Complementary and Alternative Medicine in Pediatrics in Review Part#1
As a pediatrician striving to continuously maintain a current fund of medical knowledge, and an educator of medical students and residents, I have been consistently pleased with the information provided by Pediatrics in Review (PIR). This American Academy of Pediatrics publication serves as a source for continuing education for thousands of pediatricians, and as a solid resource for doctors in training. Unfortunately, as I explained in my last post, over the past couple years there have been a number of articles published in PIR on the subject of complementary and alternative medicine which I feel have largely missed the point. They have simply not lived up to the standards that I have come to expect.
First and foremost, I believe that the authors of these articles likely have had good intentions but were ill-informed and were relying on information from questionable sources such as the website of the National Center for Complementary and Alternative Medicine (NCCAM). Also, probably in a noble effort to provide a fair assessment of the topic, several authors have committed errors of false balance and false compromise. These occur when the reader is given the impression that a particular alternative medicine entity has evidentiary support equivalent to more mainstream modalities or that a compromise between alt med and science-based medicine is the best approach to health care. Reality does not in general support either of these contentions. To be quite honest, however, I also suspect that there is more than a little investigative laziness at play, and personal bias in some cases.
A good example of the weak coverage of alt med in PIR is the recently published article on “The Ethics of Complementary and Alternative Medicine” by Brenda J. Mears. In Dr. Mears’ discussion of the ethics of alt med, which is far from the worst example of what PIR has published in this genre, I found several objectionable statements and a seemingly naive understanding of the subject matter. I was impressed though with her inclusion of a number of specific risks for direct harm from CAM therapies, such as vertebral artery injury from chiropractic manipulation of the neck, and for her call for pediatricians to be more aware of CAM. In general, we are fairly ignorant of what goes on in “the real world”.
A red flag that should raise suspicion that an author has a poor grasp of the history, as well as the current state, of alternative medicine in the United States is the quoting of the NCCAM definition of complementary and alternative medicine (CAM). The NCCAM’s defining of CAM in general as “a group of diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine” is about as helpful as defining the relationship between the three sides of any triangle as A squared plus B squared equals pineapple. In an equally useless fashion, and one which is also repeated nearly verbatim in Mears’ article, the NCCAM provides individual definitions for the trichotomous nature of what has come to be known as as just “CAM”. When used in place of conventional medicine, it is alternative. When used seperately but concurrently with conventional medicine, it is complementary. Finally, when alternative medicine is combined in a seemingly synergistic fashion with conventional therapy, it somehow magically transforms into integrative medicine. It may be nice to have such easily digested categories, but they distract the uninitiated resident or pediatrician rather than help to provide any true understanding of the unrelated and often contradictory practices in question.
Mears, once again borrowing information from NCCAM, expounds on the relationship between these categories and reveals, perhaps inadvertently, one of the key weaknesses with the concept. She writes, “The boundaries may blur, and some therapies once believed to be CAM, such as cognitive behavior therapy or prebiotic and probiotic use, now are considered by many to be conventional.” There is much wrong with this line of reasoning, and it illustrates perfectly why using CAM terminology is so problematic and uneccessary. The boundaries only blur because the boundaries the NCCAM use were manufactured to do just that, and in the process provide unearned respect for a host of unproven concepts and therapies. The true boundary, and it is a boundary between therapies not considered to be part of any CAM lexicon as well, is the one that seperates practices that work from those that do not, therapies that are safe from those that have not been proven to be so, and claims that have been subjected to scientific scrutiny from those that have thus far avoided it. This is all that matters.
CAM terminology promoted so heavily by the NCCAM and other proponents is about marketing, about obtaining awareness and acknowledgement without having to actually bring any evidence to the table other than anecdotes and testimonies. Thus, in reality, calling something alternative, complementary, integrative, or conventional for that matter, provides no real and useful information. Each of those categories contain within them treatments that have failed the test of science. And each of them contain treatments that have the potential to provide objective benefit in the treatment of human disease. The use of CAM terminology has led to the existence of a double standard where individual therapies, given the right label, are not judged on plausibility and scientific evidence. Instead they receive a free pass that allows the circumventing of a process that has led to advancements which have greatly decreased suffering in the world and added decades to our lifespan. And with the current “cerebrum excedere” approach to health claims taken in both public and academic circles, this is all that it has taken for large percentages of the population to be taken in by outright quackery.
But why would being lumped together with other unproven therapies provide unearned credibility? The reason this occurs is because, as Mears reveals in the above quote, proponents of individual therapies use the fact that some therapies considered to be CAM are accepted as part of science-based medicine. This tactic is especially easy to employ when the “therapies once believed to be CAM” that are now “considered by many to be conventional” are things like nutrition, exercise, smoking cessation, and various plant based pharmaceuticals. By essentially co-opting/stealing avenues of research and proven preventative measures that are science-based, a large foot has been shoved in the door for all manners of pseudoscience to slip in. Just because plants are investigated by scientists for their potential role in improving the human condition, and those investigations have led to a number of safe and effective pharmaceutical interventions, it doesn’t mean that the unregulated use of unproven herbs, or that healing touch for instance, is legitimate.
Mears claims that conventional medicine is “intended to be based on knowledge of safety and efficacy obtained from randomized, controlled trials (RCT) and attempts to avoid treatments that are not supported by such evidence”. This is an straw man definition of what we do and allows proponents of pseudoscience and quackery to simply chalk the objections of scientists and skeptical doctors such as myself up to some kind of religious devotion to the RCT. RCTs are the gold standard when it comes to determining whether or not a treatment actually works, but the practice of science-based medicine takes into account all evidence, from clinical observations and anecdotes up to the RCT, including our understanding of basic science and the overall plausibility of a claim. Does Dr. Mears think that we only hang our hats on RCTs to support telling a patient to stop smoking because it increases the incidence of lung cancer, as if there was an IRB approved prospective trial where we encouraged subjects to smoke so that we could compare lung cancer rates to a group smoking sham cigarretes. Much of the evidence we use to support treatments and lifestyle recommendations does not come from an RCT.
She then admits, in what may be the understatement of the year thus far, that “CAM therapies may have fewer supporting data.” May have fewer supporting data? Is that even up for debate? I guess it is depending on who you ask. If a treatment that is considered to be CAM, and I mean real CAM not a co-opted science-based therapy, had decent evidence to support its use it wouldn’t be CAM. The most functional definition of CAM is stuff that doesn’t have any supporting data to speak of and likely will never have any supporting data, or stuff where a definitive answer has been arrived at but ignored. Think homeopathy or anything a chiropractor does that a physical therapists won’t. Think manipulating human energy fields or the use of herbs and supplements like echinacea for the cold or ginkgo biloba for memory problems. Of course CAM therapies have fewer supporting data. That flaming ball of fire in the sky is also actually a star, and it’ll come back in the morning. I promise.
She follows this shocking revelation with the obvious statement that there are mainstream practices as well as CAM “activities” that lack “rigorous evaluations.” She explains how this does not exempt any of us from backing up our practices with the latest and greatest scientific evidence, something which she claims the NCCAM is doing. Well, not exactly. There may be a some well-designed studies coming out of NCCAM but, as the past decade has shown us, their negative results have little to no impact on the belief of CAM practitioners and could have come from other areas of the NIH that don’t have so much baggage and bias. The NCCAM spends roughly 128 million dollars per year, and has spent over a billion dollars in total, producing a few good negative studies and numerous poorly designed positive studies that somehow all lead to the conclusion that more studies are needed. Furthermore, in its efforts to serve its master, Senator Tom Harkin, as a propaganda machine for unproven therapies, the bogus marketing terms “complementary” and “alternative” are now so firmly attached to the word medicine I am forced to use them liberally in any attempt to discuss this application of magical thinking to my chosen profession.
I’ve got a few more bones to pick with this article, but I’ll save them for my next post.