Issue 4 / 6 February 2012

THERE hasn’t been a lot of middle ground in the fiery debate about Australian universities offering courses in the various branches of alternative medicine.

On one side stand the Friends of Science in Medicine — 400 or so doctors and scientists lobbying universities to abandon degrees in “quackery”. On the other, a mass of outraged practitioners and their clients.

The FSM says almost one in three Australian universities now offer courses in complementary and alternative medicine (CAM), including traditional Chinese medicine, chiropractic, homeopathy, naturopathy, reflexology and aromatherapy.

Dr Ray Myers, acting head of the School of Health Sciences at RMIT, defended his university’s CAM programs against the scientific attack.

Chiropractic and osteopathy were two areas taught in which clinical research was limited, he told The Conversation, but the program incorporated the “best available evidence”, while also promoting further clinical research.

I have no argument with the university researching these widely used treatments, but the comments do rather beg the question of whether something should be taught as “health science” to future practitioners if the evidence for it is limited.

And I’m not the first to raise the concern that the provision of science degrees in these areas could give consumers an unrealistic, and potentially dangerous, expectation about the level of evidence underlying the treatments.

When we start talking about that key issue of evidence, we come up against the enormous, and I suspect growing, distrust of science among many in our community.

Here’s one woman commenting on The Conversation article: “I just find this issue oppressive for a number of reasons. It reeks of censorship. It’s fascist and elitist. Are we really going to let a bunch of elitists dictate our philosophy? Are we also going to let them determine our choice of healthcare or education? If we relinquish the ‘peoples’ knowledge of herbs then we lose something intrinsic, something not quantifiable, a history, a history that includes our culture and our connection to nature…”

Things that are not quantifiable may indeed hold great value for us, but is a science degree their natural home?

At its most fundamental level, this is a debate between science and faith, and the two simply don’t speak the same language. Science has about as much chance of undermining the tenets of faith as does the reverse.

Many practitioners and consumers of complementary therapies, angered by the FSM attack, seem to believe it is the blinkered vision of scientists that is at fault.

One acupuncturist, for example, repeatedly argued that the placebo effect was irrelevant when it came to assessing the efficacy of acupuncture because the interaction with the therapist was the intervention.

His conclusion? Once the “tainted” evidence provided by placebo-controlled trials was excluded, what was left was “an overwhelming mountain of case-study evidence spanning billions of patients stretching across a history thousands of years long”.

I’m not sure anybody has ever tracked down the origin of the quote: “The plural of anecdote is not data”, but it would seem to apply here (even when the claimed number of anecdotes is in the billions).

Of course, even the most scientifically minded hold beliefs we might struggle to explain in strictly rational terms and, like faith, science can cling to old truths and be hostile to new ways of thinking about the world.

But that is only science at its worst. At its best, the discipline carries a willingness, even a desire, to be proved wrong. And that is where it breaks ranks with faith and the faith-based professions.

There is an argument for including the study of alternative medicine in mainstream health science degrees — practitioners need to be in a position to talk to their patients about the risks and benefits of these extremely popular offerings.

But teaching faith-based practice as part of a “science” degree seems to me the equivalent of physics departments offering a BSc (Astrology).

Jane McCredie is a Sydney-based science and medicine writer.

Posted 6 February 2012

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24 thoughts on “Jane McCredie: Turning faith into science

  1. Tom Ruut says:

    CAM, love the analogy with the BSc[Astrology]It says it all.

  2. daman langguth says:

    Science is debased by the rising tide of anti-intellectualism in Australia. The lack of respect for intellectual (ie, rational, evidence-based) thought is being encouraged by universities (and many doctors who practise it whilst taking Medicare money!)
    All those who practise science learn to question onself and others, though no one is perefct in this matter. Allowing witchcraft to be integrated into real science debases the last 2000 years of progress.
    This is not to say these alternative to science concepts should not be studied, but they are not science.

  3. Donald says:

    I propose if we can diagnose people’s needs faster, get them better quicker and keep them better longer, there may be no real need for CAM programs. Maybe we are missing something?

  4. Francis Loutsky says:

    The issue is not whether CAM should be studied at Universities, but how that study should be taught. If the interested students aren’t going to be taught the basic principles (and then progress to professional level understanding) of scientific method/statistics/literature appraisal that was an integral (if not necessarily enjoyed!) part of our medical training, then the degrees in Aromatherapy etc. should be provided by the Arts department.

  5. Chris Richardson says:

    By all means universities should offer this “alternative” stuff up for study – the history, how much of it is now proven not to work, how much of it is totally implausible. To offer a qualification based upon it is, however, to grant a “Degree in Baloney” (to use a wonderful quote from the world of skepticism). It demeans the institution and devalues all the other qualifications from it. It’s a one way ticket to mediocrity and nonsense. Ray Myers by the way has clearly abandoned any effort to maintain credibility. “Best available evidence” – I don’t think he’d know what evidence was if it came up and bit him in the foot.

  6. John Buchanan says:

    In my view, we must hold the line against irrationality in the health system. The ordinary citizen does not realise that many things available in pharmacies and through assorted health care practitioners have no evidence of effectiveness, hence they are mostly wasting their money- the curious thing is that people often waste their money in that way, but complain about the fees of properly trained practitioners!
    The thing we are missing in my view, is the effect of the placebo factor, which is largely the effect of being listened to and taken seriously, ie. supportive therapy in a medical context – good old fashioned doctoring.
    Our health system encourages fast throughput with a business focus, hence often an inappropriate focus on medication solutions, and minimal listening – patients complain to me (as a psychiatrist) that their GPs mostly look at their computer screen, and not at them!
    We need to reduce the irrationality of much alternative medicine, but understand that why people go to such practitioners is often to be listened to and heard!

  7. Sue Ieraci says:

    Donald – perhaps you might be right – but that hope is limited by patients’ preparedness to invest in the system. People pay for long consultations with their CAM practitioners out of their own pockets, and they enjoy the back-up of the orthodox health system for out-of-hours, serious illness and emergencies. IF people were prepared to pay a large fee out-of-pocket to see their GP for half-to-one hour weekly consults, and continue this indefinitely, perhaps the relationship would be more satisfying for both practitioner and patient.

  8. Max Kamien says:

    In 1980 I started a module on learning about CAM since 1:3 GP patients were also using it. The Medical Board and dean complained and told me to stop it. They had difficulty in distingushing between teaching CAM and teaching about it. I wrote to the chair of MB saying that “If he preferred our medical graduates to be ignorant rather than knowledgable about ‘alternative medicine’ then he had a fight on his hands that he could not possibly win”.
    The Medical Board desisted. Sad how the same issues recur every decade.

  9. Anonymous says:

    There are a number of issues in this debate that I don’t think are being adequately questioned. Firstly, if FSM are serious about this issue, lumping all CAM therapies together is too simplistic and rather unhelpful. Comparing the evidence base for aromatherapy or reflexology with, say, chiropractic is inappropriate and unscientific. The only purpose it serves is if you are trying to discredit the entire CAM field.
    Secondly, as far as I am aware, FSM hasn’t stated what it would accept as “evidence-based” and what constitutes “psuedoscience”. Again, in my opinion this is a rather unscientific approach from group of highly respected scientists. If FSM hasn’t openly stated what or how it defines the terms “evidence-based” or “pseudoscience”, then how can its supporters make an informed decision about whether to support this group?
    Are FSM attempting to limit ‘evidence’ to RCT? Are they arguing against the use of ‘expert opinion’ when developing guidelines for treatment or care for particular conditions. Understandably, FSM are treading very carefully in this area so as not to alienate specialties within their own profession
    These are just some of the important questions that FSM needs to answer.

  10. gnomon says:

    I am flabbergasted.
    ‘Once the “tainted” evidence provided by placebo-controlled trials was excluded, what was left was “an overwhelming mountain of case-study evidence spanning billions of patients stretching across a history thousands of years long”.’
    Would someone please lead me to this compendium of information? Much of it must be written on clay tablets from before the Sumerian era. There will be a vast library of papyri scrolls, and a Rosetta stone (possibly two or three) that enable access to this incredibly potent source of ancient clinical information. All magically preserved from the ravages of fire, flood, military campaigns and conquests – even the occasional cockroach. Minoan, Egyptian, Hittite, Assyrian, Druidic and Etruscan therapeutic lore, tested by time, indeed centuries, nay millenia of clinical practice. It is time we forgot about Harvey and Pasteur, and all the other ‘johnny come latelies’ of contemporary clinical practice. There is this rich, incredible, credible, infallible source of clinical insight. If only I could lay my hands on it…

  11. james arthur says:

    Like some of your other comments I agree that to lump all ‘CAM’ together is irrational and actually shows those who argue for this to be either ignorant or simply too narrow minded about CAM. Chiropractic is a science based subject and as a chiropractor with 2 Master’s degrees in science based subjects and 2 first degrees in science I am always disheartened when I am compared to a reflexologist or the like (although I do have reflexology as it relaxes me!). RCTs exist in chiropractic and Australia has some of the best research and internationally chiropractic training takes between 4 and 7 years, depending on the country. My question to the mainstream ‘medicine’ is why do you think your approach is best when patients benefit from other approaches? Are you protecting patients or yourself? Arrogance and ignorance is a powerful way to keep the status quo and rarely improves anything.

  12. Sue Ieraci says:

    James Arthur, it is certainly true that different “CAM” practises have a wide range of evidence, feasibility and efficacy. The issue with chiropractic, though, is that there is also a wide range within the profession – from those who practice science-based manipulation to those who treat neonates and subscribe to the subluxation theories. The evidence-based part of chiropractic shows that, for low back pain, it is equally effective to other manipulative treatments such as physiotherapy. Many chiropractors, though, continue to promote the subluxation model, which suggests that spinal adjustments affect all organ systems. A valid therapy should not just be supported by evidence, it should be BASED on science – the clinical sciences. We have a lot of information about anatomy, physiology, pathology, pharmacology, psychology and psychiatry – we know a lot about how the body systems work through advanced imaging, electron microscopy, dissection etc etc. Therapies that are based on clinical sciences and supported by evidence should be considered to be legitimate therapies (such as chiropractic therapy for back pain). Therapies that are neither based on science nor supported by evidence should be discredited – such as chiropractic manipulation of newborns. Prominent chiropractors in Australia today challenge the very validity of vaccination. A regulated profession should emphasise the scientific parts of practice and sanction the poor practitioners.

  13. Anonymous says:

    If chiropractors help people with low back pain by manipulating the spine, what exactly are they manipulating to produce the perceived benefit and by what mechanism does the manipulation seem to be effective?

  14. James Arthur says:

    Sue, I totally agree that there is problem within chiropractic in that there are still some who ‘sell’ approaches and theories that have no place in modern health care. However this is the case for all health care professioanls and not unique to chiropractic. There are many medics out there who ‘sell’ approaches that are often of limited or dubious value, there are still physios who use interferential when most evidence says it is of litte or no value. On the subject of the subluxation theory – the issue here is the not the theory but how some people put it across. Go check out Lisa Bloom and you will see the biomechanical and neurological basis for the theory (which actaully isn’t as simplistic as your one line makes it) Unfortunately some of ‘straight’ chiros are a pain and have loud voices. I totally disagree with ongoing treatment of babies and small children but again you have to recognise that sometimes this treatment is the same as an osteopath or physios would give. Herein lies the problem, chiropractors are not chiropractic but are the sum of their training in the same way that Medical doctors do not all have the same skills but are all called doctors – I spoke with a medic friend and he is a radiologist but I know more about medication than he does – does that make him a poor doctor, of course not. And finally to anonymous, if spinal manipulation doesn’t work why do physios decide to train and utilise it? And if you are really interested in an answer just look at the research and you can make your own mind up rather than just listening to uninformed opinion. Sorry it’s a long post.

  15. Sue Ieraci says:

    Thanks for your response, James. My concern about the variability in practice is not so much about only doing stuff that is 100% proven by double-blind controlled trials (we know this is unrealistic), but only doing things, and espousing theories, that are based on our knowledge of how the body works. My point is not that all practitioners should have equal skills in all areas, but that all practice should be based on the clnicial sciences. As you know, subluxation theory does not have a basis in clinical science – there are no demonstrated “pathways” or physiological mechanisms that support it. There are prominent chiropractic practices in Australia that practice manipulation of newborns. They may claim it is gentle and therefore not dangerous, but is it honest? The same practises argue against vaccination, which is against the public interest. As a regulated profession, chiropractic would be well-served by restricting practice to that which is effective and based on clinical science. In medicine, doctors who use scam therapies are sanctioned – and sometimes de-registered.

  16. Anonymous says:

    Hi James,
    Spinal manipulation does work. My question to Sue is, if manipulation/adjustments have been shown to be effective for low back pain (and various other complaints) how and by what mechanism does she believe it work?

  17. Sue Ieraci says:

    Anonymous – I am aware of some of the evidence of the manipulative therapies. The relevant Cochrane review found that chiropractic manipulation was as effective as physiotherapy manipulation and medical treatment for low back pain. Can you explain what you mean by “adjustments”?

  18. Anonymous says:

    For the purposes of our chat I am happy to use the terms interchangeably. You have commented on the Cochrane reports already, and I am sure you are also aware of the Bronfort report. But that is not what I was asking.

  19. James Arthur says:

    I have to say what a polite board this is. All the comments are valid and it’s a shame people can’t be in the same room to meet each other with open minds. Re:subluxation, again Sue please take the time to check out Lisa Bloom who is a neurology based chiropractor. She will make you realise that the illogical and numbingly daft idea spread by some actually has a real basis in science – but not the way the zealots tell it. Personally I never use the phrase nor do many of my colleagues simply because of the connotations. What I would say to anyone questioning chiropractic is to first look at what is studied during the training and it is pretty simliar to a medical degree depending on where you study. Main difference is that we spend much longer on the musculoskeletal system. Re: peddling unsafe ideas, chiropractors are regulated like medics in most countries and it takes somebody to complain and if found guilty sanctions are taken. If you feel so strongly then complain – you won’t get an argument from me on the vaccination front, but make sure all the evidence is equally strong in your favour. Finally as I am signing off this chat now I would also say, I agree all health interventions should be evidence guided but the ‘medical’ model does not have all the answers, is not all evidence guided and certainly does not hold the moral high ground in any way shape or form.

  20. Chris Richardson says:

    If by ‘medical model’ James means a ‘science-based understanding of human health’ then I would agree with him that our (the human race’s) knowledge in this area is incomplete. If he is suggesting that there are alternative pathways to better addressing that gap in knowledge than a scientific one, then I disagree. If he’s simply saying that, in practice, the implementation of our science-based understanding of human health leaves a bit to be desired, then I’m back to agreeing with him. If he’s saying that universities should be allowed to offer accreditation in human health interventions that are known to be impossible, dangerous, or ineffective, then, you guessed it, I have to disagree with him again. It’s probably fair to say that I am a bit unclear on exactly what James is saying!

  21. Sue Ieraci says:

    FOllowing James Arthur’s suggestion, I did seek out Lisa Bloom’s writing. What I found was all theortetical, and not supported by basic research. I am not referring to RCTs, but to basic lab and bench research that shows how the organs work, and what neural stimulation and transmission does where. Many people think of “evidence-based” as meaning that everything has to have been proven in RCTs. What is even more important, however, is that the practices are UNDERPINNED by the clinical sciences. We know about the neural influences on various organs for basic clinical research. Hence the practice of vagotomies, sympathectomies etc. We can do nerve conduction studies and muscle contractions studies. We can do ECGs, EEGs, visual evoked responses, lumbar punctures, flow MRIs. To suggest that the theorising of a single author (Lisa Bloom) is somehow equivalent does not stand up to scrutiny. The knowledge and technology we now have about how the body works is not complete by any means, but it has developed enormously since the time that “subluxation theory” was developed. Science-based therapies need to adapt to new evidence, as does orthodox medicine. If a theory can’t be supported by the sophisticated systems of imaging, measurement and basic research that is now possible, it should be reviewed.

  22. James Arthur says:

    Opps I said I had gone, but like the mouse and cheese I couldnt help one last look – and comments made needed a reply. 1. Richard “If he’s simply saying that, in practice, the implementation of our science-based understanding of human health leaves a bit to be desired”, yes that is what I am saying, but also to be aware that the definition and scope of what is and what is not science has changed over the years and hopefully that will continue. Maybe some people of ‘science’ should remember that the ‘scientists’ of the day laughed at many of Leonardo’s (Davinci) ideas.
    Re: universtities. I think they should be honest about the courses they offer and totally agree with the sentiments expressed but herein lies the problem-if a health intervention does no harm and makes people feel better (e.g reflexolgy)what is the real issue? Out of interest is hypnotherapy part of scientific health interventions now? I think it is in most places. Hmm, well it wasn’t a hundred years ago and may be that’s where we are now with some of the CAM – difference now is that research is too expensive and controlled to enable many developments.

    Sue: re Lisa Bloom. Unfortunately I think you saw what you wanted to see which is part of any individuals frame of reference. Firstly I was not proposing that you should take Lisa Bloom’s work as the totality but merely that you should open your eyes and mind to the fact that there is science behind things where you see none due perhaps to a narrow view of a term or a limited understanding. a recent study showed that everyone has an opinion on everything and often those with the least knowledge have the strongest opinons.
    Secondly I know for a fact that Lisa’s work is entirely ‘bench’ science based and dismisses some of the chiropractic ‘quackery’ and ‘dodgy’ docs views on subluxation. Email her with your questions.
    I’m a natural skeptic and tell my students never to believe anything they hear nor anything they read no matter who is the author, but to take as much information about a subject and make their own minds up based on logic and maybe a ittle faith. That’s the only way we takes step forward. Best Wishes, the mouse is off now

  23. Anonymous says:

    Hi Sue,
    I believe the subluxation model used by chiropractors has changed over time. Beginning from the bone out of place, pinched nerve model developed by Palmer, to the various component models suggested by Flesia and Lantz and more recently the dysafferentiation model and now even the work by Haavik and others who are researching a more CNS approach to neurophysiological dysfunction associated with subluxations. I would suggest that they too will be developed further over time. It has been noted that the factors that have remained common through all of these models is some sort of kinesiological dysfunction and some sort of neurologic involvement. I have to disagree that chiropractic has not attempted to evolve the chiropractic subluxation model with corresponding technological changes and is not underpinned by the clinic sciences. Given that you have looked into Lisa Bloom (whom I must admit I had not heard of until mentioned by james) you may also be interested in the work done by Heidi Haavik who is a researcher in NZ. Her work is developing the subluxation further into a CNS / motor control problem. David Seaman has also written some papers on subluxations, possible mechanisms and causes. Here is an article if you are interested .

  24. Sue Ieraci says:

    Dear Anonymous (I must say it is difficult conducting a “conversation” with someone who will not identify themself, but I will persist). I have looked at Heidi Haavik’s work looking at the effects of chiropractic “adjustments” on the EEG. It does seem to be an illogical way of testing manipulative therapy, as EEGs test electrical activity WITHIN the brain. The work does not show evidence of a mechanism in which manipulating the back or limbs could influence in-brain electrical activity. That is what I mean by having the mechanism explained by clinical science. David Seaman’s work: I could not find the link that you provided – but Seaman’s work also seems to be theoretical. For a practice that has been around for such a long time, it seems unusual to me to be naming only one or two people who are trying to explain the mechanisms by basic scientific research. In orthodox medicine, on the other hand, the basic research into physiology is abundant – we know about the nature of neurons, myelin, nerve conduction, action potentials, cell membrane pumps, types of muscle fibres, impusle transmission, nerve and brain injury – and so much more about neurophysiology. A science-based practice is not just about RCTs – it’s about demonstrating an understanding of how the body works – not just by one or two individuals, but by all practitioners.

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