) what I said. I can’t comment on #2, but #e certainly sounds about right. Dr. Cowan, though, instead of sticking with that reasonable solution goes a bit off the deep end:

Obviously, we cannot be expected to know about every treatment option in every medical system under the sun. The armamentarium of the homeopathic or Classical Chinese healer or Ayurvedic doctor is every bit as complex as that used in Western medicine. Each practitioner is obligated to provide enough information to allow our patients to make informed decisions about their health care. Moreover, we need to know enough about different therapies to help protect our patients from potentially dangerous practices, and finally, we need to be as non-judgmental as possible without compromising our own critical thinking.

Here, Dr. Cowan seems to be mistaking complexity for profundity or plausibility. Otherwise, he wouldn’t mention homeopathy in this context. After all, given that the very principles that underlie homeopathy are complete and total pseudoscience and most homeopathic remedies are diluted to the point that the odds against there being a single molecule of active remedy left over are incredible, it is not necessary for a physician to know much about all the various remedies prescribed by homeopath. All one has to know are two things. First, what dilutions are low enough that there might be actual substance left (12C—or 10-24—being the dilution that would roughly leave maybe one molecule left. Realistically, any dilution over 6C (10-12) would be highly unlikely to have enough substance left to have a pharmacological effect. Second, one has to know that the very basis of homeopathy is pseudoscience. Knowing that, one can know that the vast majority of homeopathic remedies are water and therefore inert placebos.

As for Ayurveda and traditional Chinese medicine, all one needs to know is that both are based on prescientific concepts that don’t have a basis in science. Unfortunately, that doesn’t stop Dr. Cowan from, in essence, treating them as equals:

Every one of the medicines (for want of a better word) that AG is taking has some basis in the treatment of headache in one or another medical system.[4] Some have an evidence-based rationale, while others have a historical rationale dating back thousands of years. Some are based on a Western diagnosis such as migraine without aura, while others are based on a classical Chinese medicine diagnosis of cool, damp headache, or an Ayurvedic diagnosis headache due to too much pitta dosha (see Dr. Gokani’s accompanying explanation). A couple trace back to traditional American folk treatments. It is not reasonable, practical, or perhaps even appropriate for Western physicians to be skilled in classical Chinese, Ayurvedic and homeopathic medicine. But an awareness of the reality that other medical systems exist, and perhaps more importantly, are practiced by our patients, is critical to our ability to properly care for patients. When these differing approaches conflict or complement each other, shouldn’t we broaden our knowledge base to allow for interaction?

Broadening one’s knowledge base is good, but if, by “interaction” Dr. Cowan means embracing pseudoscience just because our patients embrace it, then that is where we part ways. Unfortunately, that does appear to be what he means. Rather than knowing about these things so that we can explain why they have no basis in science and/or be aware of possible interactions with pharmaceutical agents, Dr. Cowan seems to be arguing that we should know more about these “non-Western” treatments so that we can work with our patients in using them. Of course, the wag in me can’t help but note at this point that homeopathy, for example, is as “Western” a treatment as there is, given that Samuel Hahnemann was German and popularized homeopathy first in Germany.

Dr. Cowan also seems to have a bug up his posterior about the Flexner report. Yes, the Flexner report, the report that spurred American medical Schools over 100 years ago to abandon a lot of the non-science-based treatments and modalities being used throughout the land:

The Carnegie Foundation took it upon itself to survey and evaluate the more than 150 medical institutions in the United States and determine which among them were using an educational model that was suitable by their standards.[6] They selected Abraham Flexner to conduct the survey. Flexner was an educator by training, not a physician. He was a strong proponent of the “German” approach to education and a firm believer in the new “scientific approach.” Thus, when he surveyed schools, he used reliance on the scientific method as a major criterion for recommending accreditation. He dismissed any notion of healing based on historical evidence or anecdote.

While no one could rationally dispute the enormous benefit this has had for the advancement of science and medicine in the ensuing century, it should be noted that Flexner and his report had its detractors, not the least of whom was William Osler, who felt such a heavy reliance on the science of medicine, to the exclusion of the art and history of the practice, was a serious flaw.

In any case, one consequence of the Flexner Report of 1910 was that virtually all “proprietary” schools were closed. Moreover, those that attempted to remain active (despite legislation that all medical schools would require state licensure and vetting by the American Medical Association), no longer had access to major endowment funding by the likes of the Carnegie and Rockefeller foundations, and later from the federal government itself. It is worth noting that these “proprietary” schools were generally not university affiliated and provided “practical” training in “folk” medicine, including naturopathy, homeopathy, etc. From that point forward, these approaches were no longer generally considered conventional medicine. Other consequences of the Flexner Report were the establishment of the “full time system” in medical education, in which professors were no longer obligated or expected to provide patient care, and pre-eminence of advancing science over ethics and patient care came to the forefront of medical education. The adoption of the Flexner Report signaled the end of the apprenticeship system.

To summarize, what is presently accepted as conventional medicine came to be so by caveat. Other medical systems have neither been subject to the rigorous vetting that Western medicine approaches have undergone in order to further develop nor have they been demonstrated to be ineffective or dangerous in any systematic way. In other words, there are no scientifically accepted criteria for inclusion or exclusion of specific modalities as CAM or as conventional. Conventional medicine is exactly that – medicine by convention.

Note the loaded language throughout this entire description. Notice how the Carnegie foundation “took it upon itself” to survey the medical schools in the US and determine which ones were using an educational model “suitable” to their standards. Dr. Cowan describes Flexner as using reliance on the scientific method as a major criterion for recommending accreditation of medical schools as if it were a bad thing. One thing that Dr. Cowan also neglects to mention is that most “proprietary” schools not associated with a major university were run to make a profit, that only two years of study wer required, and that laboratory work and dissection were not even necessarily required. In other words, practical knowledge of human anatomy was not necessarily a requirement in these schools. Most such schools also didn’t require any university training. The Flexner report changed that, and resulted in the lengthening of the medical school curriculum to the current four years. Moreover, a lot of medical schools offered courses in quack modalities such as chiropractic medicine, eclectic medicine, naturopathy, homeopathy, electromagnetic field therapy, phototherapy, eclectic medicine, and physiomedicalism. The Flexner report led to the leaders of these medical schools either to drop this quackery from their curriculum or lose their accreditation and underwriting support.

In other words, Dr. Cowan gets it backwards. The reason that these other medical systems were removed from the curriculum of medical schools and schools teaching them closed was because it was already known in 1910 that these medical systems had no basis in science. Homeopathy doesn’t have to be demonstrated to be ineffective. Its very rationale tells us that it’s only water and can’t be effective; that is, unless huge swaths of physics and chemistry are wrong. Yes, these medical systems were eliminated by caveat, but it was completely the right thing to do. In the over 100 years since then, advocates of these other treatments have failed to produce evidence that these systems should be re-introduced into medicine, but advocates of “integrative medicine” are sure enough trying.

In the end, Dr. Cowan makes points that are fairly unobjectionable in that he says that patient preference needs to be considered (which we usually do as physicians); that physicians should be at least somewhat knowledgeable about CAM; and that we should listen to our patients nonjudgmentally. Unfortunately, he has a lot of assumptions about CAM that don’t jibe with reality, not the least of which is that the only reason it doesn’t have a rigorous scientific basis is because it hasn’t been studied is because its study has been precluded by the Flexner report and the arrogance of “Western” physicians, rather than because there’s no “there” there.