Skeptimedia

Skeptimedia is a commentary on mass media treatment of issues concerning science, the paranormal, and the supernatural.

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Skeptimedia replaces  Mass Media Funk and Mass Media Bunk. Those blogs are now archived.

Framing the Medicine Wars

2 March 2009. As every blogger knows, how an issue is framed can be the difference between being persuasive and being ignored. Language is our main tool in framing issues, but language is not always our friend. Try as we may to control and manipulate the effect of our words, they seem to have a life of their own and be bound by a set of unpredictable rules. Who could have predicted the success of the word 'gay'? or the demise of the word 'liberal'? How has 'quantum' come to be so abused? And does anyone even remember 'eupraxophy'?

Alternative medicine is said to be meaningless because there is no alternative to medicine. Something either is or isn't medicine. Something that wants to be medicine, but hasn't proved itself, isn't an alternative medicine. It isn't medicine at all. Still, attempts to snuff out 'alternative' when applied to medicine haven't been wholly successful. The term 'alternative' is now often joined with the term 'complementary', as in CAM, complementary and alternative medicine. CAM is now ensconced in one of the National Institutes of Health and looks like it may be around for the foreseeable future.

Some opponents of CAM propose that alternative medicine be called non-conventional medicine, a move that seems to imply that the alternative to alternative medicine should be called conventional medicine. The idea seems to be that some medicine is ordinary medicine and some is not ordinary. The problem with that is that some alternative practices are so popular and widespread that it is fair to call them conventional, e.g., homeopathy in England and chiropractic in the U.S. Soon, acupuncture is likely to be conventional in some countries where it has been referred to as traditional medicine because it is thought to be ancient. Yet, why should only the ancient be thought of as traditional? Isn't there a traditional way to treat a broken arm or diphtheria that has nothing to do with the age of the method, but refers to the usual way of doing things?

Some have tried to separate medicine into evidence-based and all the rest, but it is hard to find any medical practice that doesn't think it's based on evidence. In order to distinguish medicine that is rooted in science from medicine that is not, some prefer the expression science-based medicine. This expression implies that some medicine is not science based. Yet, defenders of such medicine as acupuncture, chiropractic, homeopathy, and naturopathy would reject the notion that they are not science based. Should we try good-science-based medicine versus bad-science-based medicine?  I wouldn't recommend it.

Roberto Reece, a teacher and skeptic with a radio program in Quito, Ecuador, wrote to me about some problems he has with expressions like conventional, evidence-based, science-based, alternative, integrative, complementary, and traditional when applied to medicine. He wrote that in Spanish the words convencional or tradicional are often applied to scientific medicine in opposition to medicina alternativa, medicina no convencional, nueva medicina, medicina complementaria, medicina humanista, and medicina no-invasiva.

We have a similar problem in English. Scientific medicine is sometimes referred to as conventional medicine and is opposed to non-conventional medical treatments. It is rare, however, to find anyone referring to scientific medicine as traditional medicine. That term is used almost exclusively for non-science based medicine that originated and developed in magical thinking, superstitions, and anecdotes.

One problem with using science-based medicine or evidence-based medicine is that it can be used to denote both scientific medicine and pseudo-scientific medicine. Here pseudo-scientific medicine refers specifically to medicine that relies solely on anecdotes and does no randomized, double-blind controlled studies (examples are endless but see this recent story about Russian quacks), medicine that denies it can be subjected to the usual tests for causality (e.g., homeopathy and applied kinesiology), medicine that does not use controls in tests for causality (e.g., almost all acupuncture studies in China and all hypnotherapy studies), does not understand the need for adequate control for placebo effects (many acupuncture studies), or understands the need for placebo controls but doesn't know how to implement them (e.g., many acupuncture, homeopathy, and chiropractic studies). Even the worst experiment in China on acupuncture produces evidence and engages in science, even if it's bad science, and thus might justifiably refer to itself as evidence-based or science-based. Even junk science is science and evidence-based. It's bad science and the evidence is weak, irrelevant, unconvincing, inadequate, etc. I don't think a medical practice is scientific if it originated in superstition and magical thinking, became ritualized and practiced by many in a culture, and then centuries later was subjected to a few inadequately designed scientific tests that were misinterpreted by its advocates. Something is not scientific medicine until it passes the rigorous demands of science and is incorporated into standard medical care.

Roberto's suggestion is that we use the expression Scientific Medicine (Medicina Científica) rather than evidence-based medicine or science-based medicine. He writes:

....Here in South America we have heard a lot about the expression "evidence-based medicine." The educational level and poor information in most of Latin America will guarantee that such an expression will never catch on among the people and only a few scientific doctors will be willing to use it. In Spanish, for instance, that expression is translated as "medicina basada en evidencias." The term is accurate, but lacks appeal and demands explanation. "Scientific Medicine" on the other hand (Medicina Científica, in my tongue) is easier and accurate, too; and has an emotional appeal which goes hand in hand with the universal prestige of Science.

Our own cause, "Skepticism", encounters a serious challenge when using the word "Escéptico." In Spanish it is difficult to pronounce, and has a very poor connotation, almost demeaning. The reasons are cultural and, of course, religious. Thanks to Saint Thomas the Apostle, if we call ourselves "Escépticos" we are doomed to be perceived with prejudice and disdain by most of the people. Actually, they have already managed to equate the word "Escéptico" with close-minded, arrogant, and even ignorant. That is why my small and fairly new organisation selected the name "Prociencia" and we are vocal in calling and presenting ourselves as "procientificos," that is "pro-scientific" or pro-Science.

I've thought about this issue since Roberto brought it up a couple of months ago, but I balked at making any changes in language because I wasn't sure it would matter that much. Yesterday, however, I got a Google alert on "acupuncture" that changed my mind. I have decided to use the expression scientific medicine (without caps) most of the time when referring to medicine that is based on science and standard scientific testing and methods. Roberto and I are both aware that using scientific medicine or medicina científica will not be without its problems, the main one being that scientifically trained physicians and nurses don't always act as scientists. So, practitioners of scientific medicine may not always be completely accurate. Another problem is that some people may misunderstand the expression as meaning infallible medicine. Not everyone understands that science is tentative rather than dogmatic. The alternative, though, is to use the same expressions to describe both the work of physicians applying scientifically-tested therapies and the work of charlatans, incompetents, and well-meaning but self-deceived apostles of woo.

battlefield acupuncture

What finally led me to revise the language in the main entries in the Skeptic's Dictionary that contrast scientific medicine with woo was the following news item:

Medical acupuncture, which is acupuncture performed by a licensed physician trained at a conventional medical school, is being used increasingly for pain control. Richard Niemtzow, MD, PhD, MPH, Editor-in-Chief of Medical Acupuncture, a peer-reviewed journal and the official journal of the American Academy of Medical Acupuncture, is at the forefront of these efforts in the military.

The technique developed by Dr. Niemtzow has been so successful that the Air Force will begin teaching "Battlefield Acupuncture" to physicians deploying to Iraq and Afghanistan in early 2009 . "Battlefield Acupuncture" can relieve severe pain lasting several days.

Based on modern neurophysiological concepts, Niemtzow developed a variation of acupuncture that involves inserting very tiny semi-permanent needles into very specific acupoints in the skin on the ear to block pain signals from reaching the brain. This method can lessen the need for pain medications that may cause adverse or allergic reactions or addiction.

"This is one of the fastest pain attenuators in existence," said Dr. Niemtzow, who is the Consultant for complementary and alternative medicine for the Surgeon General of the Air Force, and is affiliated with Uniformed Services University of the Health Sciences in Bethesda. "The pain can be gone in five minutes."

Medical Acupuncture says it is "evidence based" and is written "for physicians, by physicians." To see what might be meant by "evidence based," I suggest you read Niemtzow's editorial on Acupuncture and Wizards, where he speculates that acupuncture is a science that may "eclipse Newtonian physics." I tried to find evidence that Niemtzow has done controlled studies on "battlefield acupuncture." I couldn't find any evidence that any of the studies he's published on acupuncture used controls or that he had sound evidence that he was not measuring a placebo effect. What I did find was Sandy Szwarc's Junkfood Science recent blog about Neimtzow and his push for battlefield acupuncture.

Szwarc has uncovered a rather dubious distinction in Niemtzow's resume that doesn't appear in his official version: he's had some nasty encounters with aliens and lived to tell the tale. His resume is quite impressive, as long as you leave out the stuff about aliens, UFOs, and his beliefs in ancient Chinese wizards. He may be an unassuming looking 65-year-old, but he has managed to get himself appointed as the first official acupuncturist in the U.S. armed forces and to turn Malcolm Grow Medical Center at Andrews Air Force Base into a de facto training center for Air Force physicians who are completing their acupuncture training.

Niemtzow's website says he specializes in acupuncture for dry mouth and dry eye, but he also treats obesity and a few other things. He's written that he and his cohorts use at least ten different kinds of acupuncture treatments for the following list of disorders:

fibromyalgia, protruding disks, reflex sympathetic dystrophy, degenerative disk disease, spinal stenosis, frozen shoulder, peripheral neuropathy secondary to diabetes or chemotherapy, torticolis, overuse syndromes, abdominal pain of unknown etiology, tendonitis, carpal tunnel syndrome, arthritis, osteoarthritis, migraines ... obesity, nicotine abuse, dry mouth and dry eyes from various etiologies, hot flashes, chronic fatigue along with depression, and dermatological conditions such as eczema....

To get a real feel for just how dangerous Niemtzow's delusions are, read Sandy's Junkfood Science entry on him. It's very long and very detailed.

Dr. Niemtzow may be doing evidence-based or science-based medicine, but he is definitely not doing scientific medicine. His delusion about acupuncture eclipsing Newtonian physics is based on a set of metaphysical beliefs about chi and his seeming lack of curiosity that leads him to forgo  randomized, double-blind, controlled studies to ferret out such things as placebo effects and false placebo effects. His claim that sticking needles in the ear blocks pain signals (from bullet wounds to the leg or back?) is not based on good science. There are millions of people in pain who would love to be able to block pain signals by putting little pins in their ears. If he could prove it's true he'd have his Nobel and my thanks as well. He may have evidence for his beliefs, but the evidence is not very good and it certainly shouldn't persuade a reasonable person to think his beliefs are based on solid science.

So, what next? Should I change the name of The Skeptic's Dictionary to an expression with less negative baggage? How about The Critical Thinker's Encyclopedia of Weird Beliefs or Critical Thinking about Strange Stuff? Sometimes it's best, as my mother used to say, to leave well enough alone.