The short answer is NO.
The core of today’s veterinary education has, for good reason, been built upon a vast web of interconnected and established science. With this in mind, the belief in the need to teach Complementary and Alternative Veterinary Medicine (CAVM) at veterinary schools immediately brings to the fore a looming dilemma.
Science is a powerful filter and provides a foundation from where medicine has discovered truly effective therapies. It has proven an excellent tool for excising the useful from the useless (i.e.; statistical significance vs. fanciful testimony and tenuous beliefs). To date, science is the only way to assure that medicine stays on the straight and narrow and optimizes its effectiveness. Without it, no matter how well intentioned, the practice of medicine falls prey to a world of delusion and fairy tales.
Medicine develops and refines innumerable modalities and therapies based on accumulating evidence. Though this evidence may vary in robustness and quality it is always grounded in science. In general, you can’t skip over this basic filter and practice any kind of “medicine” that suits your fancy- that usually leads to the realms of metaphysics and belief.
The machinery for seeking and establishing effectiveness in medicine assumes the plausibility of what is being studied. If it is not a plausible modality the best the research can offer is often just garbled noise -equivocal statistical data- that is neither here nor there. This is something novice students are not being taught and herein lays the problem.
Medical education needs to emphasize critical thinking tools and teach aspiring doctors how to navigate within the depth of established science based medicine before tackling fringe areas such as alternative medicine.
If a student sees a CAVM modality as part of the curriculum of veterinary education the assumption is made –whether these young minds know it or not- that there must be something to this particular practice. It falls under the rubric of an accepted standard of practice and therefore is a part of general practice. This simply is not the case because if it were there would be no “alternative” in alternative medicine.
When it is implicit to students that academia tolerates alternative medicine as “just another way” you compromise these students science based education. Dr. Colquhoun points out that “Once any treatment is shown beyond doubt to be effective, it ceases to be ‘alternative’ and becomes just like any other part of medical knowledge. That means that ‘alternative medicine’ must consist of unproven treatments.” It is not the domain of academia to be teaching unproven treatments to young students.
Introducing unsubstatntiated non science based modalities and therapies that might have some plausible basis (acupuncture), no matter how scientific they might appear, to these aspiring professionals before they are ready to critically evaluate them is a bad idea. It opens the doors to a Pandora’s Box as other alternative medical paradigms (i.e.; homeopathy, energy medicine) will inevitably also demand a place in academia.
This is reminiscent of “teaching the controversy” of evolution that intelligent design advocates support so vehemently. This red herring demonstrates an alarming lack of actual scientific knowledge regarding proper methodology and smacks of dogma and pseudoscience.
Dr. Colquhoun points out an interesting observation with respect to the curious confounding of pseudoscience and science ("quackademics") in medical schools. He states that “All these outfits have two things in common. They all claim to be scientific and evidence- based, and none has produced any real evidence that any of their treatments work.”
This is one of the weaknesses to claiming that the CAVM offered in veterinary schools is being scrutinized under the framework of science. If they were, they would be pulled out of the cirriculum or possibly relegated to research. As noted though, you can't use evidence-based research very well when the underlying science is suspect.
In addition, the fact that CAVM has become a fairly popular practice among some people and practitioners outside academia is not an excuse to teach it in school. This is an appeal to popularity and gets medicine no-where.
It has been noted that veterinarians need to be more non-judgmental and not stigmatize CAVM; implying a rush to judgment and a bias against CAVM. In some cases, the implication goes; this may threaten a client/doctor relationship and could lead to the loss of clients who might move entirely to alternative medicine. Medicine needs to “adapt to changes brought about by societal influence” and the popularity of CAVM –another effective way of doing medicine- needs to be accepted, embraced, and taught in school. This is threading misrepresentation with populism- a dangerous mix.
Fallacious reasoning like this creates false realities and gives little credence to the ability of a skilled practitioner and the influence they can have on client/doctor relationships. The opportunity to communicate and teach science based medicine is taken seriously my many practitioners.
They feel obligated to create a comforting, supportive, and trusting bond that openly and honestly approaches the situation at hand. Practicing the best science and evidence based medicine they can goes hand in glove with this bond and most clients will respect that.1
Though, there may be emotionally charged biases against CAVM at times, the fact remains that -for the most part- it is not science and it is definitely not a substantiated medical modality. Disregarding or not recommending CAVM if it does not fulfill the requirements of science and evidence based medicine is not being biased.
Learning how to communicate and interact empathetically with people is by far one of the most important skills a veterinary student can learn. This is what should be stressed more in university curriculums than teaching pseudo-science. On the other hand, future practitioners need the critical thinking tools and knowledge to clearly and dispassionately discuss why a given CAVM modality may not be the most ideal approach to a given problem. This can be done without creating the impression that CAVM is or should be an accepted part of scientific medicine.
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1. If a client elects to proceed with a CAVM modality then it’s their decision, and though sometimes difficult, practitioners should strive to continue working with these clients if possible and promote what is in the animal’s best interests.
Showing posts with label science. Show all posts
Showing posts with label science. Show all posts
Monday, February 2, 2009
Wednesday, August 13, 2008
Alternative medicine: a ghostly illusion
Most of Complementary and Alternative Medicine is built on a house of cards
A nicely worded post at Panda Bear, MD (sadly, no longer blogging for now) succinctly describes many of the problems I have encountered through the years while attempting to put my finger on just how alternative medicine is defined. Many personal discussions with alternative practitioners and fairly extensive research of alternative medicine texts has continually left me with no real tangible how, when, and why answers.
"Almost everything about Complementary and Alternative Medicine (CAM) is bunk and its purveyors are at best deluded and at worst quacks and charlatans who would make the snake oil salesmen of olden days blush from shame. Maybe a hundred years ago you could make a case for magic potions and mysterious cures from the East but today we should know better and only don’t because of a combination of scientific illiteracy and an ingrained bias against rational Western thought. What little benefit patients can derive from most of the quackery being sold to them is not worth a fraction of the money spent and the same effects could be achieved without the smoke and mirrors if people paid as much attention to diet, exercise, and all around clean living as they do to looking for an easy fix."
Unfortunately, this mirrors my experience in the veterinary world as many clients, swayed by their own perceptual biases, often search out these fallacious "other ways of knowing". I would like to make it clear that science based medicine is not perfect, nor does it have all the answers. Additionally, we need to consider all medicine as one concept, and look at all of it with the same critical attitude. Alternative Medicine steers clear of this rigorous approach and it became clear to me why as I realized it is mostly nothing more than myth, belief, and nostalgic notions of ancient wisdom.
"CAM exists in an alternate universe from real medicine. It wants to be legitimate but manages to avoid the responsibilities and liability of real medical practice. As most CAM treats nebulous symptoms with equally nebulous modalities, there is no measurable standard for efficacy of any of the treatments. "
This is one of the key problems that I have run into time and again. How can we know that what we are doing as practitioners is doing any good without having a reliable mechanism to steer our often imperfect attempts at helping and healing the sick?
"The real medical profession while imperfect like all human endeavors is not so conservative that ineffective or ridiculous therapies are not discarded. This is the whole basis of evidence based medicine. There is no evidence based Complementary and Alternative Medicine. It exists in the absence of and often despite the evidence. When challenged, its practitioners will retreat like the sweaty televangelists to anecdotes and testimonials. Either that or they will cite the placebo effect, that last hope and refuge of medical scoundrels and upon which rock they will cling as their last handhold in the rational world."
What is often not realized by many, is just how seriously many of these modalities have been and are considered, analyzed, and tested by "traditional" medicine. That they are mostly discarded is a function of efficacy, plausibility, results, and repeatability.
Another growing issue that needs confronted are the many implausible approaches are sucking up precious monies that could be better spent in other ways. For example, the current federal allocation for the National Center for Complementary and Alternative Medicine (NCCAM)is around $110 million/year. The NCCAM has had among its research agenda projects related to cranial osteopathy, in vitro investigation of distant Qi Gong, Gonzales therapy for cancer (consisting of coffee enemas, pancreatic enzymes, hundreds of dietary supplement pills, and hair analysis), and magnetic therapy. In comparison, consider the $5 million /year allocated for spinal muscular atrophy, a devastating pediatric disease.
The beckon call from most physicians, veterinarians, scientists, researchers, and probably the majority of people in general is that we critically evaluate what we do, constantly question our methods, modify and change them as needed, and strive for the goal of attaining the very best, most effective, and humane medicine possible.
A nicely worded post at Panda Bear, MD (sadly, no longer blogging for now) succinctly describes many of the problems I have encountered through the years while attempting to put my finger on just how alternative medicine is defined. Many personal discussions with alternative practitioners and fairly extensive research of alternative medicine texts has continually left me with no real tangible how, when, and why answers.
"Almost everything about Complementary and Alternative Medicine (CAM) is bunk and its purveyors are at best deluded and at worst quacks and charlatans who would make the snake oil salesmen of olden days blush from shame. Maybe a hundred years ago you could make a case for magic potions and mysterious cures from the East but today we should know better and only don’t because of a combination of scientific illiteracy and an ingrained bias against rational Western thought. What little benefit patients can derive from most of the quackery being sold to them is not worth a fraction of the money spent and the same effects could be achieved without the smoke and mirrors if people paid as much attention to diet, exercise, and all around clean living as they do to looking for an easy fix."
Unfortunately, this mirrors my experience in the veterinary world as many clients, swayed by their own perceptual biases, often search out these fallacious "other ways of knowing". I would like to make it clear that science based medicine is not perfect, nor does it have all the answers. Additionally, we need to consider all medicine as one concept, and look at all of it with the same critical attitude. Alternative Medicine steers clear of this rigorous approach and it became clear to me why as I realized it is mostly nothing more than myth, belief, and nostalgic notions of ancient wisdom.
"CAM exists in an alternate universe from real medicine. It wants to be legitimate but manages to avoid the responsibilities and liability of real medical practice. As most CAM treats nebulous symptoms with equally nebulous modalities, there is no measurable standard for efficacy of any of the treatments. "
This is one of the key problems that I have run into time and again. How can we know that what we are doing as practitioners is doing any good without having a reliable mechanism to steer our often imperfect attempts at helping and healing the sick?
"The real medical profession while imperfect like all human endeavors is not so conservative that ineffective or ridiculous therapies are not discarded. This is the whole basis of evidence based medicine. There is no evidence based Complementary and Alternative Medicine. It exists in the absence of and often despite the evidence. When challenged, its practitioners will retreat like the sweaty televangelists to anecdotes and testimonials. Either that or they will cite the placebo effect, that last hope and refuge of medical scoundrels and upon which rock they will cling as their last handhold in the rational world."
What is often not realized by many, is just how seriously many of these modalities have been and are considered, analyzed, and tested by "traditional" medicine. That they are mostly discarded is a function of efficacy, plausibility, results, and repeatability.
Another growing issue that needs confronted are the many implausible approaches are sucking up precious monies that could be better spent in other ways. For example, the current federal allocation for the National Center for Complementary and Alternative Medicine (NCCAM)is around $110 million/year. The NCCAM has had among its research agenda projects related to cranial osteopathy, in vitro investigation of distant Qi Gong, Gonzales therapy for cancer (consisting of coffee enemas, pancreatic enzymes, hundreds of dietary supplement pills, and hair analysis), and magnetic therapy. In comparison, consider the $5 million /year allocated for spinal muscular atrophy, a devastating pediatric disease.
The beckon call from most physicians, veterinarians, scientists, researchers, and probably the majority of people in general is that we critically evaluate what we do, constantly question our methods, modify and change them as needed, and strive for the goal of attaining the very best, most effective, and humane medicine possible.
Science
…and how to know it when you see it
Every once in a while it is good to briefly review the general concept of what science is and how to separate it from other non-science based concepts.
Science involves a set of cognitive and behavioral methods designed to describe and interpret observed or inferred phenomenon- past or present- that are aimed at building a testable body of knowledge open to rejection or confirmation(1), The crucial part of this is that science- the best system of gathering knowledge we have- grows over time as useful features are retained while non-useful items are eventually discarded based on the rejection or confirmation of the gathered testable knowledge.
Put another way, testable knowledge -a theory for example- needs to satisfy two fundamental requirements. First, it needs to explain the observed phenomenon better (more comprehensively) than other competing theories. Second, it has to be able to make testable predictions that are correct.
Non-science/pseudoscience
Michael Schermer put together ten questions(2) worth asking when trying to define the boundaries between science and non/pseudo-science that serve the inquiring mind well in the search for reason among, for example, the plethora of medical claims and therapies out there. They are as follows:
1)How reliable is the source of the claim?
2)Does this source often make similar claims?
3)Have the claims been verified by another source?
4)How does the claim fit with what we know about how the world works?
5)Has anyone gone out of the way to disprove the claim, or has only supportive evidence been sought?
6)Does the preponderance of evidence point to the claimant's conclusion or to a different one?
7)Is the claimant employing the accepted rules of reason and tools of research, or have these been abandoned in favor of others that lead to the desired conclusion?
8)Is the claimant providing an explanation for the observed phenomena or merely denying the existing explanation?
9)If the claimant proffers a new explanation, does it account for as many phenomena as the old explanation did?
10)Do the claimant's personal beliefs and biases drive the conclusions, or vice versa?
Here is another short list of considerations to have handy that help identify non-science based claims that was put together by Langmuir(3,4). It's another set of tools that helps cut through much of the confusion when perusing the literature:
1) Claimed effect being studied is often at the limits of detectability.
Subjective visual observations replace objective instrumental measurements.
The maximum observed effect is produced by an agent of barely detectable intensity.
2) Investigators readily discard prevailing ideas and theories and disregard criticism of their new ideas and theories.
Investigators concoct new ad hoc theories to account for the phenomenon.
3) Investigators do not attempt critical experiments that could refute their new theory by determining whether or not the effect is real.
Experiments done by others that refute the new theory are disregarded.
Ref:
1) Shermer M. The triumph of the scientific method: The most precious thing we have. Skeptic 1(1):34-49. 1992
2) Shermer M , Scientific American, 285:5, November, 285:6, December2001
3) Dr. Irving Langmuir, 1932 Nobel Laureate, as condensed by DL Rousseau in: "Case Studies in Pathological Science: How the Loss of Objectivity Led to False Conclusions in Studies of Polywater, Infinite Dilution and Cold Fusion," American Scientist 80:54-63 (1992))
4) Ramey, DW (1998). Pathological Science. World Eq Vet Rev 3(2):25-27.
Every once in a while it is good to briefly review the general concept of what science is and how to separate it from other non-science based concepts.
Science involves a set of cognitive and behavioral methods designed to describe and interpret observed or inferred phenomenon- past or present- that are aimed at building a testable body of knowledge open to rejection or confirmation(1), The crucial part of this is that science- the best system of gathering knowledge we have- grows over time as useful features are retained while non-useful items are eventually discarded based on the rejection or confirmation of the gathered testable knowledge.
Put another way, testable knowledge -a theory for example- needs to satisfy two fundamental requirements. First, it needs to explain the observed phenomenon better (more comprehensively) than other competing theories. Second, it has to be able to make testable predictions that are correct.
Non-science/pseudoscience
Michael Schermer put together ten questions(2) worth asking when trying to define the boundaries between science and non/pseudo-science that serve the inquiring mind well in the search for reason among, for example, the plethora of medical claims and therapies out there. They are as follows:
1)How reliable is the source of the claim?
2)Does this source often make similar claims?
3)Have the claims been verified by another source?
4)How does the claim fit with what we know about how the world works?
5)Has anyone gone out of the way to disprove the claim, or has only supportive evidence been sought?
6)Does the preponderance of evidence point to the claimant's conclusion or to a different one?
7)Is the claimant employing the accepted rules of reason and tools of research, or have these been abandoned in favor of others that lead to the desired conclusion?
8)Is the claimant providing an explanation for the observed phenomena or merely denying the existing explanation?
9)If the claimant proffers a new explanation, does it account for as many phenomena as the old explanation did?
10)Do the claimant's personal beliefs and biases drive the conclusions, or vice versa?
Here is another short list of considerations to have handy that help identify non-science based claims that was put together by Langmuir(3,4). It's another set of tools that helps cut through much of the confusion when perusing the literature:
1) Claimed effect being studied is often at the limits of detectability.
Subjective visual observations replace objective instrumental measurements.
The maximum observed effect is produced by an agent of barely detectable intensity.
2) Investigators readily discard prevailing ideas and theories and disregard criticism of their new ideas and theories.
Investigators concoct new ad hoc theories to account for the phenomenon.
3) Investigators do not attempt critical experiments that could refute their new theory by determining whether or not the effect is real.
Experiments done by others that refute the new theory are disregarded.
Ref:
1) Shermer M. The triumph of the scientific method: The most precious thing we have. Skeptic 1(1):34-49. 1992
2) Shermer M , Scientific American, 285:5, November, 285:6, December2001
3) Dr. Irving Langmuir, 1932 Nobel Laureate, as condensed by DL Rousseau in: "Case Studies in Pathological Science: How the Loss of Objectivity Led to False Conclusions in Studies of Polywater, Infinite Dilution and Cold Fusion," American Scientist 80:54-63 (1992))
4) Ramey, DW (1998). Pathological Science. World Eq Vet Rev 3(2):25-27.
Saturday, March 8, 2008
Traditional Chinese Medicine- part 2
中醫學
Chinese Medicine: then and now (cont. from TCM part 1)
The earliest known traditions related to Chinese medicine date from the 17th to 11th centuries BC during the Shang dynasty and involved ancestral influences. It was believed that ancestors had influence over the living and were able to directly endanger and destroy human life. The focus of healing practice was directed at, not only the living, but the deceased.
Ancestral ritualistic healing practices were later supplanted by more generalized yet still identifiable entities such as demoniacal, magical, and supernatural beliefs. These forces were thought to be the cause of disease. For example, "swellings" were thought to be caused by possession and healing practices utilized instruments such as needles in an effort to purge the affected body of the demon.
The Han dynasty was a period of significant importance to historical Chinese Medicine and is described as being the most formative period of its development. During the 2nd century BC to the 2nd century AD, a Chinese intellectual elite attempted to categorize and explain the world and its phenomena to a reduced number of causes and effects. An attempt to supplant "demonological forces" with so called natural laws gained momentum.
During this period, there were varying attempts to systematize the natural world by creating grouped contexts or constructs associated with the natural environment. This led to the creation of systems and thought in which the practice of healing could be connected with these now categorized phenomena. Here there are glimpses of a more rational approach to medicine. Alas, the earlier magical influences would not be eliminated and eventually a hybrid version of naturalistic/magic Chinese medicine began to take root.
There erupted a plethora of different world views, healing practices, and methods. These approaches often contradicted each other in sometimes fundamental ways. Unfortunately, this intriguing period of inquiry and observation never led to further developments and refinements of Chinese medical theory. The bubbling pool of thought that could be considered a "pre-enlightenment" era never reached a point of general consensus and no method to move toward a reconciliation ever developed.
Concepts such as the ying/yang and the five elements were combined with healing practices creating a confusing litany of disarticulated therapies. During this era, practitioners created forms of "systematic correspondence" which were comprised of assumed links between a practitioner’s perception of the natural world and the human body.
There followed a period after the Han dynasty where two general schools of thought came to the fore. A traditional view of "systematic correspondence” continued creating often baroque and elaborate intuitive theories. Interestingly, it is at this point that acupuncture literature begins to frequently appear in the historical record. These worldviews supported the belief that all things were related through some unseen web of connection and the body for example, could be influenced by changes elsewhere in this system.
"If in winter one behaves as one would in summer, bad things might happen"
In some ways, these systems like many other ontologies – even today- have some empirical seed of truth to them but then proceed to commit the error of fallacious or magical thinking. One big fallacy at the time was confusing correlation and causation –“correspondence”- the results of which produced a realm of completely fictional medical paradigms.
The other area of thought concentrated on a more pharmaceutical approach to medical treatment exploring herbal medicine, and was initially more promising. Unfortunately, this early methodology continued to emphasize very basic and erroneous themes. Disparate and conflicting concepts such as qi, yin/yang, and the five elements are intermingled with the use of herbs and they loose therapeutic coherence and potential refinement as reason and observation give way to assumption and belief.
There was an attempt, especially between the 12th and 15th centuries to reconcile these two traditions but they were ultimately unsuccessful and the whole of Chinese medicine theory remained stagnant and irreconciled from that time on. Epler (CAVMC, ch2, pg 22) elucidates;
" In the history of Chinese Medicine, rather than progressing from a reasonable, although incomplete knowledge of the body to a more detailed one by systematic dissection, the medical writers go in the opposite direction, under the sway of the cosmologists, to a less accurate picture."
It is important to note that until recent times, Western and Eastern medicine had similar belief based origins. Ramey and Rollins note “It is only in modern times, with the development of science-based medicine in the West, and the subsequent discarding of metaphysical approaches to medicine, that Chinese (Eastern “traditional”) and Western practices have been brought into opposition.”
In fact, Chinese traditional medicine is actually beginning to fade in
In Western countries, the Traditional Chinese Medicine actually observed and practiced is based on a westernized version of Zhongyi, or "modern Traditional Chinese Medicine". Zhongyi is in turn a distillation, a "best hits" version of the more rational parts of Chinese Medicines vast and disarticulated past. Much of Zhongyi was put together from the 1950's to the 1970's at which point the West eagerly received what they thought of as "ancient medicine".
According to Ramey and Rollins “…the transformation of Chinese traditional medicine into Traditional Chinese Medicine from the 1950s and 1970s did much to bring Chinese medicine closer to modern rationality…the vast heritage of Chinese traditional medicine that directly contradict modern science and rationality have been omitted from the many publications on zhongyi published in the People’s Republic of China since the mid-1970s. Hence, Westerners returning from
Here the tale loops to the beginning of the West’s current fascination with Traditional Chinese Medicine or better said a twice removed, manipulated, and designer made Western version of Traditional Chinese Medicine.
Ref:
Wednesday, March 5, 2008
Vetskeptics: a blog
The internet is an easy to use and powerful tool for accessing all kinds of useful information. It represents a real revolution in communications and offers a hopeful way for spreading useful and constructive ideas to a global community.
At the same time, this virtual landscape is littered with misleading and false information that misrepresents and twists the facts to fit all kinds of beliefs, dogmas, and points of view. It is important to have your “thinking cap” on when navigating these sometimes turbulent waters searching for the good stuff- especially when it come to important matters such as medicine.
This brings me to the core of the issue. When it comes to health we are obligated to tread with great care. Medical therapies need to go through a rigorous and continual process that works to keep them “honest”. Therapies in veterinary medicine also have to pass this all important prerequisite. They need to be vetted and put through the filter of scientific methodology- the best tool we have for holding on to and refining that which works while being able to disregard what doesn’t.
This is becoming ever more critical in this -what many would call- an “anti-enlightenment” era of confusion and non-science based pressures which threaten to dilute true medicine with delusional practices and magical thinking- even if they seem well meaning.
The veterinary e-world reflects this frustrating situation especially with respect to Complementary, Alternative or Integrative Veterinary Medicine (CAIVM) where one can find a sea of promotional and apologetic sites supporting its use, but precious little in the way of balanced resources that evaluate them critically. The often over the top claims by CAIVM proponents needs to be tempered with a good dose of science and skepticism of which there is precious little of.
In that regard, Vetskeptics endeavors to provide a haven for those interested in reason and critical thought from where CAIVM or -for that matter- any veterinary topic can be considered and discussed with the goal of open and honest inquiry. There are some excellent veterinary resources that support this goal and I will continually add to our link list as I- and you- discover them.
Initially, Vetskeptics will serve as a concentrated repository for several veterinary topics I have written about in the Wanderingprimate blog site which is developing a broader topic range. I plan to review many of these posts and improve on them here, while others will be archived here for better referencing.
Another goal for Vetskeptics is to encourage and promote new work and posts from various authors. Whether you are a veterinarian, veterinary technician, animal care giver or animal lover this blog is interested in quality writing that will improve on and add to what’s here.
It is our hope that this blog will become one of a growing number of voices that promote science and evidenced based veterinary medicine. With your continued help it can become an ever better critical thinking oasis for the veterinary and animal care community.
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