 Hello again. I'm Dr. Harriet Hall, and this is lecture two in a series of ten lectures on science-based medicine. In the first lecture, I talked about what science-based medicine is. Now I'll talk about what it isn't. Alternative medicine. Today it's more commonly referred to as complementary in alternative medicine, and that's a mouthful. It's easier to cut it down to one syllable and just call it by its acronym, CAM. Sometimes, CAM rejects science entirely. Sometimes it tries to use science and fails. Even when CAM claims to have scientific evidence to support its claims, that evidence doesn't measure up to the rigorous standards of good science. This lecture will be a general discussion of CAM, and in future lectures I'll cover specific areas of CAM like acupuncture, chiropractic, and homeopathy. What is CAM? An old definition of alternative medicine was stuff that isn't taught in medical schools. That definition doesn't really work anymore, since CAM has been sneaking into our medical schools. More about that later. But here's a list of some of the things that weren't taught in my medical school. In fact, I'd never even heard of most of the things on this list when I graduated back in 1970. I had heard a few of the things on this list, like chiropractic and acupuncture, but I didn't understand enough about them to have formed any opinion. And I'd never heard the term alternative medicine. Back then we would have dismissed most of the things on this list as folk medicine or superstition or quackery. Some of them sound more reasonable than others, like herbal medicine. After all, herbal medicine was the beginning of scientific pharmacology. But some of them are just batshit crazy, like sticking lighted candles in your ears or drinking your own urine or deluding all the active ingredient out of a remedy to make it stronger. Now, about the time I graduated, a new term was coined, alternative medicine. It was an umbrella term that lumped all the things on that list together. The impossible right along with the more plausible, the untested right along with the ones that had already been tested and proven not to work. Later, in the 1980s and 1990s, we started to hear the terms complementary medicine and integrative medicine. Alternative medicine may be used alone as an alternative to conventional medicine, or people may hedge their bets by using both alternative and conventional medicine at the same time. Complementary medicine, by definition, is never used alone. It's used along with conventional medicine to complement the conventional treatment. Integrative medicine implies that you don't just use alternative medicine along with conventional medicine, you somehow integrate two into one unified, coherent system of practice. Now, I want to lodge a protest here. There is really no such thing as alternative medicine. There are only treatments that have been tested and proven to work and treatments that haven't. If a treatment had been proven to work, we wouldn't call it alternative, we just call it medicine. My colleague Steven Novella explains that CAM is a political ideological entity, not a scientific one. It's an artificial category created for the purpose of promoting a diverse set of dubious, untested, or fraudulent health practices. It is an excellent example of the successful use of language as a propaganda tool. Some people prefer to call it so-called complementary and alternative medicine, or supplements plus CAM. Either of those gives the convenient acronym SCAM. Science-based medicine starts with an idea, tests it, and if it passes the test, then it applies it to patients. CAM bypasses the step of adequate testing. It's a shortcut from idea to bedside. Let's look at this list again. The real question is not what to call those things, but whether they work. I don't think anyone believes that everything on this list works. If they do, they're not being rational because some of these things are incompatible with each other. But for every item on this list, there are people who are convinced that it works. It's curious that they never seem to fight amongst themselves. You never hear of debates between acupuncturists and homeopaths. Practitioners of one system sometimes incorporate the practices of another system, like chiropractors who adopt acupuncture or who recommend homeopathic remedies. They never seem to care that if the beliefs behind the other system were right, the beliefs behind their own system would have to be wrong. Now, CAM typically attributes all disease to one imaginary cause. Chiropractic claims that all disease is caused when spinal bones get out of alignment and interfere with nerve function. Homeopathies inventor Samuel Hahnemann believed that all disease was caused by miasms. I'll explain about that in lecture five. Acupuncture attributes all disease to disturbances in the flow of a mythical life force called chi. Ayurveda attributes disease to improper digestion, being out of harmony with the environment, and ama due to aggravated doshes. When I think of aggravated doshes, I can't help imagining an angry vicious cartoon beast like the Tasmanian devil. And Christian science says that all disease is merely illusion due to a lack of faith. A few years ago, I did an internet search for the one true cause of all disease. And I found 67 of them. There were probably a lot more, but I got tired of looking at that point. Here's just a few of them. Allergies, oxygen deficiency, toxins, food acidity, parasites, a congested colon, yeast, free radicals, inadequate nutrition. The list went on and on, and it got sillier and sillier. Perhaps the silliest was the United KKK States of America is the one true cause of all disease. Now, I don't know what that means, and I don't think I want to know. So there are at least 67 one true causes in all. Is this some kind of new math where 67 equals one? If all disease is caused by toxins, it can't very well be caused by parasites. If it's parasites, it can't be a congested colon. When scientists encounter two mutually exclusive claims, it bothers them. They experience cognitive dissonance, and they try diligently to find evidence to reject one of the competing hypotheses. They eventually reach a consensus. Now, alternative medicine pseudoscientists don't seem to be bothered by cognitive dissonance. They're content to look for evidence to support their own chosen treatment, and they blithely disregard any competing claims. They don't want to look for evidence that something doesn't work. While each claims to know the one cause of disease, they don't seem interested in looking for the one reality. Often, they don't believe there is one truth. As one woman said to me, it could be true for you, but that doesn't mean it's true for me. In his book, Voodoo Science, here's how Bob Park described a press conference held by representatives of the Office of Alternative Medicine. One insisted that the number one health problem in the United States is magnesium deficiency. Another was convinced that the expanded use of acupuncture could revolutionize medicine, and so it went around the table with each touting his or her preferred therapy. But there was no sense of conflict or rivalry. As each spoke, the others would nod in agreement. The purpose of the OAM, I began to realize, was to demonstrate that these disparate therapies all work. It was my first glimpse of what holds alternative medicine together. There is no internal descent in a community that feels itself besieged from the outside. Each CAM recognizes its own single cause of all disease, a single cause that is wrong. Science recognizes that there are many causes of disease, and it organizes them into these nine categories under the acronym Vindicate. V for vascular, I for infectious or inflammatory, N for neoplastic, D for drugs and toxins, I for interventional or iatrogenic, in other words caused by treatment, C for congenital and developmental, A for autoimmune, T for trauma, E for endocrine and metabolic. And science recognizes that a single illness can involve more than one cause, for instance, when a traumatic injury becomes infected. We're seeing a trend where obsolete treatments are making a comeback. The top picture is the Royal London Homeopathic Hospital founded in 1849. It's still in business, but it recently changed its name from homeopathic to integrative. The bottom picture is the Massachusetts Homeopathic Hospital around 1916. Now back in 1900, there were 79 homeopathic hospitals in the U.S. The last one closed in 1950. So homeopathy was almost extinct in the U.S., but recently it seems to be reviving. Some healthcare providers are recommending homeopathy, and homeopathic remedies are being sold over the counter in pharmacies. So what happened? Why did those old discredited treatment methods that had almost disappeared start to come back in the 1980s and 90s? In 1994, the U.S. Congress passed the Diet Supplement Health and Education Act, exempting herbal medicines from FDA regulation under the pretense that they were diet supplements intended to be used as foods rather than as medicines. In 1998, the NIH founded the National Centers for Complimentary and Alternative Medicine to do scientific studies on alternative medicine. Insurance companies began paying for things like acupuncture and chiropractic. And some of these formerly discredited treatments were introduced into hospitals and medical schools in a movement that we call quacademic medicine. I'll be coming back to these issues in lecture 10. How did attitudes change? Why is CAM suddenly so popular? Well, there's no simple answer, but I think there are several reasons for the trend. For one thing, science had a run of outstanding successes. Antibiotics cured pneumonia. We eradicated smallpox. We transplanted kidneys. We expected science to go on to cure cancer and every other disease. And when that didn't happen, we got frustrated. We're healthier than we've ever been, and now the absence of disease is no longer enough for us. We want something more. We want some elusive state of perfect health. Instead of dying young of infections, we live into old age, and we develop the diseases of aging like arthritis, heart disease, and cancer. Prosperity is increasing. Fewer people have to worry about where their next meal is coming from. And the worried well have the luxury of being concerned about every little mole and itch. The normal vicissitudes of everyday life have been reinterpreted as symptoms requiring treatment. And we've even invented imaginary diseases like chronic candidiasis and the need for detoxification. Science isn't perfect. Drugs have side effects. People distrust the establishment, the government, Big Pharma, the AMA. They perceive the scientific method as artificial and unnatural. People don't really understand the scientific method. There's always been an anti-intellectual tendency in America throughout history. Americans value equality, self-help, individualism, and the democratic idea that everyone's opinion counts. We have derogatory names for people who know stuff like geeks and nerds and eggheads and high-brows. Modern medicine is seen as impersonal and obsessed with technology, and it's perceived as not responding to the patient's experience of illness on a human level. One of the commenters on the science-based medicine blog said this, public demand for scam is due to only one factor, the deplorable widespread lack of critical thinking skills. I tend to agree. Just how widespread is scam? Well, that depends on how you ask the question. This is from a 2002 CDC study. It shows the percentage of people who reported using each scam modality in the previous 12 months. Look at the bottom two items. 62% said they used scam, but when they excluded prayer, only about 36% said they used scam. The most popular scam was natural products at 19%, and leading the list of natural products were echinacea, ginseng, ginkgo, and garlic supplements. Breathing exercises came next at 12%. Chiropractic followed at 7.5%, then meditation, yoga, massage, and diet-based therapies. Notice that acupuncture and homeopathy didn't even make the list. They were only used by 1% each in the United States. They're more popular in other countries, but they're still not very widespread. 10% of the people in the UK use homeopathy, and only 6% of people in Taiwan use acupuncture. Here's what people answered when they were asked why they used scam. 55% believed that combining it with conventional treatment would help. 50% thought that it would be interesting to try. 26% said a medical professional had suggested it. 28% believed conventional medicine wouldn't help them. And 13% said conventional medicine was too expensive. And what health conditions did they use it for? Well, back pain was by far the most common condition treated with alternative medicine. The top three were back and musculoskeletal pain, colds, and anxiety or depression at 50%, 9.5%, and 4.5% respectively. A smaller percentage used it for gastrointestinal problems for headache and for insomnia. Fewer still used it for sinusitis, cholesterol, asthma, blood pressure, and menopause around 1% each. And what kind of people use CAM? Well, CAM users were more likely to be women than men. They weren't the oldest or the youngest. They were most likely to be Asians and least likely to be African Americans. They were likely to be better educated, to have a higher income, to have private health insurance, to live in urban areas, particularly the West Coast, to drink alcohol, to be former smokers, and to have been recently hospitalized. So I think we can conclude that there's no one simple answer to who is likely to use CAM and why. What sets CAM apart from science-based medicine is basically a lack of testing. Really, by definition, CAM consists of treatments that are not supported by enough evidence to have earned a place in mainstream medicine. Quite often, CAM denies that there's even any need for testing. They're content with testimonials and poorly documented anecdotes, in contrast to science-based medicines rigorously documented case reports and clinical studies. And when CAM does test treatments, it tries to prove that something works rather than to ask if it works. And many of the studies it does are poorly designed and substandard. CAM's ideology tends to ignore biologic mechanisms, to disparage modern science, and to rely on ancient and natural remedies. My friend Carol is very intelligent, well-educated, and skeptical about most things, but here's how she decides whether to use a CAM treatment. She'll try pretty much anything as long as it meets these three criteria. A friend said it helped them, it sounds plausible to her, and it doesn't sound harmful. She's willing to go by anecdotal evidence when a friend says it worked for me. Science isn't even on her list of criteria. She doesn't bother to ask if testing shows that it works. She says science doesn't know everything. She told me that when she feels a cold coming on, she takes echinacea, and she hasn't had a cold in seven years. I told her when I feel a cold coming on, I don't take echinacea, and I haven't had a cold in seven years either. So if she accepted her own experience as proof that echinacea worked to prevent colds, she ought to accept my experience that not taking echinacea works to prevent colds. She decided we would just have to agree to disagree. CAM is considered more natural than conventional medicine, and people find this very appealing, but the appeal to nature is a logical fallacy called argumentum ad neturum. Natural isn't always good, I think strict mean. And there's really nothing natural about many of the treatments CAM offers, like sticking needles in the ear. In his excellent book, Snake Oil Science, The Truth About Complimentary and Alternative Medicine, R. Barker Basel reviewed the published evidence for CAM and concluded, there is no compelling credible evidence to suggest that any CAM therapy benefits any medical condition or reduces any medical symptom, pain or otherwise, better than a placebo. This is my friend Edsard Ernst, an MD from Germany. Early in his career, he was involved with several kinds of CAM, including homeopathy, acupuncture, herbalism, and manipulation. But as time went on, he began to question them. He got a PhD and set out to research CAM treatments and find out what worked and what didn't. He found that most of CAM didn't work. He became the world's first professor of complementary medicine at the University of Exeter in the UK. He and his team have published over 700 scientific papers evaluating CAM. Edsard Ernst and Simon Singh wrote this excellent book, Trick or Treatment, The Undeniable Facts About Alternative Medicine. After reviewing all the undeniable facts, they concluded, while there is tentative evidence that acupuncture might be effective for some forms of pain relief and nausea. It fails to deliver any medical benefit in any other situations and its underlying concepts are meaningless. And note the qualifications, tentative and might. With respect to homeopathy, the evidence points towards a bogus industry that offers patients nothing more than a fantasy. Chiropractors, on the other hand, might compete with physiotherapists in terms of treating some back problems, but all their other claims are beyond belief and can carry a range of significant risks. Herbal medicine undoubtedly offers some interesting remedies, but they are significantly outnumbered by the unproven, disproven and downright dangerous herbal medicines on the market. Wow, that's not very impressive, is it? I'll be covering each of those in separate lectures. There's a spectrum of plausibility in CAM. The plausibility of homeopathy is essentially zero. Acupuncture has some plausibility. The underlying oriental concepts are implausible, but it is plausible that inserting needles in the skin could possibly cause physiological effects. The plausibility of herbal medicine is high. After all, the whole science of pharmacology developed out of studying plants. And about half of all the drugs we use today are derived from plants. So herbal remedies might work, but they need to be individually tested just like any other drug. CAM insists it is better than conventional medicine. They constantly criticize doctors with accusations like these. Doctors cut, burn, and poison, referring to surgery, radiation, and chemotherapy. Well, conventional treatments have side effects, but they also save lives, which CAM doesn't. They say doctors only treat symptoms, not the underlying cause. And that's an outright lie. If you have pneumonia, doctors don't just treat your symptoms of fever and cough with aspirin and cough syrup. They identify the causative bacteria and they kill it with antibiotics. MDs treat real underlying causes. CAM treats imaginary ones. They say doctors are only in it for the money. Well, so is CAM. Doctors have to make a living and so do CAM practitioners. They don't offer their services for free. Then they say that most of conventional medicine isn't evidence-based either. But it is, too. That's another lie. They'll tell you that only 10 to 20% of what conventional doctors do is based on evidence. But that's a myth based on misinterpretation of an old British study about controlling prescription costs. It looked at whether evidence was being followed, not about whether there was valid evidence. By the best estimates, at least 76% of conventional medicine is supported by some form of compelling evidence, and 37% is supported by gold standard randomized control trials. A lot of what we do is common sense and it doesn't need to be tested, like whether we should try to stop wounds from bleeding or immobilize a fracture. And some of what we do, like vaccines, has been adequately tested and is solidly based on good evidence. But vaccines critics ask for more studies, the kind of studies that can't be ethically done because it would put the placebo group at risk of vaccine preventable diseases, as well as risking public health by decreasing herd immunity. Now think about it. Even if it were true that only 20% of conventional medicine was based on good evidence, why would anyone want to trade it for a system that was based on 0% evidence? One of the hallmarks of science is that it's self-correcting. When the evidence shows that something doesn't work, science discards it. We're not doing bloodletting anymore. We're not doing routine annual chest x-rays anymore. Cam rarely discards anything. In over 100 years, chiropractic has added over 200 new techniques and has discarded exactly one thing, a bogus diagnostic technique of tracing nerves with the fingers. If a scientific study appears to support a CAM treatment, they brag about it, and they cite it as justification. If science shows that a CAM treatment doesn't work, they disregard the evidence and make excuses. They say their treatments are special and they're individualized for each unique person, and they can't really be studied with randomized control scientific trials. But of course they can, as long as the studies are properly designed. For instance, a homeopath could prescribe individualized remedies and somewhat else could randomly give the patient either what was prescribed or a placebo. One negative trial concluded that the treatment worked, but this study was unable to demonstrate that. I mean, come on. Bausel, the author of Snake Oil Science, says CAM therapists do not value and often do not understand the scientific process. Here are the typical stages of CAM reasoning. First they say, I've seen it work for my patients. I don't need science to tell me that it works. And then they realize science is important. So they say, okay, we'll do science. And they do studies, not to ask if X works, but to prove to others that X works. They collect proof in the form of small poorly designed studies that are marginally positive. When the flaws in those studies are pointed out, they do better studies. But the better the study, the worse the results. Eventually they realize, oops, the best evidence shows that X is no better than placebo. Finally, they fall back on, placebos are good, so let's use X anyway. They argue that we want people to feel better. And placebos make people feel better. But there are problems with that argument. This is a good place to go into a digression about placebos. Placebos are very widely misunderstood. And understanding them is essential to understanding science-based medicine. First, let me clarify one thing. The word placebo confuses our thinking. It has two very different meanings and two very different settings. Placebos is used in the research setting for a control group in a placebo control trial. And placebos is used in the clinical setting to treat patients in the doctor's office. We can't even talk about placebos meaningfully until we get this straight. Here are some of the things people have said about placebos. It has been proven that placebos can cure 30% of disease. And how about this? The placebo effect is arguably the most underrated discovery of modern medicine. Replace just the placebo effect with the amazing placebo effect, the mind-boggling placebo effect. To my way of thinking, the very existence of this mysterious effect proves that God exists. That's right. You can find evidence for the foundational truths taught by religion in virtually every double-line medical research study. Well, I think most of you would reject the second claim. I sure hope you would. But a lot of people would agree with the first claim that placebos can cure 30% of disease. They would be wrong because placebos have never cured any disease. That's important enough to merit its own slide. Placebos have never cured any disease. The 30% claim is based on a misunderstanding of a 1955 study by a doctor named Beecher. He reviewed studies with treatment and placebo arms and he found that an average of 32% of subjects in the placebo group reported improvement. But that doesn't mean that placebos cured those 32%. In the first place, improvement is not the same as cure. And some of them improved because of the natural course of illness or appeared to improve because of errors in biases in measurement, errors like regression to the mean. In 2001, Rob Jartson did a much more meaningful study. He reviewed studies that had both a placebo and a no-treatment arm so that he could compare the improvement with placebo treatments to the improvement with no treatment at all. And he concluded that placebos don't work. The no-treatment groups improve just as much as the placebo groups, with two exceptions, pain and nausea. Patients may report subjective improvement of symptoms like pain and nausea with placebos, but placebos have no effect on any objective measurements. They don't improve survival from cancer or speed recovery from infections. They won't lower your cholesterol, reduce your risk of a heart attack, or improve your pulmonary function test results in asthma. Here's what Beecher's 32% really means. The response in the drug group is a combination of the specific pharmacological effect in red and everything else in yellow. In the placebo control group, there's no pharmacological effect, only the effect of non-specific factors like suggestion and the natural course of illness. In a placebo control study, we're asking one simple question. Does the drug work better than placebo? The pharmaceutical company doesn't care about why people in the placebo group improved. They're only interested in telling whether their drug works better. But we're interested in finding out what's happening in the placebo group. Some people believe placebos are really doing something. They say, if treatment X were only a placebo, it wouldn't work on animals. Treatment X works on animals, so it must be more effective than a placebo. But there is a problem with that reasoning. Animals can't tell us how they feel. It's their owners who have to interpret their behavior, and there can be placebo effects on the owner. If they expect to see improvement, they probably will. They may treat the animal differently, and animals respond to attention. We know that suggestion plays a big part in the placebo response. Studies have shown that some placebos are better than others. There's a whole hierarchy of placebo response. Surgery is more effective than pills. Injections are better than pills. Capsules are better than tablets. Big pills are better than small. The more doses a day, the better. The more expensive the better. Color makes a difference. And if placebos are given for a firm diagnosis, they work better than if there's uncertainty. Here's a new framework that doesn't require using the word placebo at all. The two bars on the left show the research setting where all we care about is whether the specific effect of the drug being tested in red is greater than the non-specific effects of treatment in yellow. On the right is the clinical setting where red is the specific effect of treatment and green is natural healing. There's a small remaining effect that is not explained by the specific effect of the treatment or by the natural course of healing, and we can call that the contextual effect of the treatment encounter. But how do these contextual effects work? Well, we know about several mechanisms. Psychological mechanisms like conditioning and suggestion, and neurobiological mechanisms like the release of natural painkillers and neurotransmitters in the brain. An elegant study by Thomas demonstrated the power of suggestion. He divided patients into four groups. The first group got a positive consultation. The second group got a positive consultation plus a placebo. The third group got a negative consultation. And the fourth group got a negative consultation plus a placebo. In the positive consultations, the patient was given a firm diagnosis and was told confidently that he would be better in a few days. If no placebo was to be given, he was told that in the doctor's opinion he didn't require any treatment. And if a placebo was to be given, he was told, here's a medicine that will certainly make you better. In the negative consultation, the doctor said, I can't be certain what's the matter with you. If no placebo was to be given, he said, and therefore I will give you no treatment. If a placebo was to be given, he said, I'm not sure that this treatment I'm going to give you will have any effect. And here's what happened. In the two groups that had a positive consultation, the response was 64 percent. In the two groups that got a negative consultation, the response was significantly lower at 39 percent. In the two groups that got placebos, the response rate was 53 percent. And in the two groups that didn't get placebos, the response rate was 50 percent, not significantly different. They concluded that improvement was due to suggestion created by the doctor. And it had nothing to do with whether they were given a placebo object. So you can get a placebo effect without a placebo. This 2008 study of subjects with irritable bowel syndrome showed just how important the doctor-patient relationship is. One group was simply put on a waiting list and got no treatment. 28 percent of them improved. Another group got no-feryls acupuncture, just needle insertion without any interaction with the provider. 44 percent of those improved. The last group got acupuncture with TLC involving special attention from the provider, a warm relationship, building trust, sustained attention, and 62 percent of them improved. They concluded, non-specific effects can produce statistically and clinically significant outcomes, and the patient-practitioner relationship is the most robust component. Placebos are essential in medical research, but they have no place in clinical practice. Here are some of the arguments against using them. They destroy trust in the doctor-patient relationship. Their effect is unpredictable, small, and it doesn't last long. There is an unfavorable risk-benefit ratio with a small possibility of harm. Placebos waste time and money. The use of placebos may involve delaying or rejecting effective treatment, and believing false claims leads to rejection of real science. But here are the two strongest arguments against doctors giving placebos to patients. First, they're unethical. Medical ethicists unanimously agree that doctors should not deceive patients. Second, they're unnecessary. You can get a placebo effect without giving placebos and without lying to patients just from the contextual effects of the therapeutic encounter. Ted Kapchuk thought there might be a way around the ethical dilemma. You could give patients a placebo and tell them it was a placebo, and it might still work. And it did. When patients were told they were getting placebo sugar pills, they got better. So Kapchuk thought he had given placebos without deception. But when you look at what he told patients, it's obvious that there was deception. The informed consent form claimed that placebos could have powerful effects. Now, when is CAM a scam? Stephen Barrett of QuackWatch has defined quackery as the promotion of unsubstantiated methods that lack a scientifically plausible rationale, and that describes most of CAM. Quackery doesn't necessarily require deliberate deception. Some quacks are deliberately fooling their customers, but some truly believe in what they're doing. They fool themselves. The latest incarnation of CAM is so-called integrated medicine. Integrated medicine clinics are springing up everywhere. According to the National Centers for Complimentary and Alternative Medicine, integrated medicine combines mainstream medical therapies and CAM therapies for which there is some high-quality scientific evidence of safety and effectiveness. Which doesn't make any sense, because if there was high-quality scientific evidence of safety and effectiveness, it wouldn't be CAM. It would be part of conventional medicine. What integrated medicine is really doing is combining science-based medicine with non-science-based medicine. Mark Crislip says that integrating CAM with science-based medicine is like integrating fantasy with reality, like integrating cow pies with apple pies. It doesn't improve the taste of either. Michael Vagg calls integrated medicine lipstick on the ideological pig of CAM. So back to the original question, what is CAM? Where we once defined CAM as things that aren't taught in medical schools, today we can define it as medicine that is so unproven, untested, or implausible that it hasn't earned a place in conventional medicine. Here's another definition of CAM. A spectrum of implausible beliefs and claims about health and disease. These range from the untestable and absurd to the possible but not very intriguing. In all cases, the enthusiasm of advocates vastly outseeds the scientific promise. In the next lecture, I'll talk about how these general principles apply to a specific CAM modality chiropractic.