410px-Chinese_barefoot_doctor_performing_acupuncture

Pictured: Cutting-edge medicine

I remain flummoxed. How do physicians and health care systems, trained in all the sciences that lie at the heart of medicine, justify the use of pseudo-medical interventions with no basis in reality? Rationalization. Making excuses:

a defense mechanism in which controversial behaviors or feelings are justified and explained in a seemingly rational or logical manner to avoid the true explanation, and are made consciously tolerable – or even admirable and superior – by plausible means.

Rationalization of the ridiculous comes in many forms. It has been said that it is a mark of a first rate intelligence to able to hold two contradictory ideas in the mind at the same time and still retain the ability to function. Clever as it is, I suspect the opposite is true.

Acupuncture: Ignoring your own analysis

So often rationalization is as simple as denying your own data where the content of a pseudo-medicine paper is at odds with its conclusions. The most egregious example is the Cassidy study on stroke and chiropractic. But other examples are easy to find. Take “Acupuncture and related techniques in ambulatory anesthesia“, a review of the use of acupunctures (regular, electric and acupressure) for postoperative pain and nausea.

They start off with an abstract that says:

Research suggests that acustimulation may alleviate postoperative morbidities, although the body of evidence of the effect is equivocal.

‘Suggests’, ‘may’, ‘equivocal’. Hardly a ringing endorsement. The introduction is equally lukewarm:

trials of hands-on-therapies face inherent difficulties in the design of placebo controls, and the body of evidence is equivocal. The use of sham acustimulation as a placebo control is inclined to have high placebo effects

They compared a hodgepodge of acupunctures, with variable outcomes, some positive and some negative. There were very few double blind studies and most with a positive effect for a subjective endpoint (pain or nausea) often had no change in objective endpoints (use of pain or nausea medications).

If this were a real intervention based on real physiology, I would conclude the intervention did nothing. As an intervention with no prior plausibility, the results are even less impressive.

In this case? Well, they say:

With reservations, as some of the trials reviewed are small and must be perceived with caution, the results suggest that acustimulation may be beneficial in alleviating postanesthetic morbidities. The techniques are easy to perform, and adverse events and costs are minimal. In particular, acupressure is noninvasive, well tolerated, and may have a good patient acceptability. Acupressure can be applied by medical staff, patients or parents and maintained after discharge. A feasibility study shows neither delay in the surgical procedure, nor additional anesthesia time attributed to the introduction of acupuncture and acupressure. It may be profitable to consider implementing acustimulation to ambulatory patients.

I presume they mean profitable in the sense of beneficial or useful.

It is really remarkable how a therapy that in this analysis is questionable at best (and in other analyses worthless) is still suggested because it is cheap and easy to apply, not because it is effective and based on sound medical evidence. It is difficult to imagine such a low standard for approval of an antibiotic. But with antibiotics you would expect a real effect against a real infection.

Acupuncture clinics

The National Research Center in Complementary and Alternative Medicine, Institute of Community Medicine in Norway, might suggest using acupuncture for postoperative pain and nausea. In the US major medical institutions do not suggest, they act. For example:

Loyola announces opening of new acupuncture clinic for patients with pelvic health disorders.

The usual nonsense is put forth to justify charging patients for fantasy-based therapies:

These conditions place a significant burden on our health-care system and the economy due to the prevalence and the fact that many patients don’t respond to traditional treatments, said Larissa Bresler, MD, a medical acupuncture doctor, Loyola University Health System, and an assistant professor of Urology, Loyola University Chicago Stritch School of Medicine. The goal of the clinic will be to offer patients another tool to help alleviate their symptoms without the side effects of medication.

That is the ‘since air travel and airplanes have problems we should rely on flying carpets’ argument.

Acupuncture has been used as a healing tool for more than 2,000 years.

The ever-popular appeal to antiquity logical fallacy, and not even a true appeal since the use of needles is a recent development and as practiced at the turn of the century TCM was gruesome:

Chinese doctors own that they know nothing at all of surgery. They cannot tie an artery, amputate a finger or perform the simplest operation. The only mode of treatment in vogue which might be called surgical is acupuncture, practised for all kinds of ailments. The needles are of nine forms, and are frequently used red-hot, and occasionally left in the body for days. Having no practical knowledge of anatomy, the practitioners often pass needles into large blood vessels and important organs, and immediate death has sometimes resulted. A little child was carried to the dispensary presenting a pitiable spectacle. The doctor had told the parents that there was an excess of fire in its body, to let out which he must use cold needles, so he had pierced the abdomen deeply in several places. The poor little sufferer died shortly afterwards. For cholera the needling is in the arms. For some children’s diseases, especially convulsions, the needles are inserted under the nails. For eye diseases they are often driven into the back between the shoulders to a depth of several inches. Patients have come to us with large surfaces on their backs sloughing by reason of excessive treatment of this kind with instruments none too clean.

The Loyola press release mentions the mechanism by which acupuncture is alleged to work:

Acupuncture is based on the traditional Chinese teaching that energy flows through the body along channels called meridians. Illness occurs when energy is blocked or disrupted. The insertion of needles into designated points improves the flow of energy and releases feel-good hormones, beneficial chemicals and immune system cells to reduce inflammation, aid healing and promote pain relief.

Without mentioning that meridians and the energy it contains are nonsense, divorced from physiology and anatomy and has never been demonstrated to exist.

They will use acupuncture for

…pelvic pain, nausea from pelvic surgery, interstitial cystitis, painful bladder syndrome, postoperative pain, prostatitis and overactive bladder.

The reviews for use of acupuncture for the above conditions are typical – maybe it works but the studies are poorly done:

Evidence for the efficacy of needle acupuncture for treating the disorders evaluated remains inconclusive. The intervention showed promising results for reducing pelvic and back pain during pregnancy and climacteric vasomotor symptoms, although well-designed studies are needed to make the results more precise and reliable.

And:

The evidence that acupuncture is effective for chronic prostatitis/chronic pelvic pain syndrome is encouraging but, because of several caveats, not conclusive. Therefore, more rigorous studies seem warranted.

Which is the same as it ever was. Acupuncture only has effects in studies with poor methodology. The better the study, the worse the effect until well-designed studies that remove all potential biases fail to show acupuncture has any effect.

Which, given the prior plausibly that acupuncture would be effective for anything is zero, is what would be expected. But always more studies need to be done.

It hardly seems a solid foundation for a clinic for treating and charging the ill. I always wonder why the Board of Trustees of these institutions allows the use of magic in their hospitals.

But I hope that, since the acupuncturist involved is also a urologist, there will finally be an answer to the question that has puzzled me for years: why they are no meridians and acupoints in the male genitals? Why no life energy flowing in the life-generating organs? You can probably guess my answer.

Integrating naturopathy

Forget acupuncture, what about using naturopaths? “Integrating naturopathy: can we move forward?” The short answer is no. I have discussed both naturopathic education and ND fitness as primary care providers in the past.

The gist of the article is the author wants to dump all his difficult-to-treat patients on naturopaths:

With so many of our patients presenting with chronic pain, functional disorders, and other difficult-to-manage chronic conditions, allopathic primary care physicians clearly need more compelling options for managing chronic disease…Naturopaths would seem ideally positioned to fill this partnership role.

Clever in a Machiavellian kind of way. Play up the holistic BS and send them off to the mostly harmless, although mostly fantasy-based, therapies that make up naturopathic practice. If you have a troublesome patient what could be better than to identify another practitioner who can take care of them better than you? As a resident, transferring a patient to another service (from medicine to surgery was most common) was not only for the patient’s benefit, you had a transient dip in the work load and no longer had a patient whose issues (bad gallbladder) you were not comfortable managing.

The only problem is that referring to naturopathy as a credible source for medical diagnosis and treatment doesn’t make it so. To say:

Naturopathic medicine is a distinct method of primary health care—an art, science, philosophy and practice of diagnosis, treatment, and prevention of illness. In stark contrast to a narrowly interpreted biomedical model, where pharmaceuticals are administered to battle disease, Naturopathic physicians seek to restore and maintain optimum health in their patients by emphasizing nature’s inherent self-healing process …. This is accomplished through education and the rational use of natural therapeutics. The naturopathic physician thus uses holistic approaches to enhance and restore the body’s own innate healing systems. Naturopaths undergo a 4-year graduate-level course of study but are generally not residency trained.

Ignores the fact that they are trained in unproven, often irrational, fantasy: nutritional supplements, homeopathy, acupuncture, hydrotherapy and electrical stimulation. There is no nonsensical therapy that is not in the naturopathic armamentarium. That is part of the problem with naturopathy: any and all medical magic is in their purview. And they are usually anti-vaccine.

The author recognizes there are conflicting paradigms between doctors and ND’s. You think? He gives several examples of the different approaches between MD and ND for some common diseases, but suggests that somehow these differences can be overcome. It would is like recommending raising an alligator as a household pet. In the end, it will end badly. Say, honey, have you seen the dog and the baby?

Despite his suggestions that education and medical standards could somehow integrate ND’s into a reality-based practice of medicine, to do so would require the ND to abandon the fantasies in which they have invested time and money. I doubt that will happen.

Establishing and improving lines of open, respectful, constructive communication will be a first step toward developing the type of collaboration between allopathic and naturopathic physicians that our patients deserve.

Our patients do not deserve naturopathic practice, although the lateral pass of the difficult patient might make clinic easier. To quote me, if you mix cow pie with apple pie, it does not make the cow pie taste better; it makes the apple pie worse. Our patients need a better apple pie, not cow pie.

 

Posted by Mark Crislip

Mark Crislip, MD has been a practicing Infectious Disease specialist in Portland, Oregon, since 1990. He is a founder and  the President of the Society for Science-Based Medicine where he blogs under the name sbmsdictator. He has been voted a US News and World Report best US doctor, best ID doctor in Portland Magazine multiple times, has multiple teaching awards and, most importantly,  the ‘Attending Most Likely To Tell It Like It Is’ by the medical residents at his hospital. His growing multi-media empire can be found at edgydoc.com.