Talk:Archive:Healing Arts Workgroup

(Porting this over as a start) Maybe a picture will help. On the right, you have (red) medicine, with a theoretical underpinning of biomedical sciences. Some of conventional medicine makes it through the filter of evidence-based medicine, and combines into orange: the best common practice of standalone conventional medicine. Some of conventional medicine doesn't have supporting evidence and as much quackery as the wildest alt theory.

Now, to the left, you have five boxes, not the neatest grouping but based on the NCCAM taxonomy. Alternative or whole systems, by definition, deal with all the healthcare needs of an individual and don't want to work with any other discipline. Perhaps the least controversial example would be a form of spiritual therapy that wants absolutely nothing but prayer, or sacrificing goats, or whatever. By its very definition, alternative medicine is alternative to everything else, and isn't going to be complementary or integrative.

To the right, there are four boxes of categories of technique. Now, there's no good way to draw something I'll explain: a given technique may be used in alternate medicine, or it might be used in complementary medicine. Complementary means "willing to play nicely with other disciplines".

Some blue complementary theories make it through the EBM filter and become light green. Bright green Integrative medicine is the combination of complementary and mainstream techniques, working together, which all meet varying standards for evidence-based medicine.

Each technique has verying levels of theory. Just like some conventional medicine doesn't make it through EBM and is quackery, some of the CAM techniques drop down and go quack-quack too.

My suspicion is that there's no one plausible theory article for CAM, any more than there's really common theory between the mechanical requirements of a replacement hip joint and the biochemical treatment of schizophrenia. The four types of CAM, to some extent, do have some commonality, although the assumptions of one energy technique, such as acupuncture , are very different from those of reflexology, and the specific discipline theory will be in the discipline-specific article.

There are cases where a given type of practitioner uses more than one class. For example, Traditional Chinese Medicine practioners use, among other things, herbals and acupuncture.

The team approach in integrated medicine can use all of the EBM-approved techiques. For some complementary techniques, the level of risk is so low, they don't interfere with other techniques, and are cheap enough that they don't need the same level of evidence as something more dangerous/interfering/costly. Howard C. Berkowitz 23:45, 29 December 2008 (UTC)

Is this nice picture to help us here at talk or are you proposing some version of it for the article? If the latter, I would say emphatically NO. It's not intuitive, and, I would say, it's almost certainly Original Research.... (If it takes 500 words to explain a diagram, then it's not worth using. Hayford Peirce 01:39, 30 December 2008 (UTC)

For Talk, specifically addressed to Larry's questions about how articles fit together. I would put it as a challenge to anyone thinks there is a meaningful single theory of alt med: where does it go, given all these other pieces are reasonably well defined? What theory, for example, would be common to reflexology, acupuncture, reiki, and therapeutic touch, beyond a generic "they all involve energy". Howard C. Berkowitz 02:00, 30 December 2008 (UTC)

Though arguments could be made concerning the locations and sizes of the boxes, the jist of diagram is pretty close; that Howard shows a good understanding of the problem, which is halfway to the solution. Why don't we consider bringing this to the workgroup page where we can document the process and at the same time develop the plan for all the Healing Arts articles, not just this one. Then maybe this one will fall into place. D. Matt Innis 02:04, 30 December 2008 (UTC)

Don't read anything into the size of the boxes -- some are that way just because it was a quick way to get the necessary text into the boxes without changing fonts, or to have certain color changes (i.e., blue passing through yellow becomes green, red passing through yellow becomes orange). And yes, green and orange, as I think of it, should have been brown. I'll be happy to take comments and fix it up, but that was 15 minutes of PowerPoint, not a more powerful graphics package or hand-drawn and scanned.

Having a workgroup discussion is a great idea. Some of you may know this, but the first chapter of each monograph I've written has the same title: "what problem are you trying to solve.". Matt, have you an idea on how to start this? I have been trying to get simple definitions of the alt disciplines, many just stubs. I am fairly happy with integrative medicine, but if there's a better way, I won't lose sleep. If I lose weight, tell me more. :-)

Matt, do you want a copy of the PowerPoint original? Howard C. Berkowitz 02:45, 30 December 2008 (UTC)

Matt, have you an idea on how to start this? I have been trying to get simple definitions of the alt disciplines, many just stubs. I am fairly happy with integrative medicine, but if there's a better way, Well, I'm pretty sure that if we put you on the NCCAM board of directors, you could work this out fairly quickly. The problem is that the rational approach won't necessarily define the circular reality. I am convinced that governments have combined complementary and alternative approaches because they cannot be reasonably separated cleanly. We can define the terms as 'alternative' and 'complementary', but it is unlikely that we can place anything cleanly in a particular bracket. Then, I agree, we can relate the degree of alternative or complementary a practice can be in their own articles. Integrative is just the cutting edge description for those practises that consumer demand is causing conventional medicine to evaluate and incorporate into their paradigms.

Sure, send me the Powerpoint original and if something hits me that I can improve, I'll send it back.

D. Matt Innis 03:34, 30 December 2008 (UTC)

By the way, I still think these should be contained in one article Complementary and Alternative medicine and I actually look forward to linking to an article on the the early history of the philosophy of medicine because it is also the history of the philosophy of alternative medicine as well. D. Matt Innis 03:43, 30 December 2008 (UTC)

Integrative vs. the others

To some extent I agree, and to some extent I disagree, with the idea that CAM can't be separated. There is a set of techniques that may or may not meet requirements of evidence-based medicine. By that, I don't necessarily mean randomized controlled trial; the British Parliamentary report is quite good on addressing other forms of evidence.

The World Health Organization is starting to use the term "traditional, complementary and alternative", which confuses things even more. I'm still chuckling over a situation where a hospital, which considered itself very flexible, was doing everything it could to make a Lakota Sioux patient feel cared-for, which included giving full respect to a tribal healer working with them. There was a genuine humility and interest on all sides. Things, unfortunately, rather hit the fan, when the hospital, which had a draconian no-smoking policy, discovered that the ritual used tobacco. Eventually, they just said "turn off the oxygen, wait a while for the bedding to equilibriate with room air, and then just close the door during the rite."

The principal difference I see in complementary and alternative is not, by and large, in the techniques. It is a willingness to work with other disciplines. For example, a spiritual healer that is willing to be involved if and only if prayer is the only modality used is alternative. I have, incidentally, fired MDs that variously were not willing to get second opinions in their specialties, or opinions in another relevant specialty, or honor my informed consent or refusal to something they wanted.

Alternative, to me, means a failing mark in "plays nicely with others". Complementary means "there are multiple ways. Let's see if we can work together." Integrative is an agreement for a real group of assorted practitioners to sit down and figure out where they can help one another, and, of course, the patient.

I guess I don't look at "consumer demand" as a factor. Howard C. Berkowitz 04:35, 30 December 2008 (UTC)

Traditional are those practices that are indigenous to a region, i.e. herbs to the Navajo tribes, etc.. Conventional as we see it is not always traditional in every country that the WHO oversees. Because they are also a political organization, they have chosen this way to include the various beliefs that exist in undeveloped worlds as well.

In many ways, medicine was not 'playing well with others' in not recognzing them as legit forms of therapy until the 1983 Wilks Antitrust suit in which they were no longer allowed to boycott chiropractic. So, again, it depends on your perspective as to who is playing nicely with whom. Most of these professions, including chiropractic developed educational systems independent of medicine in order to be able to continue to practice their disciplines. As new and more creative ways of researching began in the 1970s, spinal manipulation began to show promise for low back pain, but it wasn't until the 1990s when the US government came out with guidelines for the treatment of low back pain that had spinal manipulation as one of the top choices (and more significantly that surgery was overused) that medicine had a wake up call. In the late 1990s, the report surfaced that americans were spending more on alternative medicines out of pocket than payments to primary care. If one accepts that alternative medicine is placebo effect, then the motivation to integrate alternative medicine into conventional medicine must have been market driven - consumer driven rather than science based. Otherwise, you accept that the placebo effect is more than just doing nothing and it would be a legitimate practice. D. Matt Innis 05:08, 30 December 2008 (UTC)

Matt, I don't disagree at all that medicine didn't play nice with chiropractic; I'm more used to having medical specialties fighting with each other. I remember, a couple days after heart surgery, feeling a little puckish, and, when my surgeon came on rounds, students in tow, I asked him if he was really cardiothoracic board certified. He did a doubletake until I explained "you treat everyone with respect. The nurses think more of you than any other surgeon. When you found out that I knew something about the upcoming surgery, you spent an hour and a half on the phone with me, discussing details. Your teaching is superb but you never humiliate anyone on rounds. How can you call yourself a self-respecting cardiac surgeon?"

I know there are a lot of animosities, and justification. Nevertheless, what I hope we can do here is try to focus on how things work, and not refight the battles. There's a friend I'd like to get involved here, but I would like things to be more peaceful -- he's a DO double-boarded in family and emergency medicine, with an exceptional amount of field medicine experience. I think he's one of the best, open, healers around.

What I'm about to say may seem weird, but bear with me. You know I've been doing a lot of work on Vietnam. One of the many mistakes was not starting to secure villages, and then spreading out from them, winning the countryside. I look at integrative medicine as something like smart pacification. You start from a point of agreement, and then start spreading out like an oil drop on water. Integrative people are looking to find ways to cooperate, not battle. I doubt it's perfect, but I think it's a much more likely way to get good work done than setting up discipline against discipline, or going into philosophical or cultural arguments.

Sometimes the right things get done for the wrong reason. Now, spinal manipulation is not at all a field of expertise for me, but I've heard a few presentations that suggested that the alignment might be less the value than the neurotransmitter releases that it causes. One pain management specialist wondered if this sort of release might reset the nociceptive transmission paths in the spine, much as capsaicin resets the Substance P level in the peripheral nerves. One of the most ironic things in the Nobel saga for insulin is that one of the first patients saved was a young doctor named George Minot, who later got his own Nobel for the treatment of pernicious anemia -- which we now know he really didn't understand on a molecular basis but picked a treatment that did work.

You may have noticed that I've done some work on placebo, and Gareth has some ideas for it. I am not, however, out to establish CAM is placebo effect. My biggest complaint about homeopathy is I still don't have a real sense of how diagnosis and remedy selection works. Before I look at trials, I'd like to understand the mechanism. I'm willing to suspend disbelief about innate intelligence or vital force or inhibitory neurotransmitter agonists until I understand the theory involving them. I'd like to see CAM articles starting with a good explanations of the practitioner's idea of what is done, and not immediately get into efficacy arguments.

You could call me, I suppose, spiritual but not religious. I have spent time in ICUs, watching a patient's monitor before, during, and after spiritual rituals. There were objective changes. I don't know what caused them. They dissipated, but they could be repeated.

Can we find a way to start out by defining the problem statements for the disciplines before we get into a fight about them? Never mind homeopaths and physicians -- you want something scary, find out that you are standing between an interventional cardiologist and a cardiac surgeon!Howard C. Berkowitz 05:47, 30 December 2008 (UTC)

Thinking a little further, can we agree to disagree on consumer effect and focus on descriptions? I would also like to find acceptable terminology, which applies just as much to cardiology as chiropractic, for the varying levels of evidence supporting an intervention, as well as risks. When anything is numeric, I think is has to be expressed in appropriate statistical terms and comparisons -- it doesn't tell me much if I hear procedure A had 6000 deaths and B had 20, without knowing that A was used in a million patients and B in 100.Howard C. Berkowitz 07:04, 30 December 2008 (UTC)

Can we find a way to start out by defining the problem statements for the disciplines before we get into a fight about them? Absolutely, let's not ever fight about them!

can we agree to disagree on consumer effect and focus on descriptions Sure, this is not important to write about and would take lots of expert guidance and input. I just bring it up as a reason why the apparent "time has come" for the idea of integrating alternatives into medicine. There is scholarly work crediting women with keeping alternative methods alive during the years that medicine prohibited them from practicing medicine. Midwifery for example and the "old wives tales" of remedies, etc., but this would be in a history article I think. Interesting that you bring up Vietnam as that was when, in the US at least, respect for authority began to break down - Watergate, etc., those pesky hippie days and women's rights and all. These methods made a comeback then as well. It's not so much about being against medicine or science, it was about being self-reliant; free to make your own choices.. and finally it involved a sense of being a part of something bigger - elan vital/qi - that conected us to everything else. Ideas such as morphogenesis and life being about the 'energy' that holds us together rather than the material that we see. Anyway, sure, we don't have to talk about it :-) D. Matt Innis 16:17, 30 December 2008 (UTC)

Nostalgia

This is aside, but I have to do something about the coffee in my nose.

Unfortunately, one loses track of friends over the years. One such was an nurse-midwife, admittedly with a master's (mistress's?) degree in the subject, so it wasn't just tradition. It happened that we both are interested in neopaganism, so we could look at historical and current methods. One day, she whispered that she was going to whisper on of the secrets of her art, as to why everyone is sent to boil water at home deliveries: Midwifes love pasta The funny thing is that she's of Italian heritage, her husband's is Irish, yet he is the spectacular Italian cook.

Respect for authority is one factor, although I was questioning doctors before I reached puberty. Now, I do believe in an idea of connectedness among us, but I tend to think of that as orthogonal to the more mechanistic healing techniques. That's not very clear, so let me try it differently. I have very seriously used, and participated in, some traditional and other healing rites, but I very much regarded them as complementary and incommensurable with the more rationalistic healing models. One of the hot topics in some of the bioethics journals is what to do patients can ask clinicians to pray with them, when their beliefs are different. There are also a lot of issues of at least apparently more informed "consumers", which is an extremely complex area. Somewhat to my surprise, I sent a letter to the editor of one major bioethics journal, about a different view of informed consent: what if the patient wants more detail than an informed conformed form gives, and, in the wording of the Declaration of Helsinki, can reasonably be expected to understand it? For me, one of the challenges in some of the alt areas is that it's much harder to get detailed information than it is in mainstream.

That may be an area where we can be a resource: clear language on the processes, which is still a frustration of mine with homeopathy. I have a reasonable idea, I think, of how a TCM practioner takes a history and physical, and then makes choices about what treatments to use. I still don't really have a good idea what happens in a homeopathic office visit for a new patient. I have very good ideas what happens in a first evealuation with a lot of medical sciences.

If we can have articles that explain the principles of a discipline, that is neither evangelistic nor Quackwatch level, we might have a good start. FAQs aren't quite what I mean, but getting the basic principles and techniques down.

Integration discussions and how to improve both patient choice and clinician cooperation is something that can be approached in parallel. Howard C. Berkowitz 16:51, 30 December 2008 (UTC)

I agree that we can do it with neither evangelistic nor Quackwatch levels of passion. Have you seen DC Consult. I can send you some of the other links as well. We have some new EBM practice guidelines coming out that I think is the sort of thing you were looking for. I also think the link that Gareth gave us made some strong connections that we can use. I tend to be interested in history as I like to understand the 'whys' as much as the 'whats' and I have some sources for that as well. Most are at least partially accessible online. D. Matt Innis 17:08, 30 December 2008 (UTC)

By the way, I think that what tends to happen is that alt med people start to get defensive when they are hit with 'mainstream medicine says so and so is rubish'. I think mainstream medicine is a moving target as much as alternative medicine. Any ideas about how to handle that. I guess specific attribution is the most reasonable way. D. Matt Innis 17:11, 30 December 2008 (UTC)

You are on the track of something. I both manage my own mainstream care and often act as an advocate for others. I see reasonably well-educated patients blown off by physicans when I don't have any problem conversing, seriously, with the same physician. The difference, in part, comes from 40 plus years of studying the ways that physicians talk to each other, and there is a certain way of organizing discussions that says "peer" to them.

The integrative people start from the premise that they have something in common, and work out from there. There's more willingness to learn language of the other group.

I see routine battles among different medical specialties that sound rather like what you are describing. Noninvasive cardiologist vs. cardiovascular surgeon vs. interventional cardiologist is always good for laughs.

One of the things that bothers me is that mainstream medicine is, absolutely, a moving target. Homeopathy presents itself largely in a 19th century way and starts refighting 19th century battles. It was only recently that I found out new provings re being done; it wasn't easy to discover. A mainstream oriented person is apt to be more responsive to a alt practitioner who has a field that often looks at itself. How often do alt folks say "we have a new technique, or this old one isn't used any more"? That's said constantly in mainstream. It seemed like the more that I'd ask questions about modern homeopathy, the more I'd hear about things 50-200 years old. The alt med practitioners also aren't always citing mainstream work that does tend to validate them. There's also the alt vs. comp; there's much better commuications, I think, when the question is "how do we do this together?" Howard C. Berkowitz 17:41, 30 December 2008 (UTC)

Evidence-Based Medicine and CAM disciplines

Matt gave me a link to a chiropractic professional information site, DCConsult.com. One of the first things I read is "Assessing the Quality of the Evidence Before Assessing Individual Studies of Spinal Orthopedic Tests" by Charles Herring [1]. Since one of the defining characteristics of integrative medicine is whether a technique meets at least some tests of evidence-based medicine, I was glad to see this. The approach is based on the "Strength-of-Recommendation Taxonomy (SORT) method to assessing the literature1. The decision to use this method was made because it is a more patient-centered approach to grading evidence. According to the article describing the development of this method, the editors of the U.S. family medicine and primary care journals, (which includes American Family Physician, Family Medicine, The Journal of Family Practice, Journal of the American Board of Family Practice, and The British Medical Journal-USA), and the Family Practice Inquiries Network (FPIN) jointly developed this taxonomy." There is also mention of the STARD technique used by Cochrane, and another trial assessment method, QUADAS

One of the first questions is whether other CAM disciplines use this method.

Some general questions, presumably for Matt: How well does chiropractic fit the randomized controlled trial model? Is there an individualization issue as with homeopathy? Is it possible to do a "sham adjustment" and thus have the equivalent of a placebo, or would a typical trial be a new method (not limited to adjustment) compared to a generally accepted standard? Howard C. Berkowitz 20:57, 30 December 2008 (UTC)