I recently chastised the American Family Physician (the journal of the American Academy of Family Physicians) for assigning a high SORT (strength of evidence) rating to acupuncture treatments that did not merit that rating. While the AAFP claims to strongly support evidence-based medicine, I have observed a gradual infiltration of CAM into their journal, their website, and their CME offerings. They seem to be more concerned with the popularity of CAM and with not offending its believers than with maintaining scientific rigor. The problem is only getting worse.
Recently a “News Now” article was published on the AAFP website: “New Report Details Billions Americans Spend on Complementary, Alternative Medicine: Physicians Can Benefit from Adding CAM to Their Practices, Says FP” It is very disturbing.
It starts by talking about how many people use CAM and how much money is spent on it, and by recommending that family physicians try to get some of that moola for themselves. It says CAM “can help many diverse patients and earn FPs added compensation.” There is no doubt that it can earn FPs compensation, but the claim that it “can help many diverse patients” is questionable. An “integrative” family physician, Dr. Blackwelder, is quoted as saying
Family doctors should recognize many patients use such approaches, and explore for them in an open and nonjudgmental way.
I can absolutely agree with that. He advocates good bedside manner and empathy. I can absolutely agree with that too. But then he goes on to say
In many ways, the physician-patient encounter creates a suggestible moment similar to what is done in a hypnosis session. Use that power!
I would hope that we are not hypnotizing our patients and gaining undue influence to promote things that don’t work!
That seems to be exactly what he is advocating.
Family physicians can build in discussions of CAM during face-to-face office visits for specific complaints, he said, by suggesting, for example, nasal irrigation for allergies and respiratory problems; yoga relaxation breathing for insomnia and anxiety; yin yoga for back, hip and flexibility problems; journaling for grief, depression, rheumatoid arthritis and asthma; and meditation and prayer for hypertension, stress and depression.
Sure, they could suggest those things. They could also suggest bloodletting to balance the humours, witch doctors, Perkins’ tractors, homeopathic remedies that are nothing but water, a Breatharian diet, and their own personal brand of snake oil. They could, but they shouldn’t.
Prayer for hypertension? Doesn’t work. In fact, one study showed that prayer actually increased the likelihood of hypertension. Journalling for rheumatoid arthritis? Says who?
He says
family physicians can take advantage of patients’ interest in osteopathic manipulation by making it part of their family medicine practices.
He doesn’t seem to care whether it is an effective treatment – patients are “interested” in it and that’s enough.
He recommends FPs go to a weekend course to learn acupuncture techniques, because “they’re helpful when working with patients who have addictions, such as smoking.” Oh, really? A recent Cochrane review was not confident that they were helpful. It concluded
There is no consistent evidence that acupuncture, acupressure, laser therapy or electrostimulation are effective for smoking cessation, but methodological problems mean that no firm conclusions can be drawn.
Anyway, why go to a real acupuncture course? Why not just learn to do sham acupuncture? Sham acupuncture has been shown by good research to work just as well as “real” acupuncture and is a lot easier: you don’t have to bother learning the mythology of qi and the location of meridians and acupuncture points. You can just stick the needles anywhere.
He says
physicians are becoming more comfortable with botanicals and supplements now because such products can be standardized and specific dosages recommended.
Yes, they can be standardized, but unfortunately under the DSHEA most of the products on the market are neither standardized nor checked for purity. Unless you can recommend a specific product that you can be sure is safe and reliable, recommending supplements is a risky business.
Then he claims that a number of CAM remedies have solid study data demonstrating their efficacy and safety, and he lists several of these. Most of his examples are questionable. For some of them, there is solid study data showing they don’t work. For instance
- Saw palmetto for benign prostatic hypertrophy. The most recent Cochrane review (2009) found that it was “not more effective than placebo for treatment of urinary symptoms consistent with BPH.”
- Gingko for claudication. A Cochrane systematic review from 2009 found “no evidence that Ginkgo biloba has a clinically significant benefit for patients with peripheral arterial disease.”
- Turmeric to prevent Alzheimer’s. The only “evidence” I could find for this was the observation that people in India have a lower incidence of Alzheimer’s and they eat a lot of food with turmeric in it.
If he thinks these treatments are supported by solid study data, his idea of solid data is very different from mine. And yes, of course it is. Because he supports CAM and is willing to accept the results of any study that supports his beliefs, regardless of whether it is a well-designed study or junk science, or whether it is contradicted by more rigorous studies.
An AAFP policy statement on CAM says
The AAFP advocates the evaluation of these alternative treatments and complementary practice through various means including evidenced-based [sic] outcomes research as to their efficacy and effectiveness.
One wonders what other “various means” they would recommend. Stoned thinking a la Andrew Weil? Intuition? Dreams? The notoriously unreliable “in my experience” opinions of clinicians? Anecdotes? A popularity contest? Dowsing?
I was already embarrassed by my association with an Air Force that is now teaching battlefield acupuncture. Now I’m embarrassed to be a member of the AAFP.
This article was originally published in the Science-Based Medicine Blog.
