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WE are living in a postmodernist world: everyone’s opinion is valid and every discussion must include “balance”.
The community has a tendency to see medical practitioners as arrogant and narrow-minded, unaccepting of the other healing modalities that are so popular with Australians.
When we speak out about non-evidence-based therapies from other disciplines, we are reminded about glass houses.
This makes me ponder two questions: first, how much of our mainstream medical practice is truly evidence-based; and second, how open should we be to the unexplained?
Many people think that evidence-based practice is restricted to those therapies that are supported by randomised controlled trials.
That’s not always the case, though.
Some therapies are science-based because they hold scientific validity.
We know, for example, that draining a pneumothorax works anatomically and physiologically — there is no reason to test it experimentally.
In the same way, physics supports the use of a parachute when jumping from a plane.
We have physiological models for everything from diuretics and proton-pump inhibitors to bone grafts and coronary grafts.
Clinical trials of efficacy and safety build on this knowledge.
In my view, the initial test of scientific validity — or even feasibility — is a crucial one.
We have no physiological model for acupuncture — though there is evidence that it can modify pain perception.
We have a good understanding of the anatomy and physiology of nerve transmission, neurotransmitter secretion and hormone receptors, which do not explain the traditional chiropractic theories of “subluxation” affecting organ function.
We know that the dilutions involved in homeopathy, which can result in no single molecule of the active ingredient being present in the “remedy”, can have no physiological action.
And yet, these and other physiologically implausible modalities are said to “work”.
So — to what degree should medical practitioners be open to modalities that are not explained by our understanding of the human body?
We know that knowledge accumulates gradually — there is rarely a complete revolution.
Now that we can directly image the body by electron microscopy and functional magnetic resonance imaging, it seems unlikely that the clinical sciences will be turned upside-down — more likely, they will continue to be refined.
The Australasian Integrative Medicine Association refers to the “blending of conventional and natural/complementary medicines and/or therapies along with lifestyle interventions … with the aim of using the most appropriate, safe and evidence-based modality(ies) available”.
We know that chiropractic manipulation is as effective as a number of mainstream practices for patients with musculoskeletal back pain.
We know that massage, relaxation and meditation can have positive effects on wellbeing, particularly in chronic illness.
We also know, however, that some medical practitioners embrace modalities that go beyond both feasibility and evidence — be it super-doses of supplements or even invasive therapies like chelation.
Should registered practitioners only “integrate” therapies for which there is both scientific validity and therapeutic effect shown, as well as safety?
And if a therapy is feasible, effective and safe, shouldn’t it become mainstream?
Dr Sue Ieraci is a specialist emergency physician with 30 years’ experience in the public hospital system. Her particular interests include policy development and health system design, and she has held roles in medical regulation and management.
Thanks for a thoughtful article Sue. I would agree that there is no physiological model for acupuncture, but I would actually disagree that there is evidence that it is helpful for pain. There is no accepted clinical indication based on evidence in chronic pain, and recently some well-conducted studies have demonstrated lack of efficacy in human experimental models of pain. By all reasonable standards of medical science, I think there is no supportable case for further research into acupuncture for any indication.
Dear Dr Ieraci, The Chiropractors Association has recently put in place new statements and position papers that focus on these very issues. We welcome the continued strengthened collaborative processes between medical and allied health care professionals. As the president of the CAA NSW Branch I welcome any discussion on these issues for the betterment of patient outcomes, based upon evidence and not dogma of any kind.
Well done Sue Ieraci, BUT look again at the Australian Vertebroplasty article that ran a trial please, I believe it is flawed as quite a number of patients were injected after over a few months I believe, and of course vertebrae would be healed by say 3 months after a fracture, perhaps leaving pain from root pressure or other cause, but that would not be helped by vertebroplasty. I think further trials are warranted before a total conclusion.Best wishes (anonymity only because I no longer practice).
Glass Houses indeed.
There are two types of scientific evidence: that which appeals to the orthodoxy and cognitive bias of the profession, and that (the poor cousin) which doesn’t. The actual distinction between these is arbitrary and the distinction between them in their adoption by the profession is not sound. Cherry-picking evidence based on any factor other than its scientific merit is not a scientifically valid approach. Many profoundly true scientific discoveries are counter-intuitive and so relying on intuition in evaluating findings is invalid.
Doctors need to ensure they are sufficiently equipped with the skills to assess evidence and to be aware of any cognitive leanings which may interfere with a neutral appraisal of the material.
We also need to be aware that the filtering applied to evidence by guideline publishers are often more influenced by political agenda than they are on scientific findings.
Thanks for your comments, Joseph Ierano. In the spirit of both plausibility and evidence, will the chiropractors now regulate against the manipulation of newborns and children, and reign in the anti-vaccinationists? Medicine is now producing lists of therapies that should be abandoned due to lack of evidence – vertebroplasty amongst them. There is good evidence for chiropractic in the therapy of adult musculoskeletal back pain, but little else. What is the profession doing about those who still promote chiro for organ system dysfunction?
Thankyou for your article. I am surprised that someone with your outstanding record in medicine and public health knows so little about acupuncture. Not only are the mechanisms in pain been known for many years, the clinical evidnce is at Level 1 across several areas. Your central theme about whether a clinical treatment works and is safe is an important one. It should be discussed more.
Tony – you quoted me correctly: said to “work”” – terminology and quotation marks intended. Indeed, if a non-plausible (thanks, Rob) therapy does appear to work, the placebo effect is likely. Intentional use of placebo is no longer considered ethical in orthodox medicine. I find it therefore ironic that patients who wish to feel empowered by rejecting the authority of medicine are drawn to the deceptive use of placebo in other ”therapies”.
This is certainly a welcomed article. For debate and understanding of the ‘greyness’ of clinicial practice and the difficulty that we all have with ‘evidence’. Most of us, no matter which discipline has engaged us, all want to help people with the cheapest, cleanest, most effective and compassionate tools available. May we have the intellectual honesty to proceed with collaborative intent for the best patient outcomes. Thank you.
In response to Richard Pearson, you do not live in a ‘postmodernist’ world but our society is definitely post modern. You need to know something about modernism to know anything about postmodernism. Then you will realise that both of these important movements in thinking have influenced every important aspect of our culture in the last fifty years. Just google Bruno Latour to understand something of the effect of postmodern thinking on medicine and science generally. Its asking a bit much of Karl Popper to provide you with the scientific basis for practising medicine. You may well end up as an ATM. Postmodernism is not a rubbish philosophy…its not even a philosophy; rather a reaction against modernism’s nasty offshoots. For the open minded, its a breath of fresh air.
Well done Sue. Thought provoking. Provoking. But I refuse to live in the postmodernist world – in its philososophical sense. It is a rubbish philosophy that medical practitioners should reject. It extends its tentacles to push ‘post-normal science’ and pretends that is what doctors do, particularly surgeons, as analogy for rubbish science like ‘climate change’ science. Medicine is and always has been an amalgam of science and art with an ethical base. Science is not defined by peer-review nor is it defined by controlled trials. Science in the philosophical view of Karl Popper is about conjecture and refutation – in effect, empirical falsification. That view is by far the most satisfactory basis for the scientific method – put simply, the idea that one ugly fact brings down the most beautiful theory.
Sue, I believe that there is a flaw in your reasoning. You state “And yet, these and other physiologically implausable modalities are said to ‘work’.” However the evidence would suggest that they do not work, at least no more than placebo. This means the rest of your questions are invalid. There may be grains of real truth (scientific evidence) in alternative medicine and so testing should be done but let’s leave mysterious magical healing phenomena to the quacks.
This is a dillemma health professionals face daily. I prefer the term evidence informed practice, because that is all the evidence base will ever be. The patients who visit us are basically undergoing a N=1 trial every time they have a consultation. None of them are likely to have the exact inclusion criteria of available trials on their condition. Most of them may not even have a condition – more likely an undifferentiated illness that is not necessarily easy to label. So we do our best to apply the evidence after negotiation with our patients desires. We lay out possible treatments/management options and discuss other treatments that they are interested in. AIMA seem to have a very patient -centred approach and one worth serious consideration. I’m not a member of their organisation but certainly respect their philosophy of health care.
Sue – I agree with your sentiments, but think you mean ‘plausibility’ rather than ‘feasibility’. Homoeopathy is entirely feasible (anyone can do it), but has no scientific plausibility.