I have been a fan of Dr. Edzard Ernst for over a decade. His book Trick of Treatment, co-written with Simon Singh, was one of the first books I read on alternative medicine that gave me a perspective of just what “alternative medicine” was (or purported to be). As a pharmacist working occasionally in a drug store that focused on supplements and products like homeopathy, I knew these products lacked evidence of effectiveness, but had never really considered Complementary and Alternative Medicine (CAM) as a cult-like industry, or the double-standard from regulators that enabled all of these sometimes-absurd products to be sold in pharmacies. Dr. Ernst has written several books on alternative medicine, and Harriet Hall has reviewed most of them. Now Dr. Ernst has written SCAM: So-Called Alternative Medicine, a collection of 50 essays on topics related to SCAM. Each chapter is an essay, and each essay examines some aspect of SCAM. This book is not for true believers. If you’re a regular reader of this blog, then this book is for you.
Why “so-called” alternative medicine?
So-called alternative medicine (SCAM) goes by many names such as integrative medicine (which is really more of a brand than a specialty), holistic medicine, unorthodox medicine, and functional medicine. Tim Minchin describes it best, in my opinion. Ernst says that whatever you want to call it, it is not an alternative:
If a therapy does not work, it cannot be an alternative to medicine
If a therapy does work, it does not belong to alternative medicine, but to medicine.
Ernst is a physician and an academic, and his impressive credentials deserve a mention. A German by birth, he earned a medical degree and practiced in a setting where SCAM was fully embedded into conventional medicine. He was a homeopath and even worked in a homeopathic hospital. After spending time in a research position in Austria, he took the (world’s first) professorship in Complementary Medicine at the University of Exeter in England. Ernst built a research team and a research program, determined to critically evaluate SCAM with good science. His team was highly productive, conducting dozens of clinical trials and systematic reviews and compiling, over time, over 1,000 publications. But it was clear relatively early on that:
- few forms of SCAM seemed to work
- many seemed not to do more good than harm
- and most SCAMs were so under-researched that it was impossible to tell
Ernst’s 2001 book, The Desktop Guide to Complementary and Alternative Medicine examined 700 treatment/condition pairs and concluded that only 7.4% were supported by good evidence. Realizing the vast gap between popular perceptions about the efficacy of SCAM and the reality, Ernst broadened his publishing targets from academic publications for health professional to eventually, consumer books like Trick or Treatment. Ernst prefers science over wishful thinking, and was surprised to find that SCAM enthusiasts felt otherwise. Ernst realized this early on in academic posting at Exeter:
On short notice, I had accepted an invitation to address this meeting packed with about 100 proponents of alternative medicine. I felt that their enthusiasm and passion were charming but, no matter whom I talked to, there seemed to be little or no understanding of the role of science in all this. A strange naïvety pervaded this audience: alternative practitioners and their supporters seemed a bit like children playing “doctor and patient”. The language, the rituals and the façade were all more or less in place, but somehow they seemed strangely detached from reality. It felt a bit as though I had landed on a different planet. The delegates passionately wanted to promote alternative medicine, while I, with equal passion and conviction, wanted to conduct good science. The two aims were profoundly different. Nevertheless, I managed to convince myself that they were not irreconcilable, and that we would manage to combine our passions and create something worthwhile, perhaps even groundbreaking.
During my short speech, I summarized my own history as a physician and a scientist and outlined what I intended to do in my new post—nothing concrete yet, merely the general gist. I stressed that my plan was to apply science to this field in order to find out what works and what doesn’t; what is safe and what isn’t. Science, I pointed out, generates progress through asking critical questions and through testing hypotheses. Alternative medicine would either be shown by good science to be of value, or it would turn out to be little more than a passing fad. The endowment of the Laing chair represented an important mile-stone on the way towards the impartial evaluation of alternative medicine, and surely this would be in the best interest of all parties concerned.
My audience, however, was not impressed. When I had finished, there was a stunned, embarrassed silence. Finally someone shouted angrily from the back row: “How did they dare to appoint a doctor to this chair?” I was startled by this question and did not quite understand. What had prompted this reaction? What did this audience expect? Did they think my qualifications were not good enough? Why were they upset by the appointment of a doctor? Who else, in their view, might be better equipped to conduct medical research?
It wasn’t until weeks later that it dawned on me: they had been waiting for someone with a strong commitment to the promotion of alternative medicine. Such a commitment could only come from an alternative practitioner. A doctor personified the establishment, and “alternative” foremost symbolized “anti-establishment”. My little speech had upset them because it confirmed their worst fears of being annexed by “the establishment”. These enthusiasts had hoped for a believer from their own ranks and certainly not for a doctor-scientist to be appointed to the world’s first chair of complementary medicine. They had expected that Exeter University would lend its support to their commercial and ideological interests; they had little understanding of the concept that universities should not be in the business of promoting anything other than high standards.
The content
Ernst divides his essays into several categories:
- The Basics: What is SCAM? What is EBM? How much of EBM is actually evidence-based?
- Common Problems in SCAM: The “root cause”, fear mongering, holism, conspiracy theories, and quackademia
- Research and Researchers: Research in SCAM, promotion masquerading as research, NCCAIM, how to tell good from bad research
- Healthcare Practitioners: Inside the brain of a SCAM practitioner, Doctors of Integrative Medicine, Veterinary Medicine, Nursing, Midwifery, Pharmacy
- Patients and Consumers: Patient choice, when orthodox medicine has nothing more to offer, the wellness mania, alternative cancer cures
- The Funny Side: Several humorous essays including How to become a Charlatan
Many SCAM advocates have accused Ernst of having a conflict of interest. He agrees he has a conflict, but not in the way his opponents claim. He notes:
- evidence is a prerequisite for progress in healthcare,
- evidence must be established by rigorous research,
- we should not tolerate double standards in healthcare,
- patients deserve to be treated with the best available treatments,
- making therapeutic claims that are not supported by sound evidence is wrong.
Why SCAM research is rarely negative
Some SCAM journals and SCAM researchers never publish negative findings. This isn’t evidence of SCAM’s effect, but rather it’s the consequence of a trial design that cannot be negative. Ernst calls this the A vs. A+B design, and he describes it in a blog post studying a trial that purported to show benefit from acupuncture on cancer-related fatigue. Patients received “usual care” or “usual care” plus acupuncture. The acupuncture group did better. Ernst notes this design is designed to show an effect:
Imagine you have an amount of money A and your friend owns the same sum plus another amount B. Who has more money? Simple, it is, of course your friend: A+B will always be more than A [unless B is a negative amount]. For the same reason, such “pragmatic” trials will always generate positive results [unless the treatment in question does actual harm]. Treatment as usual plus acupuncture is more than treatment as usual, and the former is therefore more than likely to produce a better result. This will be true, even if acupuncture is no more than a placebo – after all, a placebo is more than nothing, and the placebo effect will impact on the outcome, particularly if we are dealing with a highly subjective symptom such as fatigue.
The Tricks of the SCAM Trade
One of my favourite essays describes some of the tactics used by SCAM advocates to promote their services.
Treat a non-existent condition: There’s nothing better than treating a condition the patient doesn’t even have. From the chiropractor’s subluxation to the acupuncturist’s chi blockage, these diagnoses are made up by the practitioner, and have no basis in reality.
Maintenance treatment: Persuade the patient who is healthy that they need “maintenance” treatments to stay healthy, such as IV vitamin infusions or the chiropractor recommending regular adjustments for spinal alignment. To the worried well, this may sound attractive, but it isn’t based on any objective benefit.
Things must get worse before they get better: Patients may feel nothing, or even worse, after a SCAM treatment. Practitioners may describe this as a “healing crisis”, an imaginary phenomena. In the case of conditions that are chronic or wax and wane, the practitioner can attribute worsening to the “healing crisis” and claim any improvement as evidence of effectiveness.
A cure takes a long time: To continue SCAM treatments despite a lack of any improvement is hard to justify on medical grounds, but practitioners make this claim routinely.
The problem is due to conventional medicine: With a nod to the conspiracy theories that are endemic to SCAM, problems are often blamed on conventional medicine. You see this routinely in harms or circumstances attributed to therapies like vaccines.
Detox: A marketing slogan and not an actual treatment, CAM proponents claim detox will rid the body of non-specified “toxins” that conventional medicine fails to acknowledge or treat.
The test of time: Some SCAMs have been around for hundreds of years (or more). SCAM advocates point to this long history of use as evidence of safety and effectiveness. Ernst points to bloodletting as a treatment with a long history of use that was appropriately discarded when the human body became better understood.
Energy: Energy is one of those terms that means whatever the SCAM practitioner wants it to mean, but it’s usually a proxy for “vital force“. Energy just sounds more scientific. While vitalism has been discarded by science-based medicine, it’s at the root of many SCAMs, like naturopathy.
Stimulating the immune system: Demonstrating rather startling ignorance of immunity, SCAM “stimulation” is a placebo. Moreover, it’s probably something we wouldn’t want to do, if we could.
A good book for the fledgling skeptic or SBM enthusiast
If you read SBM daily and are familiar with Dr. Ernst’s work or his blog, this book covers familiar topics. As a non-academic, I enjoyed this book because it made me consider aspects of SCAM from the perspective of a researcher. Despite Ernst’s deep knowledge of this topic, he writes in an easily approachable style – this is not dense medical writing. This book is not likely to change the minds of any true believers – but nor is that the audience. If you’re interested in the role of science in medicine, and on how to sort out good from bad when it comes to health and healthcare decision-making, Ernst’s book is highly recommended.
[Full disclosure: Dr. Ernst’s publisher provided me with a free copy of his book.]