Angry Doctor

Tuesday, October 30, 2007

How NOT to argue for Alternative Medicine 9


An anonymous reader's comment on this earlier post on acupuncture provides angry doc with the material for the next exercise in our series.

"Your link at the start of your comments takes you to information on trials on acupuncture for back pain. These mention the use of 'sham' points - given that Ashi points do not lie neccessarily on meridians, its questionable whether the 'sham' points are in fact sham points. The reserach design seems to have been developed without much undrestanding of the modality. Still, each to their own. Personally, I'm not angry about patients using any modality that works for them to get better or maintain health. But then again, I'm not that randomly angry.... Perhaps you should try some acupuncture for your stress and then you wouldn't be so generally angry ?! As a doctor you should know its not good for your health-long term!!"

Let's examine the arguments one by one then.


1. "given that Ashi points do not lie neccessarily on meridians, its questionable whether the 'sham' points are in fact sham points."

angry doc has read many defences for acupuncture, but this one is new to him.

Now leaving aside the fact that the study specified that sham acupuncture in this study consisted "of superficial needling at nonacupuncture points" (emphasis mine), this argument tries to renders the theory of acupuncture non-falsifiable.

If we are going to identify every point on the skin which shows an effect when needled to be an acupoint (or Ashi point) and then attribute the effect observed acupuncture, then it becomes impossible to prove that acupuncture doesn't work.

However, if we do not shift the goal-posts during our study (i.e. an identified acupoint is an acupoint, and a point not identified as an acupoint does not become an acupoint), then the evidence so far is that sham acupuncture often performs as well as 'true' acupuncture, which calls into question the theories behind acupuncture.


2. "The reserach design seems to have been developed without much undrestanding of the modality."

The study states that the authors are from the following institutions and departments (emphasis mine):

Orthopedic Department, University of Regensburg, Bad Abbach, Germany (Dr Haake); Institutes for Medical Biometry and Epidemiology (Drs Müller and Schäfer) and Medical Psychology (Dr Basler) and Centre for Clinical Trials (Ms Schade-Brittinger), Philipps-University Marburg, Marburg, Germany; Departments of Pain Management, BG-Kliniken Bergmannsheil (Dr Maier) and Medical Informatics, Statistics and Epidemiology, Ruhr-University Bochum, Bochum, Germany (Drs Endres and Trampisch); and Centre for Clinical Acupuncture and Research, Düsseldorf, Germany (Dr Molsberger).

Without trying to appeal to authority, angry doc would venture to say that it would be rather unwise for a Centre of Clinical Acupuncture and Research to set up a whole centre for studying acupuncture, go through the process of recruitment and intervention, and then finally publish the study, without having first gained some familiarity with the modality.

Unfortunately, our anonymous poster did not specify how he or she arrived at the conclusion that the "reserach design seems to have been developed without much undrestanding of the modality".


3. "Still, each to their own."

Acupuncture either works the way it is said to work, or it doesn't - that does not depend on whether you or I believe it, but on what the evidence show. To use phrases like "to each his own" or "we are all entitled to our own opinions" is to try to hide a lack of evidence or convincing argument behind freedom of choice.


4. "But then again, I'm not that randomly angry...."

Well, angry doc hopes his long-time readers will realise that while he may be angry, he is not *randomly* angry.

This statement is a form of ad hominem attack; angry doc does not think acupuncture doesn't work because he is 'angry at acupuncture', angry doc is 'angry at acupuncture' because it doesn't work.


5. "Perhaps you should try some acupuncture for your stress and then you wouldn't be so generally angry ?!"

angry doc is not sure whether this is another ad hominem attack, or an argument that subjective experience or anecdotes trump statistics and evidence.

In any case, if angry doc tried acupuncture and it didn't work for him, it does not prove that acupuncture doesn't work. Conversely, if angry doc tried acupuncture and it did work for him, it would not prove that acupuncture works - that's why we are conducting all these studies with blinding and controls.


(angry doc would like to thank his anonymous reader for providing the material for our discussion today.)

Labels:

posted by angry doc at 5:40 pm

24 Comments:

  • "Still, each to their own."

    Acupuncture either works the way it is said to work, or it doesn't - that does not depend on whether you or I believe it, but on what the evidence show. To use phrases like "to each his own" or "we are all entitled to our own opinions" is to try to hide a lack of evidence or convincing argument behind freedom of choice.

    Yes, it is a common everyday phrase, but in the medical or science fields it's dangerous to say that.

    I'm not sure if this is obvious to most people, but robust scientific discoveries (such as universal gravitation and biological evolution) and medical treatments are effective whether people believe in them or not.

    By Blogger The Key Question, At October 30, 2007 7:30 pm  

  • Acupuncture in particular and traditional Chinese medicine in general, is a deeply ingrained cultural presence in some people.

    It does not matter how much evidence, or lack of it, is shown to them. In the first place, they probably may not understand the concept of a double-blind, randomised control trial.

    Forget it.

    By Blogger Unknown, At October 31, 2007 8:34 am  

  • Just to share.

    Ashi points are basically the equivalent of trigger points in western medicine.

    They do not lie on the meridians.

    In this sense, (we did ask our lecturers) why needle the Ashi points if they have no meridian basis?

    The answer was similar to why we would give H/L injections into trigger points for chronic back pains etc.

    It all depends what you define "does acupuncture work".

    I think angry doc and the others here are asking really "does treatment based on the theory of meridians work"?

    Acupuncture works in pain management but so far no evidence to prove that meridian theory is at work. For that matter what are meridians anyway? Can we prove there are meridians? So far no one has proved that they exist or for the matter whether they are actual channel physically or not.

    One of our lecturers was talking about some quite complex theory (I can't remember now) to explain meridians.

    I look at all this as philosophy our ancestors came up to give a system to the observations they gathered so that it would not be too chaotic.

    Acupuncture can relieve pain. But the evidence shows it is due to release of endorphins in the Periaqueductal grey area. And sham needles produce the same effect although the level of endorphins produced was higher if the real needles were used. However there was little difference between the two groups if I recall the study shared with us by Prof Lee.

    Hence a large dose of placebo effect.

    Ashi points.....might as well give a H/L injection lah.

    Studying the modalities helps eliminate being caught off guard in discussions with TCM physicians or heavy alternative medical practitioners with overly biased views.

    By Blogger Dr Oz bloke, At October 31, 2007 2:49 pm  

  • We can't convince everyone, John, and I don't mean to. But hopefully some will read the posts and decide to think critically about some of the things they have taken for granted for a long time. It is more important to me that they think about things for themselves than that they agree with me.

    Critical-thinking is probably not an inborn ability, but it can be learnt. Uncritical acceptance of beliefs is however a social norm, which accounts for the widespread use and promotion of alternative medicine 'as they are'.

    Much of alternative medicine were developed in the pre-scientific era, so it is little wonder that they don't stand up to examination.

    However, like Oz Bloke said, this was just the way our ancestors sought to make sense of certain observations they made - there is no shame in admitting that because back then, everybody's ancestor was making that kind of speculative theory too.

    We should not, however, continue to try to explain away evidence to protect our world view. Certainly I will continue to reply to those who try to post misinformation and fallacious arguments on my blog and try to pass them off as the truth or valid arguments.

    By Blogger angry doc, At October 31, 2007 5:21 pm  

  • "It all depends what you define "does acupuncture work".

    I think angry doc and the others here are asking really "does treatment based on the theory of meridians work"?"


    Yup, as usual you get my point. :)

    The reason why I think this distinction is important ('acupuncture doesn't work - dermapuncture does') are two:

    1. Basic intellectual honesty.

    2. The theory of meridien and qi is not then used to prop up other unscientific theory of TCM and other modalities claiming invisible flow of energy as their basis.

    By Blogger angry doc, At October 31, 2007 5:30 pm  

  • Hi angrydoc,

    During our classes we had several of these sort of "debates".

    A western doctor would ask about evidence based etc..

    There was some talk about how the Chinese were trying to apply western trial standards (ie randomization, double blind etc) to TCM and found the results very poor.

    But that some western researchers who grouped patients according to syndrome would get better findings and results. But the argument would be element of bias.

    There are also cases where we witness with our own eyes, patients getting better with acupuncture but it was nothing to do with pain relief. Eg rhinitis.

    Self limiting? I dunno.

    But the running joke is that if the patient gets a result then it's TCM works. If not then too bad.

    There was this patient who said he had FESS and turbinectomy done for his chronic sinusitis but it didn't "cure" his rhinitis.

    The TCM physician told him that in some cases the patient may not get good results after surgery because the surgery changes all the paths of the meridians so it screws up the treatment.

    So smart eh? If it works he takes credit. If not then blame the surgeon who screwed up the meridians!

    LOL!

    By Blogger Dr Oz bloke, At October 31, 2007 5:50 pm  

  • Having said all this, here's what I have observed several competent alternative medical practitioner operate :

    They would let the patient know that this is not evidence based and has no research that unequivocally proves it works.

    But the patients still want to try because all else has failed (that's why they came to the alternative medicine practitioner in the first place).

    So it is purely consensual.

    And the alternative guys like to prey on the fact that the western docs know nothing about what they do and hence always condemn it.

    I never liked this fact. Which was why I took interest to study it so that I could speak in a more balanced tone and much more objectively. The patient would also know I know.

    More convincing. I feel this is what we might have to do to really help patients not get conned.

    Not to say there is NO PLACE for alternative medicine, but expectations must be tempered and certainly don't waste time with it if there is a definite evidence based treatment in western medicine.

    By Blogger Dr Oz bloke, At October 31, 2007 6:05 pm  

  • Here's an interesting letter in today's Chinese newspaper:

    http://www.zaobao.com/yl/yl071031_505.html

    Just goes to show that to the layman, the best doctor he saw was the last one he saw, and the worst doctor the one before that. :)

    By Blogger angry doc, At October 31, 2007 8:19 pm  

  • "Just goes to show that to the layman, the best doctor he saw was the last one he saw, and the worst doctor the one before that."

    that's generalising all layman.but what's the patient to think of since all the previous docs can't solve the problem?-LH

    By Anonymous Anonymous, At November 04, 2007 12:15 pm  

  • "But the patients still want to try because all else has failed (that's why they came to the alternative medicine practitioner in the first place)."

    I agree,but don't think it's purely consensual.More like at wit's end for some. most patients will not have so much technical knowledge to judge whether the treatment works, so if western med can't help them, they turn to TCM for hope.Glad that Dr Bloke takes it upon himself to know more to educate and advise patient. The problem is most western docs just dismiss TCM with a wave of hand.Whether TCM works is one matter. Whether TCM solves pt's problem is another.-LH

    By Anonymous Anonymous, At November 04, 2007 12:30 pm  

  • "but what's the patient to think of since all the previous docs can't solve the problem?"

    That's why I blog, LH, and that's why I continue to blog.

    "Whether TCM works is one matter. Whether TCM solves pt's problem is another."

    And I will continue to make the distinction between saying that a modality of treatment traditionally used in TCM works, and saying that TCM works.

    By Blogger angry doc, At November 04, 2007 6:24 pm  

  • "And I will continue to make the distinction between saying that a modality of treatment traditionally used in TCM works, and saying that TCM works."

    I totally agree with you angrydoc on that!

    I think to us doctors this is an important issue on many levels.

    But to laymen they just care if the treatment works, they don't bother too much into the explanation of why it works and how it works.

    By Blogger Dr Oz bloke, At November 05, 2007 2:05 pm  

  • Hi drs angry & bloke-
    "And I will continue to make the distinction between saying that a modality of treatment traditionally used in TCM works, and saying that TCM works."

    I agree partly.Though the distinction is very fine to make.

    "But to laymen they just care if the treatment works, they don't bother too much into the explanation of why it works and how it works."

    Not quite agree,because-like I'm trying to say-it's generalising all layman. It's like the mentality "take this medicine and don't need to know side effects etc". It's important that patients (ok-not all are that interested I concede)"know* what they are eating. So they trust the person prescribing it.
    Having said that, it may sound contradictory because in tcm, many patients don't know the contents (and they still are willing to eat)-because they see it as a form of option that gives them hope for cure/lessen pain.
    So why shoot tcm? Instead try exploring it-it benefits the very person you are trying to treat.-LH

    By Anonymous Anonymous, At November 05, 2007 4:18 pm  

  • Hi LH,

    I did explore and study acupuncture/TCM.

    I apologize about generalizing laymen. Not everyone is like that. Agree with you there.

    Actually my main purpose in studying TCM was to learn more about it so I could better communicate with many of my patients who like to ask questions that are best answered by TCM. But I let them know it is TCM and not western medical science.

    My personal approach is whatever the patient wants. If the patient wants TCM style explanations then I give it. If they want western scientific explanations I give it too. I let them know beforehand that it is TCM or western medicine I am explaining.

    Whatever they want and like. :)

    By Blogger Dr Oz bloke, At November 05, 2007 4:33 pm  

  • Hi Dr Bloke, you sounded a bit *resigned*.many docs will flip and cringe to think that *they" should be givng "whatever the patient wants" because doctors know best.

    While layman-being layman-may not know the technicalities, as patients, most probably can tell if the person treating them is doing his/her best or not.As it is, they have to depend either on their own knowledge (altho'obviously limited compared to the doc's) or through the doctor's mannerisms.

    "so I could better communicate with many of my patients who like to ask questions that are best answered by TCM."-think such efforts won't go wasted with your patients. :)-LH

    By Anonymous Anonymous, At November 05, 2007 5:20 pm  

  • Here's what I think.

    I think its best to observe those who live long and healthy lives and simply model them.

    At the very least I believe anything is better then Western Medicine, because at least it doesnt produce the side effects that come with all the chemicals doctors make you swallow.

    And lets not forget all the scientific experiments sponsored by the big pharma. What is more bogus than that?

    At least these ancient guys explored the world for the sake of exploring it. Pharma companies do it for the sake of earning more money.

    Their health vs modern mans health doesnt need an explanation anyways.

    By Anonymous Anonymous, At November 13, 2007 7:04 pm  

  • Wow, anon.

    You have in one short comment revealed the secret to good health and long life, taught us that *anything* is better than Western Medicine, and shown us that *all* scientific experiments are in fact bogus.

    You should inform the Ministry of Health or the World Health Organisation; I am sure they will appreciate your insight.

    By Blogger angry doc, At November 13, 2007 11:30 pm  

  • Well my angry friend,

    I have had my share of deaths in my family and people I know. Some of them died because of their lifestyles, but most died as a result of mis diagnosis and the toxic drugs that were given to them which did nothing other than giving them horrible side effects and mask the symptoms.

    Should I remind you that according to the Journal of the American Medical Association every year, 225000 people die as a result of iatrogenesis(wrong diagnosis, wrong medicine etc.)? That makes it the 3rd leading cause of death in the U.S.

    Heres the problem with your thinking. The organizations you are naming are simply biased. That is to say they are only regarded as an authority because by the developed nation it is in,it has the economic strength and model to advertise itself in the world as the right thing. Which doesnt mean it actually is better than other types of treatments. Who is it that labeled anything other than mainstream as alternative? When did what nature produces become alternative and the chemicals produced by labs become the right way? Well I am sure if you are actually brave enough to step out of what everyone thinks right because they have been told so, than you will be able to see things in a different light. That takes guts.

    You might think I am some acupuncture guy, but the reality is I dont know a thing about acupuncture, and I never needed any kind of treatment. Thats because I just listened to the advice my 105 year old great grandpa.

    Instead of searching disease, I looked for what the really long living people do. And as simple as it is yes that is the secret to lifelong health and a long life. So my post actually explained long life. You just have to google it and the info is there for you to take.

    Regarding the experiements, I didnt wanna say all of them are bogus. But as they have all the power in the world in terms of advertising budget and hiring any guy they want, and at the same time the need to compete with other big pharma companies, doesnt it make sense that they would sponsor some study and shed more light to particular variables and advertise those in order to get people to buy?

    There are many instances that just things as simple as eating blueberries is more effective than swallowing an expensive medicine and it comes with no side effects.

    Just use common sense and never stop questioning, thats what I can advise anyone.


    Harun

    By Anonymous Anonymous, At November 13, 2007 11:42 pm  

  • "Should I remind you that according to the Journal of the American Medical Association every year, 225000 people die as a result of iatrogenesis(wrong diagnosis, wrong medicine etc.)?"

    I see. So doctors are pharama shill and studies are bogus, except when they support your point of view?

    By Blogger angry doc, At November 14, 2007 10:42 am  

  • Nope you dont see , but you ignore really well...

    I have written a whole post detailing what I have said and you take one sentence and use it to ignore the rest of the post.

    How cool doc, yet its so ordinary. Being a doctor you seem more close minded than other people when it is you who has to be more open minded than anyone. But at least ,I see the point of your blog now, ranting about your single minded perspective.

    Until we meet again,
    Keep on ranting
    Harun

    By Anonymous Anonymous, At November 14, 2007 6:01 pm  

  • Harun,

    I did not embark on a point-by-point rebuttal of your assertions (yes, they are but assertions not backed up by data or evidence, except for the JAMA study you quoted) because experience has shown me that it is pointless.

    For you to have made your assertions, you would have had to ignore the fact that modern medicine, in the form of public health and interventions such as drugs and surgeries, have vastly improved life expectancy, infant mortality rate, maternal mortality rate, etc.

    You choose to ignore all that, but quote just one study which you claim supports your point of view, when in fact the JAMA paper is a criticism of the US healthcare delivery system and not of modern medicine.

    I find it generally unproductive to debate those who display a blatant disregard for the preponderance of evidence and who are willing to misrepresent a paper to fit their own single-minded perspective.

    I admit that modern medicine is not perfect in its knowledge and delivery.

    I am open to the idea that we can learn from folk medicine (provided their efficacy can be proven).

    But until you can provide data and evidence to show that an alternative system can provide better outcomes, your posts remain but assertions.

    By Blogger angry doc, At November 14, 2007 7:46 pm  

  • I have an offer to make you, Harun:

    Write an essay on how you arrive at the conclusion that think western is bad, and why you think an alternative system of healthcare will provide better outcome, and I will re-post it as a new blog post.

    If your arguments are sound and backed up with valid data and evidence, then perhaps my small readership may win you a convert or two.

    What say you?

    By Blogger angry doc, At November 14, 2007 7:54 pm  

  • Hi doc,

    I admit I might have been a little too extreme in presenting my views here.

    You are actually right when you say that modern medicine has done alot in things like surgeries, infant mortality rate, maternal mortality rate, survivals in accidents etc...

    I really dont side in any perspective in this argument. My emotional response has been more related to the deaths in my family.

    My problem is mostly with the one sided rigid view people has generally. And that also relates to Modern Medicine. I dont like when things get labelled Alternative just because it doesnt make as good money as promoting labproduced medicine. I dont know the exact amount but I have heard that between 1970 and 2005 the money spent and given as grant to the drug companies to do research on the healing properties of food, was 60 times less than that given for the research of lab produced drugs. Now that gets me worried. For there are many examples of people living disease free to 100s and more. I dont see the point of deviating from there and selling people drugs for everything. Those who lived long and disease free never used any drugs. I am not against many interventions done by Modern Medicine. Things like broken bones or other acute cases must definitely be handled by Modern Medicine. A laporoscopy is a great convenience and so are many others.

    Yet many diseases we poor billions on to find a cure didnt exist in some cultures at some point in time. And I believe its not the medicine that will take care of this. Because that takes care of the symptoms most of the time. I believe its converting lifestyles similar to those who lived disease free is what will change the underlying cause.

    This is my point of view and apologies if I have been a little rough communicating it.

    Harun

    By Anonymous Anonymous, At November 16, 2007 7:15 am  

  • Harun,

    I appreciate your candor.

    Certainly there are things we can do to increase our chances of long life and freedom from diseases like lifestyle changes, and then there are things we cannot change like our genes. In between there are interventions both 'natural' and 'modern'. I don't think copying the lifestyle of those who live long is the answer for everyone.

    As for treatment being labelled 'alternative' because they don't make money, that is an accusation often levelled against modern medicine. However, the fact is alternative medicine is also a multi-billion dollar industry in the US and UK. The 'health supplements' industry too have a powerful lobby which prevents the FDA from labelling their products as drugs, thereby exempting them from the rigourous testing required before they can be sold.

    Also, the profit motive of the drug companies means that any substance, whether they are natrual or synthetic, will be tested and sold for profit if they are proven to be profitable. Google or wiki up 'lovastatin' and 'Taxol' and you will see that the phrama industry has ways to make money from natural remedies, as they always have - they just have to patent the process by which the natural product is purified, concentrated, or copied, instead of the substance itself.

    While the pharma industry is no saint, the profit motive has resulted in a system where cures are looked for, trials are conducted, discoveries marketed, and the drugs distributed. Capitalism, much as I dislike its extreme forms, has done something which perhaps simple good-will cannot achieve.

    I appreciate that there is much we can learn from folk medicine, and that is not what I am against. What I am against is people who resist looking at folk medicine scientifically (which I believe is the best way to understand how best to apply the knowledge), and people who promote alternative medicine which are scientifically implausible in their claims, and have in fact been proven to have no efficacy.

    Thank you for reading and replying.

    By Blogger angry doc, At November 16, 2007 12:18 pm  

Post a Comment

Subscribe to Post Comments [Atom]



<< Home