Medical uncertainties

Let’s put my bias up front; I’m a signatory to the letters of the Friends of Science In Medicine (FSM), a group of concerned citizens who speak out against the practice of some universities teaching non-scientific modalities as part of their courses in medicine. On the surface, that ought to be a non-controversial position to take. Surely courses that teach evidence-based medicine should only contain material that is evidence based, material that has gone through the ringer of scientific scrutiny and been found to be efficacious. Why wouldn’t you want some kind of reassurance that the stuff you’re being taught as science is, in fact, science?

Well the way that debate has fallen out, it appears that the main opposition is based around a complete failure of understanding about what science is and why it’s important. Much of the discussion has been carried out online at The Conversation with a couple of articles by friends and allies of the FSM including “What CAM courses at universities should look like“ and ”Pseudosciences are destroying the reputation of Australia’s universities“. These have have been pitched up against considerably more articles by a variety of individuals defending the teaching of Complementary and Alternative Medicine (CAM) in universities, for example “Evidence-based medicine v alternative therapies: moving beyond virulence“, “Homeopathy isn’t unethical, it’s just controversial“, “Why universities should teach alternative medicine“ and “No need for an alternative medicine crackdown“.

Often, individuals arguing for the inclusion of CAM into university medical courses resort to anecdotes, either personal or shared, of cases where conventional medicine had failed to produce the desired remedy and recourse to one or other CAM modalities apparently fixed the problem. But anecdotes prove nothing. Not even a whole bunch of them. As one friend on Twitter commented “The plural of anecdote is not data” (thanks @whereisdaz Darren Saunders!). What anecdotes don’t record is where the application of a CAM modality didn’t work so we have no measure as to if the anecdotal ‘cure’ was a one-off fluke against a million failures or a typical result of that application. That’s what it means to assess the practice scientifically.

In one article the claim is made that “…why do we have to prove something that’s been working for over a hundred years? Homeopathy is not the same as medicine, and it shouldn’t be measured by the same yardstick”. Where do I begin with this? Has it been working for over 100 years and, if so, where’s the evidence that it has? I agree that homeopathy is not a medicine but why shouldn’t it be exposed to the same standards of efficacy (that it actually does what it claims to do) as any other treatment or application?  All we ask for is that homeopathy and all other CAM modalities demonstrate that they can do what they claim to do. Is that too much to ask for when we’re dealing with people’s health?

Add to this that some CAM modalities have been studied scientifically and demonstrated to be largely ineffective and you really have to question why they are taught in some universities alongside efficacious medicine. Homeopathy has been tested several times and never shown any effect above placebo. Studies of chiropractic manipulations can only demonstrate some use in dealing with some back pains similar to a good session of physiotherapy (which the chiropractic manipulation emulates) and acupuncture has been shown to have a mild analgesic effect. While studies have been conducted looking for chiropractic and acupuncture treatments of a wide range of other ailments and maladies that some practitioners claim to be able to treat, no evidence of such outcomes has been found.

Which leads to another reason why CAM should not be taught in universities. The way in which it is claimed these modalities work, has no basis in fact. No one has ever shown an example of a ‘subluxation’, the supposed misalignment of the spine that prevents the flow of ‘health energies’ that form the basis of chiropractic manipulations. And that is despite countless billions of X-rays of people’s backs looking for irregularities and illnesses. Millions of human bodies have been dissected around the world as part of the training of medical students and in not one of those dissections has anyone found any of the meridians that the practitioners of acupuncture claim are there and form the basis for the energy flows they claim to manipulate. In both cases the ‘energies’ themselves stealthily refuse to be detectable to modern science.

So why would you teach methods that don’t appear to work, methods that have been demonstrated not to work or methods that have no basis in reality, as part of the training of the next generation of doctors?

There is a distinction that needs to be made here between teaching CAM at universities and researching them there. There is the possibility that some CAM practices may hold useful cures or treatments and they need to be identified through research and clarified for their entry into medical practices. Some herbs for example do appear to have pharmacological properties that may be useful in the future. But if university-level research into potentially useful CAM practices and treatments is to have any respect, it must immediately jettison the disproven and unworkable techniques that plague the area. There’s no point in further study of homeopathy; hypothesis rejected, methodology impossible – as continued research is a waste of time. Similarly chiropractic and acupuncture can only survive in a research setting if they throw out subluxations and meridians. Yes, if there is something good and useful in CAM, then we must research it. But research means rejection of failed hypotheses. It’s time for CAM to move on.

Lastly, an appeal is made that, because the various CAM modalities are popular, student doctors ought to know something about them so that they will be better informed when they meet them in their future practices. I would refer to my areas of expertise of palaeontology and geology and suggest that yes, some passing mention of creationism needs to be made in university geology and biology classes but only to explain its folly and errors. Similarly, medical students need to know that there is a lot of nonsense out there being described as complementary and alternative medicine, that doesn’t work and is mostly based on unscientific principles. But it should not be taught uncritically alongside medical knowledge that has been demonstrated to work and where we know how it works. That is, the content of medical courses must stay restricted to the realms of science. 

By Paul Willis @Fossilcrox