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“Practice drift”: A feature, not a bug, in “integrative medicine”

Two prominent advocates of “integrative medicine” bemoan the “practice drift” they see in their specialty, in which doctors drift farther and farther away from their training. What this means is (although it would never be admitted) is that these “integrative medicine” doctors are drifting further and further into quackery. Too bad this is a feature, not a bug.

I’ve said it many times, but it’s always worth repeating. “Integrative medicine” means, in essence, “integrating quackery and pseudoscience into medicine.” After all, as much as integrative medicine advocates and practitioners claim perfectly fine science-based modalities such as nutrition, exercise, and other lifestyle interventions as being somehow “alternative” or “integrative” as their own rather than just medicine’s, the entire raison d’être of integrative medicine is to integrate prescientific or pseudoscientific treatments or systems of medicine like acupuncture, naturopathy, homeopathy, energy medicine, and the like into medicine using a lesser standard of evidence. Basically, I like to say about integrative medicine what Harriet Hall likes to say about naturopathy: What is good about it is not unique to it, and what’s unique about it is not good. In other words, the exercise, diet, and lifestyle interventions claimed by integrative medicine are not unique to integrative medicine, but what is unique (e.g., the naturopathy, homeopathy, and the like) isn’t good because it’s quackery.

That’s why I was amused when I came across an article, by way of Jann Bellamy, published in the Journal of Alternative and Complementary Medicine, which is, as you know, edited by our old friend John Weeks, the one who earned my ire likening me to Donald Trump. It’s by two luminaries of integrative medicine, Dr. Melinda Ring of the Osher Center for Integrative Medicine, Northwestern University Feinberg School of Medicine, and Dr. Sandy Newmark of the Osher Center for Integrative Medicine, University of California, San Francisco. The article is entitled Practice Drift: Are There Risks When Integrative Medicine Physicians Exceed Their Scope? However, it should really be called Are there risks when doctors embrace quackery? The answer, of course, is yes, because there should be.

What would any article promoting integrative medicine be without a bit of revisionist history. First, Drs. Ring and Newmark:

Twenty-five years ago David Eisenberg’s seminal article on public use of “unconventional medicine” created momentum around the approach for treatment and prevention now known as integrative medicine.1 Physicians drawn to the field were able to participate in the first integrative medicine fellowship through the University of Arizona in 1997. The first convening of what is now the Academic Consortium for Integrative Medicine and Health took place in 1999 to conceptualize a vision for the emerging field and work toward achieving it.2 Now, there are thirteen academic fellowships approved by the ABOIM and over 600 board-certified diplomats, over 1200 fellowship graduates through the University of Arizona alone, and the Consortium has grown from 8 to over 70 member institutions.

Eisberg’s article, you might recall, was published in the New England Journal of Medicine in 1993, and it was hardly a call for integrating quackery into medicine. Basically, it found that more people than expected were using alternative medicine (or “unconventional therapies,” as the authors put it) and suggested that medical doctors “should ask about their patients’ use of unconventional therapy whenever they obtain a medical history.” That’s about it. Where most doctors would be alarmed by this finding and agree that perhaps they should make sure to ask their patients about any alternative medicine that they might be using, people like Drs. Ring and Newmark apparently view such a result as a good thing and a jumping-off point for adding quackery to medicine. In any case, it is true that the 1990s was the decade that saw the first serious movement to “integrate” quackery into medicine, with the formation of the Academic Consortium for Integrative Medicine and, above all, the formation of the National Center for Complementary and Alternative Medicine in 1998 as a massive leap to from its modest origins as the Office of Alternative Medicine in 1992.

Drs. Ring and Newmark note that physicians in integrative medicine are drifting “away from their original training.” They attribute this “practice drift” to the increasing complexity of integrative medicine, although my retort to that is: How complex can it be, given how much of it is based on magical thinking? OK, I realize that systems of pure quackery can be very complex. Functional medicine is complex, but it’s complexity without utility and meaning. Ditto naturopathy, homeopathy, and the vast majority of traditional Chinese medicine. In any event, they observe:

In this context of practice expansion for clinical, business, or mixed reasons, providers from disciplines across the board risk going beyond their primary training in unethical or dangerous ways. The arena is challenging; certainly much good for patient choice and professional development has come from increased integrative options. The purpose of this article is neither to censor any particular group of providers nor to advocate for unreasonable restrictions on integrative practices. It is rather to engender a thoughtful discussion about an issue regarding standards of care that should be of concern to all medical providers and especially to those in the field of integrative medicine.

Of course they don’t want to “censor” anyone. If there’s one thing about integrative medicine, it’s that its proverbial mind is so open that its brains fall out. Energy medicine, a system of medicine based on the manipulation of mystical magical energy fields that science can’t detect? It’s perfectly fine! Acupuncture, a treatment based on nonexistent anatomical structures like meridians? No problem! Functional medicine, a system based on massive overtesting and overtreatment plus quackery? Bring it on! It’s all good!

So is this, apparently:

The growing complexity can be viewed as a positive in many ways, with greater access for patients and increasing diagnosis and treatment options for medical doctors who are interested in expanding their care options and approaches. Yet, in this new era of integrative medicine there is also risk, as physicians drift away from their original training. By the end of residency, a medical doctor has accrued a minimum of 16,000 h of clinical experience, the vast majority during residency, when physicians gain expertise in their chosen specialty under the supervision of an attending physician.7,8 Now, an increasingly common scenario is seen in which integrative healthcare professionals move outside this medical training and its implicit scope of practice to incorporate new approaches to healthcare diagnosis and treatment.

Here’s the thing. In real medical specialties, there are mechanisms for doctors to learn new skills when practice evolves. That’s how I learned to do various new procedures that rose to the standard of care after I finished my training. In surgery, it’s usually mentorship by a more senior surgeon or someone skilled at the procedure you’re trying to learn. In other specialties, there are courses that can be taken for continuing medical education. (Surgery has these as well.)

In integrative medicine, however, apparently this is what’s going on:

While the issue is alive across medicine, including in some other complementary and integrative professions, it seems particularly prevalent in the practices of medical doctors who have chosen to enter into complementary and integrative medicine. Here are some examples:

  • A psychiatrist completes functional medicine training and Lyme-literacy courses. He establishes a practice as an integrative psychiatrist and begins doing specialized testing, diagnosing patients with adrenal fatigue, parasites, and chronic Lyme and prescribes antibiotics, high-dose steroids, and extensive supplements for his patients. The physician’s postgraduate training, which establishes him as a board-certified medical doctor, consists of 3 years of a psychiatry residency. Other than medical school and intern year, which occurred 20 years earlier, his training did not include any infectious disease or endocrinology training.
  • An integrative gynecologist who prescribes bioidentical hormone therapy for women expands his practice to diagnose and treat not only women but also children and men- populations not included in his postgraduate residency- with hormones, pharmaceuticals, and dietary supplements.
  • A primary care physician curious about integrative medicine has done some self-education, then takes a weeklong class and rebrands herself as an integrative consultant.

At the heart of this quandary about health professional scope of practice lies the very basic question: does simply having graduated medical school entitle a physician to practice in any area of medicine, whether or not a few short trainings are added?

The answer in the rest of medicine is: Yes and no. Legally, having a medical license allows a physician to do virtually anything in medicine and to practice in any area of medicine. However, practically, that doesn’t happen nearly as much as it used to. Hospitals and insurers require board certification in a specialty, and physicians can only be practice and be reimbursed by third party payors for activities within the scope of practice of their specialty. Hospital privileges define scopes of practice based on the doctor’s board certification. For instance, I’m not certified in advanced laparoscopic surgery (although I can still do the basics, like laparoscopic cholecystectomies); so I’m not allowed to do them in my hospital. Similarly, I can’t do endoscopy because I haven’t had enough training in it. (I did some endoscopy as a resident, but not enough.) My scope of practice for purposes of my privileges is general surgery and breast surgery.

Contrast this to the examples above. Functional medicine claims to encompass endocrinology, metabolism, physiology, and so much more; yet most functional medicine doctors have little or no training in these areas. That’s yet another reason why functional medicine is to me “making it up as you go along.” Even if functional medicine were anything other than a made-up specialty that throws as many things against the wall as it can to see what sticks, it would be in appropriate for an “integrative medicine” doctor to be doing functional medicine without formal training. As for the second example, it’s just downright scary, but it’s a common story. The third example is also far too common. Basically, anyone can claim to be an “integrative medicine” doctor.

The criticism is very odd, as well, given that the American Board of Integrative Medicine (ABoIM), on whose board Dr. Ring sits, to be board-certified in integrative medicine. Also, as Jann notes, only recently did the ABOIM require a fellowship (none of which are ACGME-accredited) in integrative medicine, but even then the fellowship isn’t required if the physician has a degree from a naturopathic, chiropractic, or oriental medicine school. Prior to that, a medical license, board eligibility in anything, plus certain experience, plus CME credits like the ones Ring and Newmark complain of, were enough.

So what are these risks? They are:

  1. Risk to the patient—Of greatest importance is risk to the patient, who may be harmed by inappropriate diagnoses, missed diagnoses, or incorrect treatment, resulting from a provider’s lack of clinical experience and expertise in a particular area. Patients may also be subjected to significant financial risks from paying for excessive laboratory testing and other costs.
  2. Risk to the provider—In case of an adverse outcome, which can happen with even the best of treatment, a provider could have significant medicolegal difficulties from the perspective of a state medical board as well as increased civil liability should a patient choose to bring suit. At the state board level, clinicians may be at risk for penalties for practicing outside their scope of practice. At the federal level, practitioners may be liable for allegations of fraud and abuse.9
  3. Risk to the credibility of integrative medicine—There are comparable issues in other fields of medicine, as noted in a 2010 North Carolina Medical Board editorial on practice “drift,” but the risks of this “off-label” care may be a special threat to the credibility of the field of integrative medicine.10 Although integrative medicine is steadily gaining acceptance in the overall medical community, there is still much doubt and skepticism. When providers treat outside of their scope of practice, negative judgment about the particular provider involved could generalize to negative impressions of the entire field of integrative medicine. A good example of this, from personal experience, is the reaction of infectious disease experts to the chronic intravenous antibiotic treatments recommended by the above noted psychiatrist.
  4. Risk of alienation of complementary providers—This is a sensitive area. Consider the question of Traditional Chinese Medicine and acupuncture. Training for a licensed acupuncturist requires 3–4 years of full time study, in contrast to the much briefer acupuncture courses for MDs/DOs. The American Board of Medical Acupuncture, for instance, requires only 300 h of training for an MD to be called an MD Acupuncturist. In most states, MDs can practice without any additional instruction, or perhaps just 100–200 h.11 This significant variance in training requirements could lead to concerns on the part of licensed acupuncturists, especially given existing differences in insurance reimbursement for LAcs versus MDs.

Imagine my relief that they listed potential harm to the patient first. Of course, if they were that concerned about harm to the patient, they wouldn’t be part of a movement that “integrates” prescientific and mystical treatments and medical systems like naturopathy and traditional Chinese medicine (TCM) into medicine. TCM, for instance, has a whole slew of diagnoses that have little or nothing to do with reality. As for the “financial toxicity” of integrative medicine, hell, functional medicine is based on excessive laboratory testing, with slates of dozens of tests of hormone levels, nutrient levels, cytokine profiles, hematology profiles, metabolic panels, genomic panels, and more, many of which are not covered by insurance. Of course, regarding the risk to the practitioner, integrative medicine practitioners don’t seem to be at too much risk for liability; they seem to be seldom sued, even though they should be sued way more often given the pseudoscience involved.

Let’s consider the last two, though. There remain much doubt and skepticism about integrative medicine for good reason. It integrates quackery with medicine! In particular, I laughed out loud when I read the example of the reaction of infectious disease experts to the chronic antibiotic treatments recommended by the aforementioned psychiatrist. Regular readers of this blog probably know that the only condition for which integrative medicine doctors recommend chronic antibiotics is chronic Lyme disease, which is a fake diagnosis. Yes, infectious disease experts have a problem with treating chronic Lyme disease, because it’s a “disease” that doesn’t exist and long term antibiotic treatment for a nonexistent disease can only do harm, not good. And it does: Catheter infections, antibiotic-related infections, and more.

I also laughed out loud at the example of acupuncture in #4. Given that acupuncture is magic based on nonexistent anatomy and physiology, who cares how much training MDs need to do acupuncture compared to acupuncturists? Does it matter? Of course it doesn’t. After all, it doesn’t matter where you stick the needles or even if you stick the needles in. As long as sufficiently sterile technique is used to avoid infection, it really doesn’t matter who’s doing the acupuncture. Of course, this all rather goes against the authors’ recommendations, such as this:

Individual level: it is the physician’s professional and ethical responsibility to make sure that he or she is competent to practice in a particular area. The MD should be transparent with patients about his or her training and expertise. Physicians moving into new clinical arenas should acknowledge their inexperience and seek reliable resources and mentors for guidance in application to patient care.

Of course, the problem with “integrative medicine” is that there really is no science-based standard to tell a physician whether he or she is competent to practice in that area. That’s because, for so many of the modalities that “integrative medicine” integrates into medicine, there is no science or even scientific plausibility to support them. So it shouldn’t be a surprise that the sort of physician attracted to such a specialty has little fealty to science and is therefore prone to “practice drift.” That’s not a bug. It’s a feature.

By Orac

Orac is the nom de blog of a humble surgeon/scientist who has an ego just big enough to delude himself that someone, somewhere might actually give a rodent's posterior about his copious verbal meanderings, but just barely small enough to admit to himself that few probably will. That surgeon is otherwise known as David Gorski.

That this particular surgeon has chosen his nom de blog based on a rather cranky and arrogant computer shaped like a clear box of blinking lights that he originally encountered when he became a fan of a 35 year old British SF television show whose special effects were renowned for their BBC/Doctor Who-style low budget look, but whose stories nonetheless resulted in some of the best, most innovative science fiction ever televised, should tell you nearly all that you need to know about Orac. (That, and the length of the preceding sentence.)

DISCLAIMER:: The various written meanderings here are the opinions of Orac and Orac alone, written on his own time. They should never be construed as representing the opinions of any other person or entity, especially Orac's cancer center, department of surgery, medical school, or university. Also note that Orac is nonpartisan; he is more than willing to criticize the statements of anyone, regardless of of political leanings, if that anyone advocates pseudoscience or quackery. Finally, medical commentary is not to be construed in any way as medical advice.

To contact Orac: [email protected]

71 replies on ““Practice drift”: A feature, not a bug, in “integrative medicine””

I wasn’t laughing. I got irritated by the notion of a psychiatrist taking “Lyme literate” courses.

It’s all about money. That’s why these quacks seldom get sued. They’re taking care of the worried well, and charging a premium for it. The patient gets to think their imaginary diseases are being treated, so they’re willing to pay. They’re true believers, so of course they’re not going to sue.

You couldn’t make up a better racket if you tried.

“… worried well…true believers”
My observation has been mostly for acutely ill, mortally ill and chronically ill with varying degrees of disability. For the latter two conditions, health and wealth typically deteriorated under regular care for a long time before getting CAM consults. And getting relief or results where regular care didn’t.

If you’re dealing with serious illness, you probably don’t have time, energy or money for lawsuits, although your survivors might.

Within my limited observation and experience, some “regular doctors” really needed a fresh, new lawsuit more.

As for forebearance on criticism and lawsuits of integrative medical providers, several views might apply:
1. They lost more time and money on regular doctors, got hurt and were treated worse.
2. Lack of time, energy and money
3. I think most patients, whether integrative or regular drs, assume good faith effort at some level
4. Investment in the training curve. Integrative doctors represent a spectrum of treatments and accumulated experience that hopefully improve with time. If you destroy them all in year 1, there won’t be any with 20 years research and experience with something important that is unavailable in regular medicine. Sometimes, when traveling, I can’t find a local MD for something greatly needed.

In my case, I don’t worry so much about what I think is psychoimmunoneurological, I focus on any things that they can deliver that I see potential merit in. Sometimes, when traveling, I can’t find a local MD for something badly needed.

Your “limited” and biased observations cannot be generalized to apply broadly across health care.

But thank you for proving my point: CAM practitioners focus on people who really aren’t that sick, if they are sick at all, while placing blame on real health care providers who face the difficult task of caring for the truly ill, and not always being able to succeed.

I am a legal nurse consultant. I am an expert witness in nursing malpractice cases, which often go hand in hand with medical malpractice cases. I have seen some truly awful cases of actual malpractice. The whining and complaining you do about doctors and our health care system doesn’t even come close to actual malpractice. The shortcomings of medicine and the fact that medicine can’t fix everything doesn’t even come close to what you’d see in actual malpractice. And even actual malpractice is a drop in the bucket compared to the vast majority of dedicated health care providers who do their very best for their patients.

You have no actual idea what you are talking about.

You are an excellent representative of what more and more people are literally running for their lives, away from. Whatever merits you may have on some subjects, they are greatly offset by your ignorant, domineering attitudes about ongoing medical failures, and other options. Because of cancer issues, I do talk with dying patients, too frequently.

You repeatedly have no accurate idea of things that I’m talking about. On the other hand, I’ve seen plenty of the ignorant-of-any-CAM-protocols-that-work, nasty nurse syndrome. Simply, we don’t have to put up with it so much anymore. We’re partly free of medical tyranny and pompous ignoramouses.

“Sometimes, when traveling, I cannot find a local MD for something badly needed.”

Because there is no such thing as “alternative” ER? Or because nobody but quacks will cater to a well patient who fancies him/herself sick?

In all my years of far-flung travel I can only recall any need for a doctor twice, a raging ear infection the first time, and dysentery the second. I had no trouble finding a real doctor and proper scientific medical treatment either time, despite language barriers.

I doubt you have tried to look for a local psychiatrist while traveling. Even you know they won’t tell you what you want to hear either.

My observation has been mostly for acutely ill, mortally ill and chronically ill with varying degrees of disability.

Oh, look, prn is playing doctor again.

Wait, you don’t have to do a fellowship if you did chiropractic school? That’s considered a great idea substitute?

I guess it’s goid they’re trying to call people not to overstep. And I agree with two. Tort liability would be, correct, hard to counter there. I wonder what their insurance companies say.

3. Risk to the credibility of integrative medicine

This made me laugh a bit. What credibility? If integrative medicine would have any credibility, it would be named medicine.

It always annoyed me when I saw quacky conferences like AutismOne offering CEUs or woo-meisters claiming that they taught doctors, now I know why: I always thought that the first instance catered to alties like homeopaths, chiros, woo-nurses and that the second was merely lame brained bragging. But no, these might have all been real.

If you have a good colour printer handy, why not invent form an organization that can “certify” you and print off the “membership certificate” to hang on the wall.

A few business cards, etc, and you are good to go.

My Applied Nutritionalist business cards have been very successful. The scary thing is that at least one person might have not realized it was a joke. I need to include the motto “Have food, will eat” on the next print run.

I need to include the motto “Have food, will eat” on the next print run.

Maybe. The PGP fingerprint is always a nice touch.

When you don’t have a scientific anchor on which a treatment is based, it’s very easy to drift.

Interesting that the Russians alleged to have poisoned the Skripals have been identified in Russian media as “sports nutritionists”. 🙂

Line right up and subject yourself and your children to an experiment where nobody is accountable! Funny how it is now becoming mandatory to letpeople with no liability inject you with potions we have no way of knowing the actual formulation of. I’m sure this is nothing at all and that I am just being stupid/hysterical…

https://www.law.cornell.edu/uscode/text/42/300aa-22

the standard of evidence is much lower than in civil court

I know that I’ve said this before myself, but I’m starting to think that “Daubert doesn’t apply” is a bit more precise, just to separate the preponderance standard. Then again, it’s a blobular collection of screwballs that robotically screws up Bruesewitz.

It’s not mandatory. No government law or regulation requires you to be vaccinated for anything. That’s why we keep have outbreaks of vaccine preventable disease.

There are, however, consequences for refusing to be vaccinated. Your kid can’t attend public schools, and may have a hard time finding a private school that will accept them. You may be barred from traveling to certain countries, or attending the college of your choice. Your employer may choose to discipline or even fire you for not getting vaccinated.

But no one is going to come to your house and make you take a jab, or take you to jail if you refuse.

And we do know the formulation of our vaccines. Most of us can’t understand what that means, because we lack the knowledge, but the information is not secret.

The vaccine manufacturers are accountable. You can still sue them. You just have to go through the Vaccine Court first, and no court is going to accept a claim of autism because it’s settled science that vaccines do not cause autism.

I don’t think you’re being hysterical. Stupid, yes, because you should know better. But not hysteria . . . that’s feigned.

Not for refusing to vaccinate.

Have a measles or a chickenpox party, and that might be different. If your kid gets meningitis and you try treating it with maple syrup, yeah the authorities are going to take an interest even if your child doesn’t die.

But not for simply refusing to vaccinate.

It’s Disingenuous to deny that for most parents, vaccines are de facto mandatory. Most parents have no real alternative to public schools.

Now, personally, I think vaccines should be (‘full stop’) mandatory, so that we can live freer, healthier, happier lives. I also think the endless weakening of public schools should be ended. But come on man.

Most parents have no real alternative to public schools.

Most parents aren’t antivaccine cranks. If you want to be a professional mommy, pick a husband who can support you and your brood.

“Regular readers of this blog probably know that the only condition for which integrative medicine doctors recommend chronic antibiotics is chronic Lyme disease, which is a fake diagnosis.”

Wrong, and on a few different levels. First of all, there are a number of other conditions for which chronic antibiotics are prescribed. Ask any dermatologist how many teenage patients they have that have open prescriptions for doxycycline or minocycline for years for simple acne. I had an open prescription when I was a teenager, and took antibiotics for years to clear it up, all sanctioned by an MD. Never a word about super bugs, antimicrobial resistance, blah, blah, blah, only when it comes to treating Lyme disease, a sometimes fatal neurological infection. Only then do these antibiotics suddenly become a problem. Pimples? Here ya go, son! Take 2 a day until you feel you don’t need them anymore. Neuroborreliosis or Lyme carditis? No soup for you! If the CDC ever banned chronic antibiotics, most dermatologists would be out of business the next day. And that has been going on for decades, yet where are those darn super bugs!? Surely there should at least one by now killing pimply teenagers by the hundreds.

There are also plenty of studies going all the way back to Allen Steere showing viable organisms post-treatment in Lyme patients as well as all kinds of animal models. Steere called it…what was it now…oh yeah. “Chronic Lyme disease”. There have also been animal studies showing that an injection of a single spirochete is enough to give the animal a raging infection. You just can’t acknowledge it because you’ve promulgated this bogus meme for years, and have painted yourself in a corner and now can’t turn round without appearing a dim-witted fool to all the pseudoskeptics. I think you did the same thing with fluoride in the drinking water a few years ago, and then the ADA came out with a study showing kids suffering from fluorosis from too much fluoride. You didn’t go back and change your tune then, so I guess you won’t be doing so now regarding CLD. Hubris has no place in science.

Since Lyme disease apparently isn’t chronic, and is easy to cure in every circumstance with 21 days of oral antibiotics, there’s hardly any point in developing a vaccine for it is there? So what are you going to do now? You’re now trapped between promoting another Lyme vaccine and downplaying Lyme disease at the same time. Can’t wait to hear you try and slither away from that rock and adjacent hard place.

If the CDC ever banned chronic antibiotics, most dermatologists would be out of business the next day.

I do so enjoy waking up to utterly idiotic statements.

“I think you did the same thing with fluoride in the drinking water a few years ago, and then the ADA came out with a study showing kids suffering from fluorosis from too much fluoride.”

I can’t find the study to which you refer. If you cannot post a link, rant about a study to which you can link.

Fluorosis has long been observed in people living in regions with high natural levels of fluoride in the water supply. That is how the connection between fluoride and cavity prevention was first made. It isn’t a secret. It also isn’t a threat to public health. It is common, and mostly to a degree observable only to dentists.

What is your point?

Providing acupuncture after a very brief course of training is another example of doctors treating outside their scope of practice. Isn’t it?

Acupuncturists should be clamoring for doctors to have the required amount of training for them to practise safely. But they are not. Why not?

Perhaps because they could never demonstrate that you need more than a few weeks training to safely stick needles in the appropriate places to treat virtually every health problem under the sun.

Q. Why is integrative-medicine conceptually legitimate.

A. When placed in a crucible and all the irrelevance is burned away, fact remains (placebo effect).

Narad’s previous critique of my efforts has encouraged me to write in a different style. Thanks Narad!

@ Orac,

Very interesting post, and well written. My impression is Integrative Medicine would be dead in the water without “practice drift”. In my opinion healthcare constantly needs to evolve, and “practice drift” plays an essential role in its evolution.

Typical. MJD thinks medicine needs to “evolve” and that doing whatever you like is how that happens.

Medicine changes through rigorous science, not by feel.

Actually, integrative medicine is conceptually illegitimate because it refuses to places its ideas in the crucible of science and burn away what fails the test.

Cleander is apparently unaware that the standard of care in dermatology is to limit systemic antibiotic therapy (for moderate to severe acne) to 3 months, due to risk of antibiotic resistance developing.

http://aad.org/practicecenter/quality/clinical-guidelines/acne/systemic-antibiotics

Contrast that evidence-based recommendation with the common practice among “Lyme-literate” practitioners of keeping patients on antibiotics for years to combat a nonexistent infection.

Cleander: “Since Lyme disease apparently isn’t chronic, and is easy to cure in every circumstance with 21 days of oral antibiotics, there’s hardly any point in developing a vaccine for it is there?”

Preventing a potentially serious disease is preferable to having to deal with it after the patient becomes sick. That concept is difficult for many antivaxers to understand (seeing that many think contracting the disease is better than vaccinating for it, it’s surprising more don’t trumpet the “benefits” of “natural Lyme disease”).

I’m not denying the existence of “practice guidelines”, but my spouse (and many others with whom I am personally acquainted) have been on low-dose antibiotics for YEARS for acne. Hubby was told that the dose is sub-clinical and therefore doesn’t cause resistance. This didn’t make sense, but I didn’t debate it at the time since I didn’t have any facts to refute it.)

Totally OT but it’s Sunday and Orac’s minions might “enjoy” how ludicrous anti-vaxxers can be in their quest for attention…

Since late August, Jake Crosby has been furiously manufacturing exposes about “turncoats” ( scientists who abandoned AJW after participating in his infamous 1998 study): there have been loads of them ( Jake must be bored) and today he topped off the entire unsavory sundae of malignant reportage with rancid whipped cream and a decaying Maraschino cherry by posting an OBITUARY …
for a man who is ALIVE .. John Walker Smith.

I swear I am not making this up.

I wonder if his parents support of his activities relies on page views?

Honestly, much of what he’s posted recently borders on libel.

Yah, but he’s such a zero that he can’t really generate any damages. A few C&D’s (c/o his mother) might be amusing, but he’d probably just brag.

Probably what can happen at this point is that he’ll be summoned by nurse Ronda Rousey to come to the friendly shrink office for a quick checkup & med check…

Al

He’s an awful person, Alain, he’s not mentally ill. I mean, I suppose he might be, but the two don’t really correlate. I’ve had plenty of shrink visits in my day.

BTW, it occurs to me that I owe you some emails. Things got a little weird for a while.

JP,

It look to me that he’s pissed off, as in beyond 6 sigma pissed off and furious; an outlier of sort. That is the reason I thought he might benefit from a shrink visit. I don’t mean to imply he’s mentally ill but shrinks do take care of other issues beside mental illnesses (neurodevelopmental or personality too). In any cases, if he receive a C&D and does not abide to it, where do you think he’ll end up?

Alain

JP,

Don’t worry about the emails…East Europe (Moldova or Russia) brewery is nowhere near in the plans. In fact, I might have a good tale about what happened between then and now.

Al

This being the week J.B. Handley’s new antivax book officially is released (it’s going to Change Everything, unlike all the other antivax books published over the years), a glowing review has appeared over at the Millions of Deluded Woo Shouters website, written by Kent Heckenlively. Kent says in the review:

“Before I had a child with vaccine-induced autism I had the reputation among family and friends of being an honest person with unquestioned integrity. Today I’m a whack job.”

So Kent finally says something reality-based.

-btw- this guy is actually a lawyer and a science teacher.
How did he get through required reading for either degree?

When the law’s not on your side argue the facts. When the facts are not on your side, argue the law. When neither are on your side, just argue.

Can’t explain the science side. Memorize and regurgitate I suppose.

“Preventing a potentially serious disease…”

Potentially serious? Lol…you pseudoskepdicks have been downplaying Lyme disease for years, claiming its rare, hard to catch, easily diagnosed, trivial to cure, not chronic, only causes symptoms equivalent to the aches and pains of everyday living, blah, blah, blah. I guess you weren’t aware there was another vaccine in development that would require scare tactics were you? Tsk, tsk. Get with the program.

If the new LYMErix is a total flop, it will be because you pseudoskepdicks downplayed the seriousness of the disease to the point where little public demand exists for a vaccine. See, that’s the problem when you create a false disease definition. To keep the house of cards from collapsing you have to continually tell new lies and that can come back round to bite you.

“standard of care in dermatology is to limit systemic antibiotic therapy (for moderate to severe acne) to 3 months, due to risk of antibiotic resistance developing.”

Incorrect. I guess you either didn’t read the link you provided, have poor reading comprehension skills or thought no one else would read it and thought you could get away with misinterpreting the guidelines. What it actually says is:

“Systemic antibiotic use should be limited to the shortest possible duration, typically 3 months, to minimize the development of bacterial resistance. Monotherapy with systemic antibiotics is not recommended.”

It says here that the shortest possible duration is 3 months, not the maximum allowable treatment, implying typical durations are longer, which they most certainly are, often years in many cases, including mine. It doesn’t recommend a hard limit of 3 months like the Lyme disease guidelines do of 21 days, as you tried to imply.

I’d love to hear an explanation of how super bugs can be created by Lyme patients past the 22nd day of treatment, while pimply teenagers don’t start creating super bugs until at least day 91. That’s some new kind of “logic”. Even if 3 months was the hard limit, that’s almost 5 times longer than for Lyme disease. Its also been shown by Johns Hopkins that doxycycline can’t even kill a Lyme infection in a test tube under ideal conditions never mind in the human body that may also have picked up other tick borne disease at the same time. Do I need to include the fact that no one has ever died from acne? Why isn’t there a vaccine for acne anyway? Shouldn’t they be working on that if antimicrobial resistance is such a concern. There are far more pimply faced teenagers than Lyme patients after all.

So a minimum of 3 months of antibiotics (or much longer, in reality) for a nuisance ailment with no long term sequalae, but no more than 21 days for a potentially persistent and fatal brain and CNS infection that can cause heart block, Lyme carditis, and long term disabilities. Ok, sure, makes sense to me…lol. I haven’t heard of any dermatologists losing their medical license for long term antibiotic treatment like what regularly happens to doctors who treat Lyme disease over 3 weeks. Just goes to show what a complete illogical farce Pharma-based medicine has become these days.

Public demand for a vaccine?? We had a vaccine. It was withdrawn from the market due to anti vaxxers fanning the flames of vaccine fear.

The reason there is a time difference between Lyme treatment and acne treatment is due to different antibiotics that are used (cephalosporins vs tetracyclines) and the time of treatment for the condition itself. A 21 day course of a 3rd generation cephalosporin such as Rocephin is what is required to cure the Lyme infection. You don’t continue antibiotics beyond the time needed to treat to avoid the development of superbugs. It’s not that they develop automatically after 21 days, it’s the risk of them developing.

Since there is no such thing as chronic Lyme disease there is no reason to continue treating it after 21 days.

Severe Acne is tough to treat. You have a risk of developing antibiotic resistance with chronic use, but that risk goes up the longer you use the antibiotic. 90 has been determined to be the best balance between that risk and treating the acne. The scarring can be significant, and impact mental health. It’s not benign.

Chronic lyme is a fake disease. Ethical providers don’t treat fake illnesses.

Why isn’t there a vaccine for acne anyway?

Well, I suppose vaccinating against keratin could have some untoward consequences.

Quite the parade of strawmen.

It’s difficult to see how the AAD recommendation for a three month limit on systemic antibiotic treatment for acne has morphed into your mind into approval for therapy lasting years.Talk about lack of reading comprehension.

Lyme quacksters who subject patients to years of antibiotics for nonexistent bugs don’t just set them up for future drug-resistant infections, but for damaging side effects as well.

Ironic that you view guidelines aimed at preventing unnecessary and harmful use of Pharma drugs as “Pharma-based medicine”. 😀

Panacea,
There’s barely a single grain of truth in your entire post. Its all propaganda that’s easily disproved, so either you are just dense, spout nonsense for fun, or you are paid to gaslight patients. There’s really no other reason I can think of to tell such obvious untruths.

LYMErix was pulled because of “antivaxxers”? Lol…if antivaxxers had had the power to pull vaccines, MMR would be long gone. No, it was a bad vaccine, and the FDA was about to pull it had SmithKline Beecham not pulled it off the market voluntarily. This is all easy information to find on the internet.

“The FDA licensed LYMErix in 1998 after a hedged recommendation for approval by its Vaccines and Related Biological Products Advisory Committee (VRBPAC). The committee’s chair, Patricia Ferrieri, noted that “it’s rare that a vaccine be voted on with such ambivalence and a stack of provisos” (Altman 1998, A1). After the FDA’s approval, recommendations for use in clinical practice were taken up by the highly influential Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC). Some ACIP members considered LYMErix to be a “yuppie vaccine,” its “manufacturer-driven and consumer-driven” market limited to worried suburbanites who “will pay a lot of money for their Nikes and their Esprit and shop at L.L. Bean’s will have no consideration for cost-effectiveness when they want a vaccine because they’re going to travel to Cape Cod” (Dr. Chinh Le, testimony, ACIP meeting 1998).

ACIP members concerned with this “yuppie vaccine” steered the committee to a lukewarm “should consider” recommendation for people at high risk and a “may be considered” for others “exposed to tick-infested habitat but whose exposure is neither frequent nor prolonged” (ACIP 1998). ACIP member Paul Offit (personal communication, 2011) noted that it was highly unusual for such a lukewarm recommendation to be given to a vaccine approved by the FDA. In addition to the small numbers of people who would unambiguously benefit, support for LYMErix among regulators and advisory boards was hedged because (1) the trials had excluded children, limiting the vaccine’s use until the efficacy and safety for children were established; (2) boosters would probably be needed to keep a high enough concentration of antibodies in the tick meal to kill spirochetes; and (3) concern that vaccine’s side effects might appear with a longer follow-up (especially concerns about vaccine-induced arthritis, discussed later).”

Interestingly enough, Allen Steere does not recommend long term treatment with antibiotics for Lyme disease.

http://www.wbur.org/hereandnow/2014/06/24/chronic-lyme-overdiagnosed-steere

he’s been on what he’s called a “long journey” to research Lyme — in part, to debunk advocates, who he says too often claim that Lyme disease is chronic and should be treated with long-term use of antibiotics.

Steere acknowledges that a small number of some Lyme disease cases are persistent, but he tells Here & Now’s Robin Young that he advocates against treating it with long courses of antibiotics.

And I see that Johns Hopkins is still recommending doxycycline as the primary antibiotic to treat Lyme disease.

https://www.hopkinsarthritis.org/arthritis-info/lyme-disease/lyme-disease-treatment/

Also research is ongoing into what is categorized as Post-Treatment Lyme Disease Syndrome.

Post-Treatment Lyme Disease Syndrome (PTLDS) represents a subset of patients who remain significantly ill following standard antibiotic therapy for Lyme disease. PTLDS is characterized by a constellation of symptoms that includes severe fatigue, musculoskeletal pain, sleep disturbance, depression, and cognitive problems such as difficulty with short-term memory, speed of thinking, or multi-tasking. In the absence of a direct diagnostic biomarker, PTLDS has been difficult to diagnose by physicians, and its existence has been controversial. However, our clinical research shows that meticulous patient evaluation when used alongside appropriate diagnostic testing can reliably identify patients with typical symptom patterns of PTLDS. Our research also indicates that PTLDS symptoms can significantly impair daily functioning and quality of life.

And the NIAID has funded three studies of antibiotic treatment of PTLDS with negative results.
https://www.niaid.nih.gov/diseases-conditions/chronic-lyme-disease

And another study showed that

people receiving antibiotics did report a greater improvement in fatigue than those on placebo. However, no benefit to cognitive function was observed. In addition, six of the study participants had serious adverse events associated with IV antibiotic use, four requiring hospitalization. Overall, the study authors concluded that additional antibiotic therapy for PTLDS was not supported by the evidence

Cleander, your first paragraph demonstrates you really have no answer to what I told you. The rest of your response is argumentum ad nauseum, completely off topic.

I exposed your false claims about the pending new version of Lymerix. Regardless of what the FDA said, the original vaccine was approved, and about 1.5 million doses administered. It worked well, about 80% effective. But it had side effects, particularly arthralgias. Anti vaxxers jumped on that with the vaccine hesitant, and use dropped. It wasn’t profitable to produce, so it was withdrawn.

If the new vaccine resolves that issue, people will get it. It’s just that simple.

My reply to Panacea (her reply, 927pm 16 Sept 18) is missing. Just so I don’t get accused of being a drive by…

Props to Cleander for alerting me to an interesting article about the fate of Lyme vaccines. Too bad his cherry-picked quote doesn’t accurately convey the substance and conclusions of the article.

Antivaccine advocacy did in fact substantially contribute to the demise of LYMErix. However it wasn’t a traditional antivax campaign, but one driven heavily by Lyme advocacy groups committed to a broad and unscientific definition of Lyme disease. From the article Cleander quotes:

“The LD advocacy community initially supported the vaccines but soon became critical opponents. The vaccines’ success was seen as threatening their central position that LD was chronic, protean, and difficult to treat. The activists’ opposition flipped the vaccines’ social and psychological efficacy. Instead of the vaccines restoring control and reducing fear, demand was undermined by beliefs that the vaccines caused an LD-like syndrome…
One lay advocacy organization that SKB (SmithKlineBeecham) initially supported was the Lyme Disease Foundation. At the 1998 VRBPAC meeting that ultimately gave approval to the vaccine, Karen Vanderhoof-Forschner, the foundation’s president, offered passionate support for LYMErix. Similar in many ways to the SKB-sponsored clinician who addressed the meeting, Vanderhoof-Forschner argued that LD was a geographically widespread, underdiagnosed, chronic, devastating, and costly disease—and thus worthy of prevention by vaccination. But in 2001 she told the same advisory board that the vaccine “represents an imminent and substantial hazard to the public health and needs to be immediately recalled.” Why did she change her mind so quickly? LD advocates were not, of course, against preventing the disease per se but were against the way the vaccine might reinforce the idea that LD was an acute, unproblematic, and clinical entity. For many in the heterodox community, the vaccine, the vaccine’s scientific efficacy, and the narrow disease definition had become mutually reinforcing concepts. Once the vaccine’s efficacy was established, there was a collateral implication that the narrow diagnostic criteria used to establish this efficacy “worked” as well. This type of stabilization of both the technology and its target is sometimes understood as “co-production” in science and technology studies (Jasanoff 2006). The heterodox antipathy to the vaccine also might have followed from the potential impact of widespread vaccination to reduce the ability of people to claim they had LD. Although there was never any evidence of this motivation, it was clearly in the minds of LD vaccine supporters. David Weld, executive director of the American LD Foundation (perhaps the sole advocacy group that supported the orthodox position), in testimony at the 1998 ACIP meeting, had wondered out loud if the vaccine “may be very beneficial in that it’s going to reduce the incidence of a lot of people claiming to have Lyme disease when they don’t.”

http://ncbi.nlm.nih.gov/pmc/articles/PMC3460208/

So the rational conclusion is that LYMErix was taken off the market not because it was unsafe, but because of economic factors and scaremongering (promoted by the “Lyme community”) over alleged health risks of the vaccine which did not pan out. As a result, we’re left with an effective and successful Lyme vaccine for dogs – but not for humans.

“Although there was never any evidence of this motivation, it was clearly in the minds of LD vaccine supporters.”

So no evidence of such claims. Am I supposed to take this on faith then? Anyone can say anything they want about what’s in the minds of others. Hardly something to hang your hat on.

As stated in your quote, the Lyme disease community were not “antivaxxers” at all as erroneously repeated ad nauseam above (“antivaxxers” seem to be the default punching bag at this blog regardless of the evidence), but were stalwart cheerleaders of it. Perhaps if the vaccine worked well, and the Lyme disease test hadn’t been rigged at the Dearborn conference in order to make LYMErix look more effective that it was, they would have continued to support it. But bad science is bad science, regardless of the impact on Pharma profits.

I was led to believe that vaccines weren’t profitable anyway, so why would its lack of profit lead to it being pulled off the market? All the research had already been done and paid for, so pulling it off the market due to “low profit” makes no sense at all, since once the vaccine is approved, its all profit after that. The expensive part was the development, approval process and marketing of LYMErix, not its manufacturing, and that had already been done. You need to keep your narrative consistent.

So you’re 100% behind the effort to genetically engineer the mice on Nantucket so that they don’t transmit Lyme disease? That’s excellent!

The gaslighting by commenters is approaching professional levels on this blog. Where did you get your training for it? North Korea? Of course, it doesn’t work on me, I see right through it, so its a bit of a wasted effort, but I do have to admire the mastery of the technique.

Gaslighting: to make someone question their own sanity.

No one here is gaslighting you. We think you’re nuts (well I do) but that’s what I think about you, because your position is nuts and your response to criticism is to deflect and double down.

But that’s not what I’m trying to get you to think about yourself.

You have a simple solution: stop with the cherry picking and distorting the facts, and be willing to accept you may be wrong when confronted with evidence.

The North Korean Gaslighters recorded a dynamite version of “Winchester Cathedral” back in the ’60s.

Well, I feel obligated to put this somewhere:

I’ve been giving psychedelics to fruit flies for years in my lab, but had yet to have seen one given to an octopus.

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