Warning - This page is biased
This page is admittedly biased in favor of health care that is science based. It is biased in favor of doctors giving advice and treatments that are plausible and are warranted by scientific evidence. The writings on this page are also biased in favor of promoting honesty and compassion in patient care. Being a skeptical doctor does not excuse one from being a compassionate doctor.
Alternative to What?
The term 'Alternative Medicine' is very confusing. It is fair to ask the question: "alternative to what?"
The National Science Foundation states, "alternative medicine refers to all treatments that have not been proven effective using scientific methods."
The National Center for Complimentary and Alternative Medicine (NCCAM) prefers the term 'Complimentary and Alternative Medicine' (CAM) and uses this definition: "(it is) a group of diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine."
NCCAM then defines 'conventional medicine' as, "...medicine as practiced by holders of M.D. (medical doctor) and D.O. (doctor of osteopathic medicine) degrees and by allied health professionals, such as physical therapists, psychologists, and registered nurses."
So, per NCCAM, it is alternative to the usual practices of M.D.'s, D.O.'s, physical therapists, psychologists and registered nurses. NCCAM's definition leaves out the part about CAM treatments not being proven effective using scientific methods.
It seems odd that an applied science, such as medicine, would have an alternative. We currently do not have alternatives to other applied sciences such as engineering or aviation. Methods of engineering and aviation either work or they do not. Some methods work, but are not as efficient as others. In engineering, designs that work are simply considered 'engineering'. In aviation, designs that work are called "airplanes" (or "helicopters", etc.). Designs that are not proven to work - or have been proven to not work - are only part of the historical footnotes. They are not 'alternatives'.
It is important to try things and fail. These applied sciences would not be where they are today without learning from mistakes. Without these failures, we would still be on the ground. The endpoints in these fields are objective and obvious. The plane flies or it doesn't. The building stands or it doesn't.
Medicine is different. Success and failure are not always obvious. When the endpoints are subjective (like pain, fatigue), our biases can blind us to what is really going on. When the endpoints may occur even without the intervention, anything may appear to work. This is why we have basic science and clinical trials to guide us.
The term 'alternative' reveals the perceived need for a different way of doing things. In medicine, it may stem from the belief that "Western Medicine" only cares about drugs and surgery. This may be fueled by the observation that many doctors seem to lack compassion. Some doctors really do prescribe drugs that are not warranted. Some doctors really do perform surgeries that are not warranted. There is no doubt that many doctors are motivated by profit. There is also no doubt that pharmaceutical companies have often placed sales figures and share prices ahead of humanitarian goals. The perceived need for an alternative system really should be a wake-up call for the medical profession. The need for an alternative way of doing things in healthcare should not mean a need for 'alternative science'. The fact that mainstream medicine is far from perfect does not justify the use of treatments with no evidence.Most would agree that we do not have an ideal system. Medicine's problems today are multifactorial. We have a frustrating bureaucracy, a disconnect between our abilities to treat objective vs. subjective problems, a lack of time and sometimes compassion on the part of doctors, frighteningly poor science / health education, unhealthy lifestyles and soaring health care costs. It may be fairly argued that we need alternatives to many things in modern medicine. We need alternatives to a system that rewards the performance of wasteful tests and treatments. We need an alternative to impersonal 10 minute office visits, inequality of resources, and a society that promotes unhealthy lifestyles.
We do not need alternative science.
Why do People Want Alternatives?
People want alternatives. The government sponsored 2007 National Health Interview Survey revealed that Americans spend $33.9 billion on alternative medical services and products. $33.9 billion. That is only one year in the United States alone. Clearly there is a big market for it.
The literature examining why people choose CAM is scarce. The few articles on PubMed are mainly in CAM journals. BMC Complimentary and Alternative Medicine published surveys of CAM users in 1988 and in 2005. The article divides the reasons into "push" reasons (people are 'pushed' away from mainstream medicine) and "pull" reasons (people are 'pulled' toward CAM). People in the samples could report more than one reason for seeking CAM. In 1988, only 7% of the cohort were 'pushed' to CAM due to bad experiences with doctors (mainly due to poor communication and treatment). In the 2005 cohort, the number rose to 40%. In 1988, 9% sought CAM due to side effects of treatments. In 2005, 55% left due to side effects. In 1988, 42% went to CAM because they felt mainstream medicine was ineffective for their problems. In 2005, that number rose to 67%.
The above study reports that large percentages of the 1988 and 2005 groups sought CAM due to "pull" reasons. By 2005, over 90% of CAM users stated that they felt that CAM empowered them to have a more active role in their own health. They claimed to choose CAM because it emphasized treating the "whole person".
There are likely many reasons for turning away from scientific medicine. Perhaps an underlying reason is that most people do not understand the difference between science and pseudoscience. Our institutions also promote CAM along with scientific medicine, giving it credibility on par with scientific medicine. Others will seek such practices that agree with their ideological belief systems and world views. This latter group will likely never be swayed by empiric data. It is the former groups that we should focus on.
So why is CAM presented to the public as a legitimate alternative to conventional medicine? World views aside, why is it so popular? As with most things, it is complicated. As skeptical doctors, perhaps we should first be skeptical of ourselves.
Patients are people. People want to be treated like people. We hate the impersonal nature of large bureaucracies. We put our trust in people, not systems. We do not give our trust easily. Trust is nurtured. We trust people who acknowledge us, engage us and validate us as people. We trust people who seem to care about us.
Doctors are the people we entrust with our healthcare. But our healthcare system is impersonal. A typical appointment with the doctor involves waiting on hold on the phone, being told that there are no convenient appointments, filling out paperwork, insurance co-pays, long waits in a waiting room for a 10 minute visit, and a hurried doctor who uses unfamiliar and intimidating terminology. The visit typically will end with a prescription that must be taken to a pharmacy where more insurance cards, co-pays and wait times are required. Finally, the treatment - the pill - is obtained that comes in a sterile looking bottle with an incomprehensible name. The bottle is in a bag with a list of horrible side-effects stapled to it. It is not hard to see where the element of human caring and trust can get lost in the shuffle.
This dehumanizing system may be part of the motivation that drives some to look for ‘alternatives’. There are plenty of practitioners out there who offer a large array of ‘alternative options’. Many of these treatment options seem simple and understandable. The practitioners focus on simpler concepts, like ‘balance’ and 'energy'. They use words like ‘natural’ and ‘holistic’, implying that they practice in harmony with nature and care for the ‘whole person’. Many alternative practitioners spend a great deal of time with their patients. They delve into people’s personal lives and fears. They emphasize the patient’s natural abilities to heal. In some cases, they tap into people’s sense of spirituality. They often tell people what they want to hear. At the end, there are usually no insurance cards. But there is a price.Alternative medicine practitioners know something that many ‘traditional doctors’ do not. They understand that people trust people, not impersonal systems. The people who seek out alternative systems trust a kind word, not science.
Science is, pretty much by definition, uncertain. We can never be 100% certain of any bit of scientific knowledge (see What is Science?). Scientifically trained doctors do not (and should not) offer certainty because the art of medicine is informed by science. People do not like uncertainty. Uncertainty removes a sense of control and drives anxiety. Yet, doctors offer uncertainty and then wonder why some of their patients don't like it.
In contrast, practitioners of alternative medicine frequently do offer a sense of certainty. They offer a sense of control. Their explanations tend to be simple and easy to understand (albeit often contradictory to science). Perhaps it is through a desire for certainty, understanding and control of one's life that so many seek alternatives to science-driven medicine.
However, this sense of control may be illusory.
We shall see that science-based healthcare can be delivered with compassion. If the seekers of alternative health care think otherwise, then that is our fault.
But Does it work?
But do alternative treatments work? That depends on what one means by 'work'. Do people feel good about the care they received? In many cases they do. Are their medical conditions actually treated beyond subjective feelings and beyond the natural history of disease? The evidence says, "No".
In the NCCAM's first 10 years, over $2.5 billion tax dollars have been spent on controlled trials to study alternative treatments. To NCCAM’s credit, they adhere to the scientific methodology of evidence based medicine, much to the chagrin of NCCAM's political support.
“One of the purposes of this center was to investigate and validate alternative approaches. Quite frankly, I must say publicly that it has fallen short. I think quite frankly that in this center and in the office previously before it, most of its focus has been on disproving things rather than seeking out and approving.” (Senator Tom Harkin (D-IA) in a 2009 Senate hearing)
Remember, the scientific studies are not meant to confirm pet theories. One of the main reasons to do proper scientific studies is to eliminate biases such as the 'confirmation bias'. Statements such as Sen. Harkin's reveal deep and fundamental misunderstandings of how science works.
"Many pseudo- and fringe-scientists often react to the failure of science to confirm their prized beliefs, not by gracefully accepting the possibility that they were wrong, but by arguing that science is defective." Ray Hyman, Ph.D.
The term “alternative medicine” adheres to the National Science Foundation’s definition in that it has "not been proven effective using scientific methods."
What's Wrong With Using the Placebo Effect?
The difference between a 'placebo', as it is used in clinical trials, and the 'placebo effect' has been discussed extensively in The Placebo Effect section. Briefly, a placebo in a clinical trial essentially refers to a physical place-holder for the null hypothesis. The placebo effect refers to the subjective positive effects experienced by patients during a treatment that are due to all of the things involved in the treatment except for the treatment itself. All treatments have placebo effects. Real treatments result in effects above and beyond the placebo effect.
In research, if a treatment is a drug, and the studies show no benefit over the placebo pills, then the practical conclusion is that the drug does not work. The drug manufacturer cannot market a drug that is proven not to work. In fact, if the manufacturer did try to promote it, there would be loud accusations of fraud.
Now, let's substitute any favored CAM treatment for the word 'drug' in the above scenario. When CAM treatments are found to be no better than placebo, they are still practiced. When acupuncture is shown not to be beneficial over sham acupuncture, we hear no loud calls for the end of the practice. Instead, we see rationalization.
We found in the earlier section that harnessing the placebo effect involves deception (lying). We also considered three major philosophic schools of thought on Ethics (Deontology, Consequentialism and Virtue Ethics). We found that lying cannot be morally justified from all 3 perspectives.
So, is promoting placebo-equivalent treatments ethical? You decide.
How Can People Believe This Stuff?
Why believe things that have not been proven? Why believe things that have been disproved? The psychology and reasoning is complex. We have dealt with much of this in earlier sections.
In the Philosophy and Science section, we found that we naturally seek patterns and form beliefs. We then seek evidence to confirm our beliefs. Beliefs come before evidence.
In the Cognitive Dissonance section, we found that when faced with evidence that threatens our beliefs, we react with a very unpleasant feeling called 'cognitive dissonance'. We attempt to resolve this feeling by attacking or discounting the disconfirming evidence.
We mistake the so-called "placebo effects" for actual effects of our believed-in treatment.
In the Cognitive Bias section, we found that we are biased to value any evidence that confirms our beliefs and ignore evidence that contradicts them.
We tend to favor anecdotes and personal testimonies over cold numbers and data.
Logical fallacies can be used to construct reasonable sounding arguments to support our unreasonable beliefs.
We can use denialism to ignore disconfirming science. We can become pseudoskeptics by claiming to be skeptical of established science. We can discount established evidence by concocting conspiracy theories that involve powerful forces who are trying to deceive us, and that only we 'in-the-know' can see through.
And finally, we can try to have it both ways by claiming to value science, but then claim that science is not equipped to test our belief.
What are Alternative Treatments?
There seems to be no end to the list of alternative treatments and products. NCCAM divides CAM into groups: natural products, mind and body medicine, manipulative and body-based practices, and the broad category of “other”. Many of these treatments will be discussed in detail in the Pseudoscience in Healthcare section.
In the EBM vs. SBM section, we discussed the dangers of doing science only from the standpoint of clinical trials without considering a claims plausibility from basic science. Many of the claims tested at NCCAM would not meet the plausibility requirement. Now, volumes of implausible claims are being tested (albeit with good methodology) and all of the claims are being listed as 'inconclusive'. Calls for further studies are then typically made by systematic reviewers like Cochrane.
These are under the heading of nutrition “supplements”. These include herbal medicines (also known as botanicals), vitamins, minerals, and other "natural products."The word supplement ,as it is used here, is a bit ambiguous. In the U.S., products that are meant to be ingested are either considered foods or drugs. The Food and Drug Administration has strict rules regarding the marketing of drugs. The F.D.A. defines "drug" as any article (except devices) "intended for use in the diagnosis, cure, mitigation, treatment, or prevention of disease" and "articles (other than food) intended to affect the structure or function of the body." Thus, products with actual health claims are considered 'drugs' and fall under the regulation of the F.D.A. In 1994, the U.S. Congress passed the Dietary Supplement Health and Education Act (DSHEA). This act allowed marketers to sell products under the ambiguous heading of ‘dietary supplement’. The marketer could then avoid regulation by the F.D.A. by putting a disclaimer on the label (usually in very small letters). Dr. Peter Lipson likens this phrase to the ‘Miranda’ warning:
“These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure or prevent any disease.”
If this phrase is found on a product, then it is under the protection of DHESA. Any inferred claim on the product label must be worded vaguely and is usually meaningless. Statements such as “boosts the immune system” and “supports brain function” imply claims without actually being claims. What does it mean to “boost the immune system” or to “support brain function”?
Botanical products contain actual substances that can and do act as drugs. Many of our current pharmaceuticals were derived from naturally occurring plant-derived chemicals. Botanicals are sold over-the-counter and are not regulated. Many of them are promoted as having benefits that go way beyond what is known scientifically.
Homeopathic products are usually sold as if they are herbal / botanical supplements, but they are not. The rub here is that homeopathic products do not even contain the reported 'active' ingredient. We will cover homeopathy more extensively in the Medical Practices Unsupported by Science section.
Many people are under the impression that ‘they’ wouldn’t be allowed to sell it if it wasn’t safe / effective (meaning passed scientific tests). This impression is incorrect. DHESA made it possible. These products require no testing or regulation for safety. Consumers are on their own.
Mind and Body Medicine
Mind and body medicine practices "focus on the interactions among the brain, mind, body, and behavior, with the intent to use the mind to affect physical functioning and promote health."
NCCAM includes the following practices as examples of mind and body medicine: meditation, yoga, deep breathing exercises, guided imagery, hypnotherapy, progressive relaxation, qi gong and tai chi
Neuroscience is a relatively young science and the relationships between the brain and the consciousness are being worked out. Much is known, and more is being learned. The brain is an organ of the body, yet many regard 'mind' as separate from 'brain'. While few would deny the effects of these practices on relaxation and subjective feelings of peace, actual claims relating the interactions between 'mind' and body should be considered premature. The implied claim (that the brain interacts with 'mind') raises the philosophic question of 'mind-body dualism'. What is 'mind'? Is there another entity within, yet separate, from the brain? This does not pass our first skeptical tool of Hume's Fork & Falsifiability. It is likely that the claim of dualism between brain and mind is not something that can be addressed by science. It is perfectly fine to hold such an opinion, but it cannot be defended rationally. Scientific sounding claims about mind and body can only be sophistry.
Manipulative and Body-Based Practices
These practices "focus primarily on the structures and systems of the body, including the bones and joints, soft tissues, and circulatory and lymphatic systems."
Here, NCCAM includes chiropractic and massage therapy, although chiropractic can also be listed under 'energy medicine' below because the idea for chiropractic (at least in its pure form) involves the manipulation 'subluxations' of the spine to unblock the flow of 'innate intelligence', an unmeasurable vitalistic energy, through the nervous system to promote healing. We will discuss chiropractic in more detail in its own section.
Massage therapy has many different types, some that involve ideas from eastern mysticism, such as the manipulation of chakras, energy flows, acupressure points, and humors. Again, our criteria of Hume's Fork / Falsification prevent us from considering appeals to unmeasurable energy fields as science.
Energy medicine is a broad category listed under "other" by NCCAM. This group of 'treatments' claim to manipulate various forms of energy fields in a patient to promote health. "Such fields may be characterized as veritable (measurable) or putative (yet to be measured)."
Treatments involving "veritable" energy fields include magnet therapy. Here, magnets (typically the strength of kitchen magnets) are placed within jewelry, shoes or clothing with the intent to use magnetic fields to alter the flow of blood and whatever else the sellers of magnets claim. The fact that the iron in blood is non-magnetic doesn't seem to matter. And, if even if it was, the magnetic field from a kitchen magnet is very weak and its effects dilute to virtually nothing outside of a few millimeters away. Thus, magnet therapy is an extremely extraordinary claim that would require alternate physics to work.
Energy medicine involving "putative" energy fields include reiki, and therapeutic touch. Acupuncture can also be included here as well as in mind & body medicine. NCCAM states plainly that these energy fields have "yet to be measured". Yet to be measured. These treatments are claimed to work via an energy field that has never been observed. This raises an important question. How does one decide that there is an energy field to manipulate if it has never been measured or observed? As discussed in the EBM vs SBM section, we are skipping the stasis point of conjecture. Dr. Hall would call this Tooth Fairy Science. Unmeasurable entities cannot be considered science and therefore should not be treated as such by academic centers.
Whole Medical Systems
These systems are listed in the "other" category of CAM. These are "complete systems of theory and practice that have evolved over time in different cultures and apart from conventional or Western medicine". These include very old systems such as Ayurvedic Medicine and traditional Chinese Medicine. They also include systems developed relatively recently like homeopathy. Homeopathy will be discussed in detail on its own page. Naturopathy is a collection of systems that include many of the above 'treatments' with the idea that the body will heal itself with the aid of CAM therapies.
This practice is another broad category of CAM but not dealt with per se on the NCCAM website. The word "detoxification" is used in traditional medicine to describe the process of helping people through the withdrawal of alcohol or other drugs of abuse. "Detoxification" in the world of CAM is used to describe a host of practices by which 'toxins' are removed from the body to promote health.
It is true that we consume toxic substances and produce them as waste. Our liver and kidneys are the main organs that eliminate them. The effects of real toxins become obvious when these organs fail. However, proponents of detoxification CAM procedures and products would have us believe that most of us are suffering from the effects of toxins due to overload of our defenses. Today, many detoxification products and schemes are available for sale to rid our bodies of these toxins. Some of these products are harmless but deceiving, while others can be quite dangerous. They range from foot pads that turn dark after several hours, enemas (including coffee enemas!), to dangerous and unwarranted procedures like chelation.
There is no scientific evidence that these claims are true.There are certainly no scientific reasons to proceed with such schemes. As with the supplement industry, buyer beware.
But Conventional Medicine Harms People Too!
At this point, it would be helpful to review the Ad Hominem Tu Quoque logical fallacy.
It is true that the treatments of conventional medicine come with well documented side-effects and medical errors. These side-effects can be devastating, costly and deadly. In fact, the dangers of conventional medicine may be greater than with CAM treatments. These facts are loudly proclaimed by many advocates of alternative medicine, implying that skeptical doctors have no right to point to the dangers of alternative medicine. This argument is emotionally compelling on the surface, but falls apart under scrutiny.
The key is to consider risks and benefits over large populations. Science is particularly good at calculating these risks and benefits. Medical practices should be employed only when the greater good will be served. Chemotherapy can cause tremendous side-effects and, in some cases, hasten death. But if it is found that more people will benefit (prolonged life or a decrease in overall suffering), then the treatment should morally be offered and instituted.
The NNT (number needed to treat) and the NNH (number needed to harm) are concepts that make this point measurable. For instance, NNT and NNH have been well studied in statin therapy for the prevention of cardiovascular events (heart attack, stroke). They can cause serious side-effects (rhabdomyolysis). The NNT for statin therapy in a moderate risk population was found to be 27. This means that a doctor would only have to treat 27 patients over 5 years with a statin to prevent one serious event. The NNH was high (3400). In other words, a doctor would have to treat 3400 patients with statins for 5 years to seriously harm one (and most of these injuries would not result in death). Obviously, this study shows that for a large group of patients over a relatively long period of time, it is far more beneficial to treat them with statins than to abstain.
On the other hand, many otherwise healthy people practice colon cleansing through colonic irrigation. There is no published benefit for this practice in healthy people. There is evidence of deadly harm. A report in the New England Journal of Medicine stated:
"From June 1978 through December 1980, at least 36 cases of amebiasis occurred in persons who had had colonic-irrigation therapy at a chiropractic clinic in western Colorado. Of 10 persons who required colectomy, six died."
Since we can infer that the NNT for colonic irrigation approaches infinity, and that the NNH is a small but whole number, the risk / benefit ratio approaches infinity.
With CAM treatments, no overall benefits beyond placebo have been found. Therefore, the risk / benefit ratio approaches infinity. No harm that comes from CAM, no matter how small the risks, should be morally tolerated.
Gurus, Experts and Consensus
These are people that deserve a great deal of up-front skepticism, but instead are rewarded with popularity and unwarranted authority. Gurus are often self-proclaimed. They frequently have questionable credentials or no relevant credentials at all. The guru is usually selling products and ideas of which they claim unique and special knowledge. These products are usually exempt from government regulation, such as supplements, detoxification devices and books. Their claims are simplistic and dramatically certain. They may claim to know the one true cause or the one cure of all disease. Gurus tend to exhibit many of the traits found on the Pseudoscience page. When selling their claims, they appeal to uplifting beliefs, use vague language, rely on anecdotes for evidence, avoid scrutiny by avoiding peer review and reporting straight to the media, and they work in isolation. When criticized, they respond with hostility and demonize their enemies.
When confronted with disconfirming evidence, they are impervious with denialism and self-seal their story with conspiracy theory. They reverse the burden of proof: they claim that they are being suppressed by a hostile establishment. They are always selling something. Profit at the expense of the gullible is their motive. When confronted with their profiteering, they will point to the fact that pharmaceutical companies and science-based doctors make a lot of money too (this is the classic ad hominem tu quoque logical fallacy). Somehow, this is supposed to justify their unwarranted, and often dangerous, claims.
A perfect example of someone who appears to fit this profile is pseudoscience huckster and convicted credit card scammer, Kevin Trudeau. Boasting a net worth of over $200 million, he makes his money by selling books that aim to convince his readers that (among other dangerous claims) scientific medicine is a scam conspired by the FDA and the pharmaceutical industry. He actively encourages the public to shun proven medical treatments for serious diseases like cancer and AIDS, implying that it is really the chemotherapy and anti-retroviral treatments that are causing the disease. We should instead pursue "natural cures". He has been found guilty of fraud and fined massive amounts of money over the years, but even these facts get twisted into 'evidence' for his conspiracy theories of being persecuted by a puppet government for promoting cures that "they" don't want you to know about. He is just one of many dangerous examples.
A list of some of pseudoscience's most notorious 'gurus' can be found through the following link:
Promoters of Questionable Methods and/or Advice (Quackwatch.org)
In medicine, a guru should never be confused with an expert.
Wikipedia's definition of expert is, "someone widely recognized as a reliable source of technique or skill whose faculty for judging or deciding rightly, justly, or wisely is accorded authority and status by their peers or the public in a specific well-distinguished domain."
In science, expertise is relevant only within its own particular, relevant field. The title of expert implies recognition from peers in that particular field. In our society, an expert is generally recognized through both proper credentials (relevant professional degree plus ongoing maintenance of certification) and reputation within that field. Experts are never self-proclaimed. The medical expert should never exhibit the hallmarks of pseudoscience listed above. They use specific language and rely on scientific data. Experts present their claims to peer review and proper outlets such as scientific journals, rather than reporting directly to the lay media. Their research is transparent and collaborative. Things are not considered to be true because experts say them, but rather experts are known for saying verifiably true things. And most of all, an expert should (ideally) assume the burden of proof and accept being wrong.
Scientific knowledge is obtained through proper scientific methodology and properly scrutinized by experts in that particular field. The information is challenged over and over through repeat studies and analysis of combined studies. If the information survives such treatment, then it generally gains acceptance withing the community of relevant experts. Thus, a consensus is reached about a particular piece of knowledge. To argue against such a consensus is to assume a massive burden of proof.
Consensus among scientists / experts IS science.
The world of alternative medicine is populated with gurus. Their claims rarely cohere with the consensus of recognized experts within the particular, relevant field. Although it is likely that most proponents of alternative medicine believe in their claims, and truly mean well, it seems unlikely that most 'gurus' share these positive qualities.
Of course, the claims of a guru are not necessarily wrong, but they do warrant skepticism.
Are All Alternative Treatments Alternative?
Remember, the National Science Foundation states, "alternative medicine refers to all treatments that have not been proven effective using scientific methods." With this in mind, many so-called “alternative” treatments could come off of the list and join the world of medicine without the need to 'integrate' them. It is the unsubstantiated claims that keep many of these treatments on the alternative list.
Clearly, healthy diet and regular exercise are not alternative. Nutrition and exercise have been studied extensively. Although the research is incomplete and the recomendations are changing, we have volumes of conclusive evidence that proper diet and exercise are good for us. They lower the risk of diabetes, heart disease, stroke, osteoarthritis, osteoporosis, some forms of cancer and perhaps even Alzheimer’s disease. It would seem that defenders of CAM may wish to keep diet and exercise under the heading of CAM because these practices are supported by real science. An argument against CAM would be an argument against diet and exercise. This is a strawman argument. Diet and exercise are not alternative. They should be considered foundational recommendations of medicine.
Massage generally feels good. Massage usually accomplishes what one would expect and also does not belong on the list of 'alternative' treatments. However, if the massage therapist makes unwarranted claims regarding "energy" or other unmeasurable effects, then we drift back into the alternative realm.
There can be an alternative slant to exercise as well. Yoga can be part of an excellent exercise program. It can help back pain as much as regular stretching. However, Yoga is credited with many health benefits beyond measurable effects such as increased immunity, "rejuvenation" of the pituitary and thyroid glands, and even less wrinkles!
Meditation and deep breathing are what they are. There should be no conflict here unless the advocate is making unsubstantiated claims about them. Meditation can be very relaxing and refreshing. Deep breathing can also calm anxieties. Many feel more relaxed and in-control with the help of 'guided imagery', a practice to help "guide your imagination toward a relaxed, focused state."
If the endpoint is to feel relaxed with a 'clear head', then practices such as these can be effective in people who practice them. Progressive relaxation, massage, and hypnotherapy are effective if the recipients of these therapies say they are. In this regard, practices such as these could easily be classified as 'aesthetics' for they are pleasing to the senses just as people can be calmed, relaxed and refreshed from different types of music or art. Other practices that can bring about the subjective endpoints of peace and calmness may include conversation with a friend, sitting by the ocean, a hug from a loved one, playing with an infant, or petting a cat. However, if one claims that the health benefits to any of these practices extend beyond the known benefits of being calm and less anxious, then we we have to properly put those practices back on the shelf of pseudoscience.
** It is the unsubstantiated claims of alternative medicine that make it "alternative".
Medical education and practice in the United States was divided and chaotic in the early twentieth century. Medicine was not governed by science. Dogmatic beliefs were taught simultaneously with the sciences of anatomy, physiology, pathology and microbiology. A scientific revolution then took place that lifted our system out of its dogmatic slumber.
However, the lessons learned are being ignored in our academic centers, possibly due to economic pressures. Pseudoscience is being "integrated" (or rather reintegrated) back into medical education, thus blurring the lines between reality and illusion.
What Can Alternative Medicine Practitioners Learn from Skeptical Doctors?
It would seem that CAM practitioners may be of the opinion that science-based doctors would like to rid the world of the things that CAM has to offer. This does not have to be the case. As we just read in the paragraphs above, there are undisputed benefits that result from healthy lifestyles, and techniques for relaxation and stress reduction. Many of the so-called "alternative" treatments need not be alternative.
What skeptical doctors wish to convey to CAM practitioners is that science matters. Basic science matters and clinical science matters. If a belief is implausible (contrary to basic science), or if a belief is consistent with the null hypothesis (contrary to clinical science), then it is honorable for us to change our minds.
It is said that CAM does not make advancements like science does. If this is true, then it is true for the very reason that CAM believers do not change their minds in light of new evidence. This is a lesson that many traditional doctors have not learned either. Changing one's mind is not a weakness, it is a strength.
Why is it that we cannot offer many of the treatments above without making unsubstantiated claims? Why must we appeal to pseudoscience to back up these practices?
If we could drop the pseudoscience, there would be no need to 'integrate' CAM with traditional medicine. Hypnotherapists can simply do what they do. Massage therapists could state that they will simply make people feel good by giving them a massage. Chiropractors could state that they may help people with their acute back pain, but refrain from claiming blocked innate intelligence and unseen subluxations. So-called supplement experts could properly study what is known about nutrition and promote those few supplements that are scientifically known to help, like vitamin D (remember, claims should pass both basic science plausibility and clinical trials). Of course, that would require a great deal of hard work and proper credentials (dietitian is the legally protected term, nutritionist is not). Personal trainers and fitness experts could simply promote exercise, as most already do.
However, it may be o.k. to 'imagine'.
Imagine there's no countries
It isn't hard to do
Nothing to kill or die for
And no religion too
Imagine all the people
Living life in peace.
What if we embraced the concept of "imagine"? John Lennon asked us to "imagine" there's no countries or religions (i.e. things that divide us). He knew full well that such countries and religions exist. He asked us to imagine, to suspend belief, and explore what might happen if things were different.
WebMD.com explains several stress management techniques. One is the calming method of 'guided imagery'. When under stress, it states:
Picture a setting that is calm and peaceful. This could be a beach, a mountain setting, a meadow, or a scene that you choose.
Imagine your scene, and try to add some detail. For example, is there a breeze? What does the sky look like? Is it clear, or are there clouds?
On the website, FibromyalgiaHope, a relaxation technique for deep breathing is explained:
"...imagine that you are breathing in through your toes, then out through your toes. Continue to breath in and out through your toes, drawing the breath further up your body each time. Imagine the breath retracing its path down your body and out the toes on each exhale. If you can't draw the breath up throughout the whole body, switch to imagining the breath drawing in through your fingertips, belly button or eyes, in order to relax the whole body."
Notice that no claims are being made. The authors simply ask the reader to imagine.
Magicians ask people to suspend belief. They ask people to imagine. They do not claim to have powers (like so-called 'psychics'). Practitioners of 'energy medicine' (such as Reiki) may harness relaxation and peace by asking patients to "imagine there is an energy field..." Massage therapists can instruct patients to "imagine" that their energy is balancing. Homeopaths can say, there is nothing actually in this, but "imagine" that it will give you strength. It is unlikely to happen, but we can imagine such a world.
And for Pete's sake, don't deny science.
Vaccines are good. 'Natural' does not mean 'better'. Water does not have memory. Gurus do not know better than a scientific consensus. There is no one cause of all disease. Enemas do not eliminate 'toxins'. Coffee is for drinking.
What Can Skeptical Doctors Learn from Alternative Medicine?
CAM practitioners often claim that they are 'holistic' in that they care about the 'whole' patient. The implication is that science-based doctors do not care about the patient as a 'whole' person, at least not to the extent of the CAM provider. Although many doctors specialize, most who commit their professional lives to medicine do so to help 'whole' people. To primary care doctors, the implication that they somehow do not care about 'the whole patient' seems absurd. However, that is the image that some have of us. We can do better.
We should first consider why people tend to be drawn toward alternative medicine in the first place.
There are those who are drawn due to ideological predispositions toward magical thinking and the belief systems involved. For such people, we must be sensitive to their beliefs. Simply pointing out facts will not be effective and, in fact, will cause immediate conflict. Such people are not swayed by data, they are swayed by personal and emotional stories. Skeptical doctors must proceed with caution, planting small seeds along the way. We must be respectful, avoid being condescending, yet maintain our integrity.
CAM may seem to better validate people's feelings, fears and anxieties. CAM practitioners are apt to spend more time with patients. They are more apt to offer treatments that are high in aesthetic value. CAM is presented with certainty and simplicity, thereby lowering anxiety about conditions and treatments.
Brien et.al. conducted a study to explore the actual clinical benefits of homeopathy among patients with rheumatoid arthritis. They reported that...
"...therapeutic benefits do arise from processes within the homeopathic consultation involving communication skills, empathy, hopefulness, enablement and narrative competence."
They concluded that...
"Homeopathic consultations but not homeopathic remedies are associated with clinically relevant benefits for patients with active but relatively stable RA." (emphasis added)
So, patients can achieve significant benefits from consultations in which the practitioner is effective at communicating empathy, hope, clarity and, essentially, decreasing uncertainty.
It is true that science-based doctors (skeptical doctors) cannot offer certainty about diagnoses or treatment outcomes. But, doctors can offer certainty about their intentions; certainty about their understanding of the patient's feelings; certainty that the patient is a person, not a number.
We can offer certainty that we care.
Let's make sure that we do.
(For more on this, please read the final section of this site, Skeptical and Compassionate.)
John Byrne, M.D.
References and Links
"Scientists Speak Out Against Federal Funds for Research on ..." 2009.
"National Center for Complementary and Alternative Medicine ..." 2004.
"Home Page | NCCAM."
"Research Results | NCCAM." 2006.
"Science Fiction and Pseudoscience - National Science Foundation." 2005.
"Quack Miranda Warning « White Coat Underground." 2011.
Roberts, Christian K, and R James Barnard. "Effects of exercise and diet on chronic disease." Journal of Applied Physiology 98.1 (2005): 3-30.
"Massage - Wikipedia, the free encyclopedia." 2003.
""Detoxification" Schemes and Scams - Quackwatch." 2009.
"$2.5 billion spent, no alternative cures found - Health ... - MSNBC."
Sirois, Fuschia M. "Motivations for consulting complementary and alternative medicine practitioners: a comparison of consumers from 1997–8 and 2005." BMC Complementary and alternative Medicine 8.1 (2008): 16.
"Science-Based Medicine » Pragmatic Studies – More Bait and Switch." 2011.
"Stress management: Doing guided imagery to relax." 2008. 14 Oct. 2012 <http://www.webmd.com/balance/stress-management/stress-management-doing-guided-imagery-to-relax>
"Science-Based Medicine » The Problem with Chiropractic NUCCA." 2011.
Brien, Sarah et al. "Homeopathy has clinical benefits in rheumatoid arthritis patients that are attributable to the consultation process but not the homeopathic remedy: a randomized controlled clinical trial." Rheumatology 50.6 (2011): 1070-1082.
"Alternative medicine: The illusion of control – Respectful Insolence." 2012.
"The World Question Center 2008 - Edge." 2007.
"CSI | The One True Cause of All Disease - CSICOP." 2010.
"Promoters of Questionable Methods - Quackwatch." 2006.
"Pharmacognosy in the 21st century." 2008.
"Tom Harkin's War on Science (or, “meet the new boss…”)." 2011.
Atwood, KC. "Naturopathy: a critical appraisal." MedGenMed: Medscape general medicine 5.4 (2003): 39.
"Is Infomercial King a Helper or Huckster? - ABC News."
"Judge Orders Kevin Trudeau to Pay More Than $37 Million for False ..." 2009.
Silva, Matthew A et al. "Statin-related adverse events: a meta-analysis." Clinical therapeutics 28.1 (2006): 26.
"Stress management: Doing guided imagery to relax - WebMD." 2008.