Woo in the medical profession?

Great Debates
61

DSeid, perhaps you will note that any trials comparing one treatment to another for ailments like pain suffer from a major flaw that can sometimes make woo look valid: the results are based on subjective evaluations by human beings. “Do you feel better now that you’ve had some treatment?” can be influenced by many factors and is the probable reason placebos sometimes outperform non-treatment.

Woo medicine can’t fool a petri dish. Penicillin isn’t affected by how you feel about it. This is why alternative medicine loves trials using humans as the laboratory. They are much more likely to get the results they want, not necessarily by out and out fraud, but subtle influence. Check out the Hawthorne factor, for example.

62

I don’t dismiss acupuncture entirely. I do think its stated basis is hooey.

I am skeptical that any form of migraine prophylaxis has all that great a chance of working in any particular migraine sufferer (excluding the avoidance of known triggers in diet). I have recommended various herbs/supplements (including feverfew and magnesium) to a family member suffering from frequent severe migraines. What eventually had modest efficacy for her was a low-dose calcium channel blocker. Whether that was placebo effect or not I can’t say. To hopefully not repeat myself unduly, any placebo-type therapy recommended in the knowledge that it has no demonstrated efficacy should be inexpensive and overwhelmingly safe.

I agree with much of what you’ve said here. I think there do have to be times that physicians have responsibility to label quackery as such even if it’s not what a patient may want to hear. And that includes enablers of quackademic medicine establishing feel-good and money-generating CAM operations promoting such things as homeopathy.

63

If it hasn’t been tested, but is being prescribed as a cure, it is indeed hugely quackery. By definition.

Note how many items in your Cochrane reports wail that few tests have been done, and those that have are negative or inconclusive. Now if you recommend that treatment to someone with that little evidence of efficacy, you are a Big Quack, not a scientist.

Evaluate it first, then prescribe. Woo does the opposite, and rarely goes to step two.

64

Windex is the miracle drug. Works for anything.

65

Musicat, if you think that I am a quack if I recommend an approach that fails to meet Cochrane’s standards of testing and positive trials, then I can promise you that I, and 99.99% of other docs are quacks. Evidence is often sparse or at least inconclusive. Much care is decided based on personal anecdotal experiences, either our own or that that others have shared with us, not big trials.

Most of the woo is not currently being sold as “cures” but as “treatments”. And what Jackmanni did for himself is often the place it holds: there is an annoying condition that traditional care is failing to treat well; an alternative care approach is something else to at least try with little potential for harm. He tried it with full knowledge that it was an unproven approach and with full knowledge that there is a huge placebo effect. It didn’t work but it could have, even as a placebo. Jackmanni appreciates that his experience was one anecdote, but I would bet you that as hard-nosed of a scientist as he is to his core, that if he got better at the same time as he was treated, his thoughts on acupuncture would be a bit softer than they are now.

If a possible treatment is, as Jackmanni requires, “inexpensive and overwhelmingly safe”, as much woo is, and is not replacing a proven more effective approach, then the being unproven does not mean it is quackery, and being based on bunkem does not mean that it cannot work (for other reasons not yet understood).

TriPolar, well you know we do like to have transparency in our clinical decision making.

66

That will come as a big shock to the FDA and the AMA.

67

I’m very sensitive to woo in my discipline, psychology, given our history and the tendency for the field to draw people in who are less than scientifically minded. We’re best when we live up to the scientist-practitioner model that we set as a standard. We also likely suffer from a difficulty distinguishing us from non-psychologist therapists and life coaches and others who do all kinds of crazy things. I want the “Ph.D.” and the term “clinical psychologist” to represent a standard that people can rely on.

Nevertheless, we still have things like EMDR (eye movement desensitization and reprocessing), which takes the standard, effective treatments for anxiety disorders and adds a non-therapeutic procedural component (waving your finger back and forth in front of the person and asking them to track it with their eyes). It was developed and turned into a franchise and still has a bunch of adherents, even though the effective component (eye movement) turns out to be equivalent to any “bilateral stimulation” (e.g. alternative tapping on shoulders) and the targeted treatment (anxiety) has gotten broader and broader. (Interestingly enough, the strengths of EMDR was a subject of an argument between DSeid and myself in the past. He may be more given to woo than he realizes.)

What we need to do is insist on more research that directly compares treatments, because presently most research demonstrates that our interventions are better than treatment as usual, or attention-based control conditions, or wait-list/non-treatment control groups. These are useful studies, but they don’t help establish or rule out specific mechanisms for change (like moving your eyes from side to side).

Fortunately, psychology also has an exceptional history of very strong empirical research, so there’s no need for a paradigm shift in order to improve.

68

I’m not defending woo, but I’m shocked at how easily people are willing to believe that medicine is a cut and dried entirely algorithmic thing.

Even the basic definition of “who is sick” is extremely subjective. To give an easy example, in a culture where reading is important, being even a bit blurry eyed is a disability. But in a culture where you have to walk three miles to water, plenty of people who are considered able-bodied in our culture would be disabled.

Culture does matter when deciding treatments. If someone cannot read, it is probably better to give them a drug that can be taken once a day, even if it is slightly less effective than a more complicated regime.If someone for whatever reason finds a particular treatment objectionable, it’d be wise to consider that when designing a treatment plan.

There are countless decisions that doctors make by “feel” and individual quirk- anti depressent drugs or CBT? If drugs- which anti-depressant to start with? Which birth control method? Aggressive or conservative cancer treatment?How long do you keep trying treatments that harm quality of life and offer only slight chances of working? There are not quick’n’easy guidelines for these things.

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Actually it won’t shock any of them at all.

70

It should be noted that politicians are a major force pushing for incorporation of woo into mainstream medicine.

The top figures who’ve long stood behind slack regulation of “nutritional supplements” are Senators Tom Harkin and Orrin Hatch (Harkin is also a big booster of the National Center for Complementary and Alternative Medicine, which has spent hundreds of millions of dollars researching woo to little or no effect). There was a push on from numerous members of Congress to incorporate woo into the health care reform bill, and apparently there’s plenty of room in the legislation that passed Congress to spend taxpayer dollars on such strategies.

"The Advisory Group on Prevention, Health Promotion, and Integrative and Public Health — which will inform the Council (set up under the health care reform bill)— is directed to be “composed of not more than 25 non-Federal members to be appointed by the President.

” In appointing members, the President is advised to ensure that “the Advisory Group includes a diverse group of licensed health professionals, including integrative health practitioners who have expertise in worksite health promotion;

 community services, including community health centers;

 preventive medicine;

 health coaching;

 public health education;

 geriatrics; and

 rehabilitation medicine.” (bolding added).

“Integrative medicine” is an umbrella term that basically means combining alt med with mainstream medicine, introducing such modalities as herbal medicine, acupuncture, massage, “therapeutic touch”, yoga etc.

Part of this effort is the continuation of alt med’s attempts to hijack wellness promotion (using the false notion that diet, exercise, and lifestyle changes have been ignored by mainstream medicine and are the province of alties). Should there be some effort to provide patients with access to proven relaxation and stress management options? Fine. This should not mean that limited health care dollars are plowed into dubious interventions and outright quackery like homeopathy. And yes Dr. Seid, dubious and unnecessary interventions utilized by mainstream medicine should also be eligible to get the ax.

Expect the facilitation of non-evidence-based care by taxpayers to be a continuing controversy in the U.S. in years to come (it took the British long enough to act to curtail homeopathic woo funding in the National Health Service).

71

Oh, this deserves a comment.

One man’s woo is Cochrane’s effective treatment I guess.* Yeah you mean this thread, the one in which I provided cites that documented that EMDR was as effective as CBT with less at home work required by the patient and in no more and possibly fewer sessions.

That “woo”?

Yeah, that was a good illustration. It has solid evidence that it works. And you choose to ignore that evidence because you already know what works and what is woo. Yes, I will look at the original evidence and at the reviews by reliable evidence based medicine reviewing organizations with an open mind and not just defer to “an expert” as you suggested … I am funny that way; I have found too many experts who do things that are not based on any evidence at all or even that go against the evidence. If that is being “given to woo” then I am happily so inclined.

*A cite that Jackmanni had provided btw.

72

Yes, that woo, and I think it is a perfect example.

Relative to the thread, this may either be an unhelpful side-track or a nice case study of how pseudoscience can still permeate a professional scientific field. I think it is the latter, but apologize if it is the former.

In short, EMDR is a treatment based on the premise that moving your eyes from side to side has some curative effects for psychological disorders. The problem is that it essentially consists of taking already established effective treatments (cognitive behavioral treatment, or CBT) and adding in the side to side eye movement. As a result, when compared to no treatment or attention-control treatments it appears to be effective, but when compared to CBT, it does not show any greater benefit. There actually is not good evidence that it works any faster than CBT, nor is there good evidence that the eye movements do anything.

It’s a bit like Big Toe Squeezing Treatment for Type I diabetes, if that treatment involved the regular squeezing of the big toe along with the systematic administration of insulin. Instead of value-added treatment, it’s pretty much woo-added treatment.

The treatment was originally developed for PTSD, but has been applied to anxiety disorders in general, and then mood disorders, personality disorders and even couples therapy! The proponents of the treatment also suggest now that it is “bilateral stimulation” rather than eye movements, since it appears equally effective if you tap alternatively on people’s shoulders as if you have them track your finger from side to side. The expanding utility and the expanding and as yet unexplained mechanism of action appear to not deter proponents at all.

Here’s some easily read but thoughtful skeptical reviews of the issue. As Lillienfeld concludes in the Scientific American article, in regards to EMDR: “What is effective in EMDR is not new, and what is new is not effective.”

http://www.skepdic.com/emdr.html

73

We agree that it is a good example. That’s a start anyway! :slight_smile:

Let’s keep this on track for the subject at hand though.

My issue is with the bias that you evince. You don’t like the fact that EMDR is commercialized, that getting certified to do it costs, and that the story of why it works makes little sense to you. To me those issues are irrelevant to the question of whether or not it is evidence based.

To me the questions vis a vis patients using it are these:

Does it work better than a control group and as well, better, or worse, than as “standard” approaches?

If so does it do so with any additional risk to the patient/client, less risk, or the same risk?

Is it any more or less cost effective both in terms of dollars and in terms of patient time investment?

Whether or not the proposed explanation is true is not one of the questions that matter in this regard. They matter to research, but not as a matter of clinical practice and use.

EMDR works better than untreated, as well as standard CBT, with no additional risk or cost either in terms of dollars or in terms of time. Full stop. I can endorse a patient using it with the same confidence I can endorse a patient using CBT.

Now you are stating that it is not clear that the alternating movements is not just a misdirection, a magician’s wave of the hands that has nothing to do with how rthe trick is actually performed. And maybe you are right. And maybe the homework given with CBT, that is standard according to CBT’s main bodies (as linked to in the past thread), is also a misdirection as well. The SciAm article at least offered a study that suggests some evidence that the same approach without the rapid alternation (fixed vision I think they called it) gave results that were not significantly different than with the rapid alternating part. To me the evidence is not complete to be able to say what aspects of CBT as done in the studies, and what aspects of EMDR as done, are essential and which are unneeded. Both should be subject to the same additional reviews to determine that. Meanwhile I am left with my conclusion as made: the approach works as well as standard CBT with no additional risk or costs and maybe less patient time investment than CBT as often practiced (since “homework” is usually required). Period. Patients can be told both work equally as well.

These are the key questions for proposed patient care options, traditional or alternative, not whether or not I buy into the proposed mechanism of action, and not if I like how it is sold.

74

Okay, I get that from a clinical treatment and non-mental health practitioner perspective, you don’t care about the differences between the established treatment and the woo-added treatment, since no distinctions in risk or outcomes are evident.

Would you feel the same about recommending that parents seek Big Toe Squeezing Treatment for Type I diabetes instead of the established treatment?

75

If a patient family wanted to use the Big Toe approach I would tell them that there is is no evidence that convinces me the extra work is needed but that there is no harm in doing it. I would be curious about why they wanted to do the Big Toe method (which does add the extra “cost” of the time of the Toe Squeeze with no obviously apparent extra benefit). For all I know I could find out that, for that family, that process ritualizes giving the insulin in such a way that they had fewer missed doses and/or were more accurate, or that the child had a fear of needles and that the Big Toe Squeeze helped him/her overcome that fear and enabled them to do the shots with less distress. Who knows? If in some way it made it easier for this particular child to stay fully compliant and to therefore hit a target A1c with minimal hypoglycemia episodes then I’d endorse it wholeheartedly for that family.

Now of course my understanding of CBT and EMDR is that they differ in other ways other, that EMDR is not exactly the same as typical CBT with an extra step of rapidly alternating stimuli, but the fairness or lack thereof, of the analogy doesn’t matter. What I’d ask is the comparable question back: if indeed EMDR was the exact same protocol as used for CBT with an additional Big Toe Squeeze protocol thrown in, and people with PTSD are able to be told that both work, then what about EMDR is driving them to choose it? Is the Big Toe Squeeze serving some function for them that makes the approach more appealing or a that makes them a bit more likely to fully comply with the treatment plan? And if so, and if what is being done will work just as well in any case, with no more effort, time, cost, or risks, than the “mainstream” approach, then supporting that choice is clearly in my patient’s best interest and good medicine.

76

CBT, EMDR, PTSD, A1C, BTS…I just love it when you talk in acronyms.

77

My intended question was whether you would recommend this, i.e. prescribe it, not whether you would endorse someone’s desire to use it. That is, as a professional, would you select the woo-added treatment as your preferred choice or the one without the non-functional piece of magic added to it?

Your reframe is interesting, because you make it sound like people are making some kind of informed decision between the treatments. I suspect that they typically are not. They’ve probably heard that EMDR is effective from trusted professionals, not that it is CBT with magic finger waving, or alternating auditory cues, or whatever else the mechanism has morphed into.

Remember, people thought that Franz Mesmer was helping them to alter the flow of energy through their bodies by his use of animal magnetism via passing his hands over their bodies. Many felt the improvement and believed it curative. Mesmer originally thought that magnets were necessary, and then the mechanism morphed into a force that his hands alone could manipulate because of his own magnetism. The medical professionals of the day had enough sense to run him out of town, and that was in the late 1700s. Perhaps we are moving backwards? Or perhaps you would endorse Mesmerism for your patients?

78

Sorry.

In order:

Cognitive Behavioral Therapy.

Eye movement desensitization and reprocessing.

Post traumatic stress disorder.

Hemoglobin A1C.

And I’ll pass on BTS.
Hentor, certainly I try to have that informed decision making be some kind of goal with patient families I am involved with. And I think that many people who are making choices that I disagree with are still engaged in some sort of informed decision making, even if sometimes the information they have received is inaccurate or incomplete. The answer to that is not to take the patients out of that loop but to more fully inform with an understanding of what they already think they know.

Mesmer and the professionals of his day. Ah yes, the medical professionals of the day who were doing things like blood letting and leeches and cutting things open and going in with bare hands when doing nothing would have been the much better option. Yup, noble defenders of evidence based medicine and the scientific method they were. A control trial would have shown better results for Mesmer than for mainstream practices of the day. So yes, I’d have preferred Mesmerism than have standard mainstream care of the day.

79

So, it’s all or nothing then? Seems like you’re being a little twisty with this. Besides, people still use leeching and bloodletting today.

But nevermind that, you’ve answered the question. You’re quite comfortable with woo, if that is what the patient wants and if they believe it has curative properties. I’d prefer that professional practitioners educate people, but I know time is short when dealing with physicians.

80

Talk about twisty!

I am evidence based and what story is told abut mechanism matters naught in deciding what actually has evidence to show that it works and how much risk and cost the care entails. It’s really pretty straight forward.

Educating patients, in my experience, works best when it is not lecturing patients and dictating to them, but rather engaging them in an interactive learning process. which begins with understanding what they already believe and why. Yes time is short but it usually ends up not taking any longer to do it that way in the long term as that process earns me a certain cred when I advise something else in the future. I think more docs do it that way than you think.

But yes we are at a point where “nevermind” is a good place to leave it.