Friday, November 16, 2007

Alternative medicine promoted to hospitalists attending CME course

I revealed in last night’s post that the Mayo Clinic CME conference in hospital medicine I’m attending had “integrated” some woo into an otherwise excellent assemblage of “hard core” scientific content. I decided to reserve judgment until after the two lectures in question were delivered today. My verdict? Mixed. Some valid points and eye opening statements were made. But much of the content, from where I sat, consisted of uncritical promotion of non-evidence treatments, suggestions of biologically implausible mechanisms and a certain amount of bobbing and weaving. Let me explain.

There were two speakers. The first one discussed general issues of CAM in hospital medicine. He opened his talk declaring that, like it or not, CAM is now very much a part of our health care system and went on to present data on the recent “CAMbrian explosion” (my words) in hospital medicine. Some interesting data on the demographics of CAM use were presented (it’s really high, as one would expect, in cancer patients) along with some discussion of the hazards of herbal medicine (St. John’s wort is a big inducer of metabolism of many drugs---watch those antiretrovirals, antirejection meds and warfarin!).

He also touched on stress medicine. The study of stress and its effects on health (brain-body medicine) is not total woo although it is plagued by methodologic obstacles. From the point of view of scientific validation brain-body medicine is not ready for prime time. On the other hand do we really need a study (the speaker dutifully cited many) to know that if music or a nice massage relaxes you it probably does some good in some way?

The second speaker, who focused on acupuncture, was more problematic. When pinned down he allowed that we don’t really know how acupuncture “works”, although spoke of the existence of the vital energy Qi and the meridians through which it flows as undisputed facts. It’s the blockage of Qi, he said, that causes illness and pain.

He made the claim that the body’s 400 and some odd acupuncture points can be verified by changes in electrical resistivity and are reproducible in location from one person to another. The history of how the locations of these points were determined, however, leads me to suspect that the science behind such a claim is dubious. According to Dr. Wallace Sampson, professor emeritus of medicine at Stanford:

First, most people assume that it's an ancient Chinese cure that has existed, unchanging, for centuries. Not so, says Sampson, noting that "acupuncture was formalized in a complex way over the past 100 years, mostly in Europe and France and after the Communist takeover in China. Before that time there was no consistent formalization of acupuncture points or what each place was supposed to do. It was largely regional, and the thinking varied from city to city."

According to an article from Quackwatch, the purported acupuncture points were at one time 365 in number, corresponding to the days of the year!

Treatment is applied to "acupuncture points," which are said to be located throughout the body. Originally there were 365 such points, corresponding to the days of the year, but the number identified by proponents during the past 2,000 years has increased gradually to about 2,000 [1].

With such confusion about where the “real” acupuncture points are supposed to be the claims of “sham acupuncture”, the new and sexy standard for research reports, become meaningless. Sham acupuncture studies are blinded to the patient but not the therapist. What’s the actual difference, then, between sham and “real” acupuncture? Do the sham therapy sessions apply the same personal touches and TLC as the real ones?

This speaker, in my view, was inappropriately and uncritically promotional of acupuncture.

Attendance at these lectures afforded me a unique opportunity. My knowledge of the woo invasion of mainstream medicine, up to now, was based on reading---reading of medical journals, medical school web sites and a few blogs. Today, by experiencing it first hand, I came to appreciate the problem on several new levels. I was amazed, for example, at the utter lack of audience reaction, even during the presentation of the worst of the woo---no snickers, groans or shaking heads and no skeptical audience questions (except for mine!).

Most eye opening for me was my interaction with the faculty during Q&A. Remember, these are Mayo Clinic faculty members, not woomeisters from the community. As such, their responses represent the official academic “party line” on CAM. I asked the acupuncture speaker if the energy flowing through the meridians could be measured, and in what form it was transported (e.g. as heat, phosphate bonds, etc.). He answered, without explanation or elaboration, merely that yes it had been measured, and smoothly deflected the question of how or in what form the energy was transferred.

The other presenter had mentioned Yoga and I asked him, in effect, what the placebo should be. In other words, to what extent has Yoga research employed comparison groups using sham postures and mantras with reasonably equivalent relaxation and conditioning value. The speaker, who is the director of Mayo’s complementary and integrative medicine program, indicated that little if any of the Yoga research has been conducted according to this rigorous standard. In fact, control groups in Yoga research have consisted of patients on waiting lists for Yoga classes!

The responses of these faculty members, the best and brightest in the field of CAM who are trying to put the best foot forward, convinced me more than ever before how faulty present day “research” in CAM actually is.

And I shouldn’t be surprised that Mayo is promoting this sort of thing. After all, they’re on Orac’s list.


The honest herbal said...

As a practicing acupuncturist I would like to offer the Contemporary Medical model to explain the therapeutic effects produced by acupuncture.
The western approach involves assessing the client with an emphasis on neuromuscular anatomy through history taking, inspection and palpation. Location of the neuromuscular junctions proximal to the affected area are used to design a treatment plan which involves the local, segmental and central aspects of the nervous system. Insertion of the acupuncture needles stimulates the real production of endorphins, endogenous opiates and the localized immune responses of the body. There have been studies which confirm these levels do increase in the blood when needling has targeted those neuromuscular junctions that are functional.

ONE THIRD of all clients will experience NO therapeutic effect as the production of CCK within the digestive system will interfere with uptake.

I can state confidently that the procedure when administered by the Contemporary Medical Model in receptive females produces endocrine changes that do regulate hormonal fluctuations.

The Eastern philosophy is rich in history, however I suspect tainted by a class society which endorses mystic details for the purpose of elevating doctors to a higher status. Western medicine has long used latin to distinguish it's authority over the average patient. The use of coded language found within the TCM practice may simply be the mechanism of distinguishing class. There is no doubt that the language of TCM has become convoluted over the centuries, however the practice of acupuncture has very real therapeutic benefits for a percentage of the population.
I respectfully submit that the doctors of North America put to use their knowledge of neuroanatomy to discover the that acupuncture does have a legitimate place in some patient treatment plans.
Nancy Winlove-Smith
Certified Contemporary Medical Acupuncturist
Certified through the McMaster University Contemporary Medical Acupuncture Program

Jonathan Hearsey said...

The CAM Bubble has burst, in my opinion. Certainly in the UK. CAM needs to change.

Great Blog,


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