Alternative Medicine and the Post-Hoc Rationalization.

If you follow me on the Skeptoid blog you’ll find that I take a dim view of complementary and alternative medicine. My opinion is based primarily on a rational evaluation of the research. Complementary and alternative medicine (CAM), as a whole, is chock full of poor studies, index studies and weak correlational studies. There is a minority of well done positive research that subsequently fails to show any benefits and goes unreplicated. Alternative medicine as a whole has all the failings of an old west medicine show plagued by scam artists and ideologues. Scammers and ideologues use the freedom that discarding the scientific method offers to reinforce an emotional response. This summer, BioMed Central, a peer-reviewed open-access journal, published an overview of alternative medicine treatments and the benefit in getting injured or sick people back to work, undertaken by researchers at Columbia University. This study, titled “Complementary and alternative medicine use and absenteeism among individuals with chronic disease,” was a retrospective correlational review of data collected from the 2012 National Health Interview Survey data.

This research took a long, hard look at days out of work and alternative/complementary treatments. Researchers sought to answer a simple question: does CAM shorten your time out of work? The resounding answer was no. Worse, it showed that people who underwent complementary and alternative treatments were out of work for a longer period of time.

Acupuncture and “moxing.” Via Wikimedia.

Structurally this research was just about as rigorous as a correlational review can be. The methods are described, in part, like this:

CAM practices considered for inclusion were determined by the National Center for Complementary and Integrative Health’s (NCCIH) definition of “complementary health approaches” for mind and body practices and natural products. Natural products were included in our definition of CAM as these therapies are the most commonly used. CAM practices included acupuncture, massage, meditation, movement therapies (does not include general exercise), relaxation techniques, mind-body practices, vitamins (excluding multi-vitamins), minerals, and herbs. Participants reported not using any of the NCCIH-defined practices were considered non-users. CAM types of interest were categorized as either dietary supplements or mind-body practices. Mind-body practices included biofeedback, mantra meditation/mindfulness meditation/spiritual meditation/guided imagery/progressive relaxation, and yoga/tai-chi/qi-gong. Dietary supplements included use of non-multivitamins, non-vitamin supplements, minerals, and herbs.

There are, of course, limitations to any type of retrospective review, but the authors seemed to hit all of the most valid limitations without any glaring omissions. It was about as scientifically rigorous as you can get given the type of research.

It’s important to point out, though, that the findings are correlational and not causational. It’s not possible to say that CAM made them more sick, or sick longer. That conclusion is not supported by this study. Making a causation conclusions from a correlation study is a common failing. This study merely indicates that a large group of people missed work and the ones who used alternative and complementary treatments for recovery missed more work than the ones who didn’t. The reason for their prolonged absenteeism could be any number of other things correlated with CAM users. Nonetheless, this finding flies in the face of what most CAM proponents say, namely that natural and/or mind body therapies are more effective than conventional medicines.

So are results like these compelling to CAM providers and advocates? Are alternative and complementary practitioners expressing concern, changing practice, or demanding more research? No, not really. Instead, CAM proponents usually turn to classic post-hoc reasons why this kind of research is wrong, drawing unsupported conclusions to excuse the findings. They basically argue that a treatment didn’t work because the patient lacked the guidance of a proficient CAM practitioner. Unfortunately this is an all too common response to negative CAM research. “We know that CAM treatment X works, so if the research shows that it doesn’t, it must have been done improperly.” That is not a scientific response to an unexpected finding. A accurate response in science is, “The data seems to show no benefit. Let’s take a closer look at that.”

From essential oils to acupuncture, I see special pleadings claiming that there is some undefined element that can be used to dismiss any negative findings: “The essential oil must not be pure enough,” “that acupuncturist must be unlicensed,” “the cancer patient didn’t fight hard enough.” They must be using the CAM wrong!

Fire cupping. Via Wikimedia.

The Columbia researchers suggested that the cause might be that many subjects using CAM services were self-administering their non-traditional therapies. They may have misadministered a treatment, because they were practicing without the guidance of a licensed clinician or trained therapist, and inadvertently caused themselves more harm than good.

The only problem with that conclusion is that it is completely imaginary. The survey doesn’t match that type of data. They have no way of knowing any of that. It could be that everyone involved could have been going to the highest level of CAM practitioner. So you can conjure up an excuse without data, but I could just as easily suggest that the voodoo dolls prevented a quick recovery. Although their supposition sounds plausible it assumes that CAM works and that it was therefore done incorrectly. That is not science, it is not logical, and invokes some non-existent level of competence as the reason.

The idea that CAM is better when administered by a licensed or trained practitioner is in itself flawed. If you are licensed or certified in wizardry from Hogwarts it doesn’t mean you can then do magic. CAM has no scientific standards of safety or effectiveness. All a CAM certification represents is proficiency in nonsense. Since CAM treatments with proven efficacy become conventional treatments — such as prescription fish oil — treatments that remain alternative are limited by insufficient or poor evidence. In the absence of a reasonable standard of effectiveness for a practice, providing an internal standard is useless. CAM practitioners get around the lack of evidence by promoting anecdote and belief as superior to facts. Even if you firmly believe that it’s OK to have no standards, and that anecdotes are compelling, there’s still the problem of how information about a treatment is stratified. Using nonsense ideas like the naturalistic fallacy or mysticism as a foundation can mean that literally anything goes, without restriction. How can anyone turn around point and say that there is a standard and treatments fail only for a lack of believing (wishing) hard enough? What does that even mean?

Honest researchers would point out that the data in this study questions the use of CAM for chronic pain. Further, it offers evidence that CAM does not offer superior treatment to conventional therapies, and that more rigorous research is required. Honest researchers ask the real questions and do not try to prop up a unsupported conclusions.

Real medicine doesn’t work that way. For example: it was common practice to recommend inpatient rehabilitation for post-operative reconstructive knee surgery. The medical community’s consensus was that daily physical therapy would be much better than three times a week. Patients don’t like to go the rehab; they want to be home after surgery. But, some new, good research was done: it demonstrated that people get the same results with home therapy that they do with inpatient, despite therapy being less frequent. Counterintuitive though it may be, it warranted a practice change. Home therapy is much less expensive than inpatient, and patients are happier. Although it was a monetary hit for doctors and facilities, it was best practice so we changed. We didn’t try to argue that the the therapists in the rehab facilities must have had substandard training.

Physical therapy technicians look on as Lt. Cmdr. Candace Cornett conducts a brief check-up on Cpl. Mathew O. Behm’s recovery from knee surgery prior to physical therapy at the Physical Therapy Department at Robert E. Bush Naval Hospital. via Wikimedia

That is CAM’s biggest failing. When something doesn’t work, they try to come up with reasons why they should keep doing it. Whenever evidence is presented showing that isn’t working, they offer nonsensical special pleadings as to why their magical treatment didn’t work today.

Ignoring evidence and developing an excuse as to why you should continue is not good medicine—it’s ideology. Medical treatments need an honest answer: does a treatment work or doesn’t it? Is it safe or not? That is all that matters. Hand-waiving mysticism, claims to natural fallacy, ancient wisdom notwithstanding, we need to stop pouring money down a CAM hole. Stop taking people’s money and handing back feel-good nonsense.

Whenever anyone objects to failed CAM treatments advocates quickly point out the wrongdoings of the “medical establishment” or “Big Pharma.” Which is just a nonsense argument. Let’s say that “Big Pharma” is costly and their products are safe and effective only 90% of the time. They are still 90% more effective than any CAM treatment, which isn’t free either. I’m not saying 90% is acceptable but that is a different argument. One argument is asking for higher standards. The other is asking you to ignore CAM’s low (or nonexistent) standards. As an analogy: imagine your child is smashing car windows with a bat. It’s hardly helpful to say, “Well, it doesn’t matter because other kids are stealing gum from the supermarket.” Deal with the problem. Don’t make comparative statements as attempt to distract from a failed practice. Just because there are problems in the medical industry doesn’t mean that CAM works.

There is no alternative medicine, there is only medicine that works and treatments that don’t. Treatments that do not work are neither an alternative, nor a complement; they are ideology, and special pleadings and anecdotes notwithstanding, ideology has no place in healing.

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You can follow me at Twitter @steveproacnp for a daily dose of skeptical nursing.

Disclaimer: This post is my personal opinion, it is not a substitute for medical care. It is for informational purposes only. Information on the Skeptoid blog is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified healthcare professional regarding any medical questions or conditions. This post does not reflect the opinion of my partners, professional affiliates, or academic affiliations. I have no financial conflicts of interest to disclose.

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