Medicine is a science. Alternative “medicine” is an ideology that is unmoored from science. It usually involves an element of defiance and a belief in conspiracy theories. Proponents of alternative medicine fancy themselves as bravely challenging the unreasoning orthodoxy of medicine. Instead, they have merely allowed their ideology to blind them to the real causes of illness.
When alternative medicine is adopted by a political leader, and the ideology is writ large, thousands of people can die of what amounts to medical neglect. It has already happened. The leader was Thabo Mbeki, the country was South Africa and the ideology was AIDS denialism.
A paper in today’s issue of the Journal of AIDS, Estimating the Lost Benefits of Antiretroviral Use in South Africa, by Chigwedere and colleagues, details the carnage:
South Africa is one of the countries most severely affected by HIV/AIDS. At the peak of the epidemic, the government, going against consensus scientific opinion, argued that HIV was not the cause of AIDS and that antiretroviral (ARV) drugs were not useful for patients and declined to accept freely donated nevirapine and grants from the Global Fund… More than 330,000 lives … were lost because a feasible and timely ARV treatment program was not implemented in South Africa. Thirty-five thousand babies were born with HIV… by not implementing a mother-to-child transmission prophylaxis program using nevirapine. The total lost benefits of ARVs are at least 3.8 million person-years for the period 2000-2005.
Mbeki, the South African president, followed the classic alternative medicine playbook for challenging medicine. According to Paul Wolpe, in The Holistic Heresy: Strategies of Ideological Challenge in the Medical Profession, an attack on an established discipline in medicine includes four specific elements. The critic:
must portray the discourse as in crisis, must provide an alternative ideology to rescue the discourse, must legitimize their ideology through appeal to a reframed historical myth, and must portray the orthodoxy as a betrayer of the discourse.
Mbeki had no trouble representing the AIDS epidemic as a crisis of historic proportions. Anyone could daily witness the horrible toll in illness and lives lost. As Wolpe points out, the critic "rarely paints its opponent in terms of benign neglect", but, rather, claims that it is evil. Therefore, Mbeki refuse to acknowledge that the AIDS epidemic is a plague like other historical plagues. Instead, he insisted, according to the New York Times that:
powerful vested interests — drug companies, governments, scientists — pushed the consensus view of AIDS in a quest for money and power, while peddling centuries-old white racist beliefs that depicted Africans as sexually rapacious.
Such claims represent the reframed historical myth to which Wolpe referred. Building on the deep seated and justified suspicion of colonialism, Mbeki portrayed AIDS, not as an infectious disease, but as an opportunity for drug companies run by white men to force toxic drugs on black people.
According to Chigwedere and colleagues, over 300,000 people died because Mbeki rejected the medical explanation for the origin and treatment of AIDS. It is important to understand that Mbeki did not simply deny the medical explanation; he crafted an ideological attack that was meant to replace the medical explanation. According to Mbeke, there was no need for his country to accept and distribute donated antiretroviral medications. Indeed, he believed that his people should fear the medication as nothing more than an attempt of drug companies to push toxic and unneeded treatments in an effort to make money.
Although Mbeki’s AIDS denialism was played out on a far larger scale, and hurt many more people, it has much in common with other popular claims of alternative medicine such as vaccine rejectionism, supplements as treatment or prevention for disease, and homebirth advocacy. All are political ideologies unmoored from the science of medicine. All are efforts to reframe what believers consider to be historical myths, and all characterize medical orthodoxy as a thinly disguised effort of companies or organizations to profit by pushing treatments that are both ineffective and harmful.
Ultimately, alternative medicine is about the flattering portrait proponents wish to draw of themselves. According to Wolpe, whether it is AIDS denialism or vaccine rejectionsism, it is always characterized as:
… the inevitable (or desirable) next step in the history of medicine, and like other heroes of medical history who were initially rejected by the orthodoxy of the day (Pasteur, Semmelweis, Sister Kenny) the [proponent] is simply ahead of his time. Innovation is always initially resisted, they argue, and since their practice causes no harm and brings greater patient satisfaction, it is also true to the ethic of safe practice. Holistic heretics portray themselves as mavericks, leaders, with every expectation that soon all of medicine will, by necessity, follow in their footsteps.
There is no doubt that Mbeki was sincere in his beliefs, and hundreds of thousands of people died as a result. Proponents of alternative medicine are almost always sincere in their beliefs, but alternative medicine is not science, it is ideology. Its false characterization of illness and treatment inevitably hurts people, at a minimum by depriving them of effective care. Mbeki and the results of his policy of AIDS denialism should serve as a cautionary tale for anyone who advocates replacing science with alternative medicine.
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I've mentioned my own experience with a chiropractor. I went from intermittent episodes of severe back spasm that pulled one hip so far upward and forward that it was obvious to anyone looking at me. The pain was searing and debilitating, and I had no luck with exercises and muscle relaxants prescribed by my physician. It went on for 12 years! Finally this year, I reluctantly visited a highly rated chiropractor in my area, and she literally fixed my back. There was nothing mystical about it. She manipulated/contorted my body into various positions and pressed and pulled on my legs and spine in various spots. It was really no different than reducing a luxation. We did it several times over a period of a few weeks and then stretched it out to once a month. Every time I go, my spine and hips are less and less out of line, and I never get the completely distorted pelvis anymroe. It's an objective improvement.
My point is that I don't agree with painting alternative medicine with a broad brush of quackery and danger. Sure, it's ludicrous to reject solid mainstream medical treatments for serious diseases, but most people are not using alternatives in that manner. It's usually things like allergy desensitization or musculoskeletal injury relief.
I'm curious as to how you feel about osteopathic medicine.
"My point is that I don't agree with painting alternative medicine with a broad brush of quackery and danger."
My position on alternative medicine is simple and straightforward. Unless and until a treatment has been corroborated by scientific study, it is quackery and dangerous.
I am a firm believer in Ayurveda and have benefited by it. But I still go to an allopathic physician for an opinion.
Your point with HIV is spot on but in case of other ailments, ( Ayurvedic therapy has been proved effective for cancers also) an alternative approach would definitely not hurt the situation.
Again, taking a black or white stand won't help. Its all about finding a grey region.
"I believe conventional and alternative medicine should go hand in hand, neither one should be completely rejected for the other."
Medicine is science. Alternative medicine is quackery. Of course it should be rejected.
It is not that they do not know to prescribe antibiotics, or are not good enough. The fact is they have a reasonable knowledge of these alternative treatments also and are able to compare and suggest the better option for specific cases.
I suffer from severe migraine and I have been suggested homeopathy by my doctor. I am glad I took his suggestion instead of stocking up on migranil and vasograin.
In this blog Doc has picked the most egregious example of a medical luddite-ism in an attempt to shore up one of her favorite themes: Medicine is the way, the truth and the light and never mind that much of what she now considers medicine was once "alternative." Alternative medicine on the other hand is of the devil and must be stamped out, drawn and quartered, and burnt at the stake. Doc is a TRUE BELIEVER. If you do not think as she does you are EVIL and a doctor HATER. Be warned.
Doc also doesn't think other docs should be held responsible for deaths caused by their dirty hands, lab coats or stethoscopes which makes her one of the worst kinds of quacks, a murderous quack.
But now you are defining alternative medicine very narrowly. By your definition, if an alternative treatment is found to be effective (say, aloe for burns or cucumbers for eye puffiness or eucalyptus oil on the chest for congestion), then you move it into the proven mainstream category and don't consider it alternative. Thus, alternative medicine can't win with you.
And really, why do you even care if someone gets acupuncture or uses reiki or moxibustion, etc.? Say it doesn't work at all. So what? It's only affecting you as a physician if they rejected sound medical advice and went with that instead.
Using the term alternative medicine in the way you do, Amy - broadly, all-inclusively, without explaining clearly what treatments or protocols are to be included or which are to be excluded under your broad brush - does an extreme disservice to the millions of people all over the globe who are helped each day by practitioners of (for example) Ayurvedic and Chinese medicine, both of which are sciences based on several thousands of years of practice and refinement.
"By your definition, if an alternative treatment is found to be effective (say, aloe for burns or cucumbers for eye puffiness or eucalyptus oil on the chest for congestion), then you move it into the proven mainstream category and don't consider it alternative."
The definition of alternative medicine is any treatment or practice that does not fall within the realm of conventional medicine. Since conventional medicine embraces any treatment, practice or theory with a strong scientific basis, alternative medicine is, by definition, without scientific support.
That does not preclude the possibility that if scientific research were done it might show the practice to have a scientific basis. It merely means that alternative health practices are recommended in spite of the fact, and often specifically because of the fact that there is no scientific basis for their use.
It seems to me there are three types of therapies:
1. Those that have been tested, and for which safety and efficacy are supported by science;
2. Those that have not been tested, or for which results are conflicting or equivocal;
3. Those that have been tested, and for which safety and efficacy are unsupported by science.
"One cannot deny that Mbeki's approach to dealing with AIDS has been a disaster for South Africa."
An even larger scale disaster would occur if the recommendations of vaccine rejectionists were adopted.
"an extreme disservice to the millions of people all over the globe who are helped each day by practitioners of (for example) Ayurvedic and Chinese medicine"
If something works, it is easy to show it. Testimonials are not scientific proof. In light of what we know about the placebo effect, testimonials are meaningless.
Neither Ayervedic nor Chinese medicine are based on science, nor are they effective. Indeed, in countries where they are widely practiced, death and disease occur on a massive scale. Are they better than nothing? Possibly, but that's not the standard that we use for judging medical effectiveness.
What is your basis for that kind of statement? Don't you think these treatments are recommended because the provider believes they generate results in terms of improving whatever symptoms the patient has? If anything, they are claiming with little merit that there are scientific effects, not promoting the fact that there are none.
"Therapeutic touch affects DNA synthesis and mineralization of human osteoblasts in culture."
"Low-frequency electro-acupuncture reduces the nociceptive response and the pain mediator enhancement induced by nerve growth factor."
I think it is a mistake to pretend we know all there is to know in science.
"Don't you think these treatments are recommended because the provider believes they generate results in terms of improving whatever symptoms the patient has?"
Most providers of alternative medicine are charlatans, whether they are aware of it or not. They may believe in their wares every bit as much as faith healers believe in theirs, but that tells us nothing about whether their personal beliefs are true. No doubt Mbeki sincerely believed that AIDS could not be treated with antiretrovirals.
Almost all providers of alternative medicine are grossly uninformed about medicine, science and statistics. They neither know nor care how to find out whether their treatments work. It is enough for them that they believe them to work.
"I think it is a mistake to pretend we know all there is to know in science."
We don't know all there is to know about medicine. We DO know that alternative medicine is quackery.
Alternative medicine makes specific claims that are easily tested. As Squillo pointed out, those claims either haven't been tested, or have already been tested and shown to be false.
"Neither Ayervedic nor Chinese medicine are based on science, nor are they effective. Indeed, in countries where they are widely practiced, death and disease occur on a massive scale."
India has a sufficient doctors for her people. We may not have the best medical infrastructure but disease and death here are not because we have forsaken allopathy but because most of us here do not have access to proper medical care.
Ayurveda is based on sound scientific principles. I cannot preach what I do not practise but I think Chinese therapy also has strong scientific foundations.
Ayurveda practitioner Charaka actually performed surgeries in the B.C s.
We have government medical colleges here which actually have proffessional courses in Ayurvedic medicine. We have licensed practitioners who have have studied this science for as long as you have your branch of medicine.
In Panchatantra, which is a collection of fables, there is this story about a frog which lived in a well. When another frog came to the well and told the first about the wonders of the outside world, about the seas and the oceans, our friend retorted " You are a liar, you foreigner, there is nothing bigger than my well. I want you out of here now".
Please make an effort to move outside your world, there are things which you do not know of.
in countries where [Chinese and Ayurvedic medicine] are widely practiced, death and disease occur on a massive scale
That's because massive numbers of people in those countries - for many reasons, though largely rooted in ignorance and inaccessibility - do not seek or receive treatment from qualified practitioners.
"Please make an effort to move outside your world, there are things which you do not know of. "
This is exactly the type of ideology that Wolpe described in his paper The Holistic Heresy: Strategies of Ideological Challenge in the Medical Profession, that I referenced above:
"... [G]reat pains are usually taken ... to show that the alien ideas are not in fact alien at all, but have existed in the discourse in a different form. [Critics] often import foreign, folk, and traditional forms of healing into their practices, [carefully describing] them as wholly compatible with Western medicine, scientifically valid, or historically present in other forms. (The ‘placebo’ effect, for example, is elevated to a central place in holistic medicine, and described as demonstrating the 'power of the mind', which is in turn said to be a central tenet of Eastern and Native healing forms. The orthodoxy is censured for slighting this most important healing modality.) ..."
And:
"Biomedicine is portrayed as a bureaucratic juggernaut whose judgments are accepted uncritically by adherents. Technological wizardry is used as proof of sophistication without truly exploring all roads to healing their patients..."
Other laymen like myself may be reluctant to chime in.
I think "alternative medicine" gains traction when accepted mainstream medicine fails--as it often does. The way my grandmother's cancer was treated, for example, seemed to do more harm to her than good. These kind of experiences lead folks toward dangerous ideas and quackery.
And Lonnie, I'm glad to see other people on here that read Harper's. I did read that story you mentioned and I too recommend it to others.
When I was a young man…when I was a boy…conventional medicine and science advised me to eat a good solid breakfast. The example most often given was:
A couple of eggs, some bacon, toast with butter, and a big glass of creamy milk.
How does this comport with your comment: “Medicine is science. Alternative medicine is quackery.”
Two things I should mention:
One, I do not subscribe to any alternative medicine fads whatsoever. I have never even been to a chiropractor…and the notion of herbs or acupuncture turns me off. Since mindset plays such an important part in “cure”, I suspect they would not be particularly beneficial for me in any case.
Two, I suspect that 500 years from now, doctors now practicing what they consider “medicine” will be lumped together by future physicians with witchdoctors, herb peddlers, and shamans. No disrespect meant…just a feeling I have.
If you were into provoking for the purpose of starting a dialogue, I could understand it, but all you seem interested in is bludgeoning people with your inflexible certainty.
As long as we ignore the times that it isn't.
"As long as we ignore the times that it isn't."
Such as?
Whether I would want to start a dialogue with Amy on a given question is beside the point.
Mbeki made a horrible health policy decision for his country. However, this conversation was presented in a collapsed manner on several levels and the discussion has been collapsed ever since.
National health policy cannot be an assumed right. And, though, some could create a defensive argument for Mbeki's position through our lens (every possible argument from politically approved mass experimentation on the poor to spending for competitive goods to uncounted opportunity costs to corruption), those arguments still rest on an assumption that national health care is his responsibility.
So the first collapse is believing that Mbeki had a responsibility to aid his country to fight AIDS. Here in the US, we believe that health policy should be directed by the federal government in conjunction with each state's programs. Now we fail miserably at this in many ways. One example- you can't get an ambulance in the countryside, but once you get the hospital, you can be seen. Here in the city, you can get an ambulance in an instant (for $750), but it will take you hours to get attention in the ER.
Some countries do not believe health policy is the responsibility of the government. In fact, a big argument in the Depression in the US was that the President did not believe that it was the responsibility of the government to provide food and medicine for the people even if they were starving, sick and unable to treat themselves. This idea of the government providing for its people is new. Even to us.
The next collapse seems to be a conclusion drawn that since it doesn't work for a country, it won't work for an individual. We know this is untrue. There are people, even if it is statistically unlikely, who will actually benefit from some strange practice that others won't, but that doesn't mean you can't try it.
My doctor prescribed a drug for cancer patients during my pregnancy to stop nausea which worked beautifully, but I had to know it wasn't prescribed for that purpose. My child is on high doses of vitamins and strict diet to offset her "on the spectrum of autismness," (different kid) that also seems to be doing really well. I am clear none of this is FDA approved, but it is working for now.
Aside from the individual accounts, I think we are all clear that targeting DNA will allow us to personalize medicine for each individual's ailments. If this is possible, then one might argue that arguing for a statistically proven drug treatments for the masses which naturally accept an amount of failure and denying specialized treatment for outlayers is cruel and inhumane.
Now, we allow en-mass treatment protocols because we live in an industrialized nation and we have mapped assembly-line thinking on every possible conundrum we encounter, but what if it is using a hammer when we need a tweezer? We cannot yet comprehend a world where individualized medicine is practical, but I believe it is not far off.
Another collapse is that we have enough testing being done in the right areas to ensure the best medical solution available for every ailment. I am assuming you already know the corruption involved with the FDA including drugs that were approved that were rescinded, the trials that were conducted by the pharmaceutical companies who had the incentive to make the drugs pass, the FDA members who approve drugs when there is a proven conflict of interest, providing doctors incentives to prescribe brand name drugs, and so on. If you could point to an objective health industry that reliably had public health in their best interest, this might be a discussion worth having.
Even with all of our nation's failings, I am not an orphan with AIDS in South Africa. I am a wife and mother of two in California. My children received vaccines (without Thermisol) and my family has health insurance and regular doctor visits. I am one of the very fortunate few in this world. I thank God everyday and pray for those who drew the short straw.
When I read your article, my heart broke. I can't imagine the horrible conditions of the people who are out there on their own without access to decent health care. More than that, I know I can never know what it was like for you, someone who has dedicated her life to saving people's lives, to have read that account knowing a solution was available and denied. I simply request you consider that whatever reasons we think Mbeki made his decision may not in fact be the reason, and if it was, it was made in a context we might have not yet discussed.
It seems like progress can never come fast enough.
K8 says: "Almost all providers of conventional (allopathic, AKA Dr. Amy's) medicine are grossly uninformed about alternative and complimentary medicine, science and statistics. They neither know nor care how to find out whether their treatments work. It is enough for them that they believe them to work. "
1. She is a zealot.
2. She believes herself very knowledgeable.
3. She's not worth arguing with.
4. If you are her patient you should be looking for a new doctor.
and Dan
"Amy, why do you do this? You make blanket statements that are guaranteed to offend people, then you dismissively and summarily reject those who want to offer a different perspective"
I suspect it's because she likes the attention, negative or positive. Attention is attention.
Medicine, like any other branch of science, simply offers the best explanation for the knowledge that we have at this moment. Newton is considered a scientific genius not because he was infallible; he was wrong on a number of points and was ultimately corrected by Einstein. He was considered a scientific genius because his Laws of Motion represented the best synthesis of the information available to him at that time. He made no claims of infallibility, and certainly expected to be corrected by scientists in the future.
Similarly, contemporary medicine offers the best synthesis of all the information we have available to us about health, disease and biochemistry at this moment. No doctor believes that medicine is infallible. Therefore, no doctor expects that the current state of medical knowledge will remain unchanged. Nor is any doctor surprised or the least bit dismayed that medicine has been wrong in the past. Of course it has; new knowledge has been acquired and medicine has changed in response. We have a word for that phenomenon: we call it scientific progress.
Alternative medicine, like all forms of pseudo-science, is unmoored from science. Alternative medicine purports to have access to ancient "truths" or "wisdom" that has no changed over centuries or millenia, but there is no such thing as ancient truth or wisdom.
The fact that medicine has been wrong in the past and has changed in response to new information is not a sign of weakness; it is medicine's greatest strength. Alternative medicine never changes because it is not science. It is a strange concatenation of ideology and psychology and it is impervious to facts.
Many people want to believe in alternative medicine, but wanting to believe in it does not make it true. Out of 30 comments, not one has offered even a single example of alternative medicine ever being correct when it was contradicted by conventional medicine.
All my life (and I'm not young) I've healed through many different ways, both scientific and alternative. I'm also a trained Master Herbalist and have seen many many people cure what ails them, with herbs and suppliments, and alternative processes.
I feel very sorry for anyone who bases their decisions solely on science.
I am not willing, however, to go so far as to say that science or the scientific method are the only valid means for explaining phenomena. I do not know if there are realities within our sphere of existence that science lacks the tools to recognize or explain. I strongly suspect that this is the case, though.
It seems to me that to insist that one's particular system is the only valid system is hubristic.
I am favorably impressed by the fact that NANDA, the North American Nursing Diagnosis Association, recognizes the following among it approved nursing diagnoses: Energy Field, Disturbed.
"I am not willing, however, to go so far as to say that science or the scientific method are the only valid means for explaining phenomena."
Why not?
How much science is there behind the routine use of fetal monitoring in laboring women of normal risk profile? Multiple large trials have shown no benefit from this practice; but it was instituted before those studies were done and now it's never going to go away.
"How much science is there behind the routine use of fetal monitoring in laboring women of normal risk profile? Multiple large trials have shown no benefit from this practice; but it was instituted before those studies were done and now it's never going to go away."
That's simply not true, and highlights why it is important to read the studies, not the media reports about them.
There is NO study that shows fetal monitoring to be without benefit. There are studies that show that fetal monitoring offers no additional benefit beyond that provided by rigorous intermittent auscultation by a trained RN following a prescribed course.
EFM is a screening test. As I'm sure you know, for every screening test, there is a sensitivity rate and a specificity rate and these numbers dramatically affect the way that the test can or cannot be used. In the context of a screening test like fetal monitoring (which is screening for fetal distress), specificity is the proportion of times that result a result indicating no fetal distress actually reflects the fact that there is no fetal distress. In contrast, a sensitivity is the proportion of times that an abnormal fetal heart rate actual indicates real fetal distress. The primary problem with electronic fetal monitoring is that it has a relatively low specificity rate. In contrast, intermittent auscultation has a relatively low sensitivity rate.
In studies, continuous fetal monitoring appears to provide no advantage over strict intermittent auscultation, but that does NOT mean that electronic fetal monitoring is useless, and it does NOT mean that intermittent auscultation is just as good as electronic monitoring. To understand why this is the case, you need to know something about the way that sensitivity and specificity affect outcomes. In the following examples, I am going to assume that electronic fetal monitoring has a sensitivity rate of 99.9% and a specificity rate of 88.8%. I will also assume that intermittent auscultation has a sensitivity rate of 88.8% and a specificity rate of 99.9%. These are not actual values, but they serve as representations of the trade offs made between EFM and intermittent auscultation. We are also going to assume that every woman who shows signs of fetal distress, on EFM or intermittent auscultation, will have a C-section.
Let's take a look at a sample population of 1 million low risk women in labor, and let's assume (for ease of calculation) that this population will have a 1% rate of true fetal distress. What would the results be if all the woman in this group had EFM during labor?
A table showing the relationship between sensitivity and specificity would demonstrate that for our hypothetical low risk population of 1 million women monitored with EFM (I have this table and the following tables but I cannot successfully embed them in a comment):
9,990 babies saved, 116,880 unnecessary C-sections, and 10 neonatal deaths
Compare that to 1 million women monitored using intermittent auscultation, which has a lower sensitivity level, but a higher specificity level.
There's a dramatic difference:
8,880 babies saved, 99 unnecessary C-sections, and 110 neonatal deaths
Using intermittent auscultation resulted in more than 100,000 fewer C-sections, but an additional 100 babies died. You can make an argument (and many people do) that the life of 1 baby is not worth 1000 unnecessary C-sections, and hence, intermittent auscultation should be substituted for EFM. Of course, that means acknowledging that 100 babies would die who might otherwise be saved.
But that's not the end of the discussion. All screening tests perform better in at risk populations as opposed to the general population.
Let's create a hypothetical population of high risk women and assume that this group will have a 10% rate of true fetal distress. It should work out the same way, right? No, not even close. The performance of screening tests improves as the risk increases within the population, even though the sensitivity and specificity remain the same.
If our hypothetical group of 1 million high risk women were to be monitored with EFM, we might see something like this:
99,900 babies saved, 100,800 unnecessary C-sections, 100 neonatal deaths.
Once again, we can compare that to 1 million women monitored using intermittent auscultation, which has a lower sensitivity level, but a higher specificity level.
These change due to the increased risk level is dramatic:
88,800 babies saved, 900 unnecessary C-sections, 11,200 neonatal deaths
This result is clearly unacceptable.
We can summarize the data showing the results of switching from EFM to intermittent monitoring. In a low risk group, switching from EFM to intermittent monitoring would result in 116,781 fewer C-sections and 100 more neonatal deaths. In a high risk group, a similar switch would produce 99,900 fewer C-sections and 11,100 more neonatal deaths.
In a low risk group, it may be feasible to replace EFM with intermittent auscultation. There will be a dramatic reduction in unnecessary C-sections, but there will be a small rise in preventable neonatal deaths. In contrast, in a high risk group, there is a comparable reduction in unnecessary C-sections, but there is a massive increase in neonatal deaths.
Looking at these numbers (even though they are all hypothetical), it is possible to make several claims. First, in order to determine how intermittent auscultation compares with EFM, it must be tested in hundreds of thousands of women. No studies like that have been done. Second, in small studies (like the ones that have been done to date) we would expect to see only small differences or even no difference in mortality rates. That does not mean that the two techniques are comparable. Third, the risk level of the population has a dramatic impact on the relative merits of the two methods of monitoring. There is no role for routine intermittent monitoring in high risk patients.
There is one thing you seem to forget and that is that an opnion isn't right or wrong. It's an opnion.
I regret anything in my comments that were truly nasty, however I won't be commenting on any of your posts in the future. Your kind of zealatry is mind numbing and a true conversation stopper.
Stay well and have a wonderful holiday.
I said why not in the two sentences that follow the sentence you quoted. But I'll put it another way:
Because I am acutely aware of my own insignificance.
For me it's akin to the difference between being an atheist and an agnostic. An atheist fervently believes - indeed has complete faith in - the idea that there is no god. An agnostic recognizes that he may never have all the pertinent information, and even if he did, he might not know what to make of it.
"There is one thing you seem to forget and that is that an opnion isn't right or wrong. It's an opnion."
Here's the problem: I'm not writing about my opinion. I'm writing about empirical facts. Everyone is entitled to their own opinion. No one is entitled to their own facts.
No one has offered any facts to counter the facts that I have presented. Most people have simply complained that their opinion has equal standing with the facts, but it does not.
Someone could say that, in their opinion, gravity does not exist. That doesn't mean that there is no gravity. Opinion on scientific matters is irrelevant. Only data counts.
Similarly, many people say that, in their opinion, alternative medicine works. That doesn't mean that it works. Only data counts, and no one has been able to offer even a shred of data.
Thabo Mbeki really and truly believes that HIV does not cause AIDS and that antiretrovirals are a scam foisted on poor people by big corporations. That didn't change the fact that HIV does cause AIDS and that the only way to save people's lives is by treating them with antiretrovirals. The only thing that happened is that hundreds of thousands of people died unnecessarily.
Many people really and truly believe that alternative medicine works and that conventional medicine is a scam foisted on the gullible by drug companies and physician organizations. That doesn't make it true. The only thing that is happening is that millions of people are wasting their money on snake oil and people who need conventional care are being hurt by refusing it.
Whether or not an alternative medical treatment works can ONLY be shown by scientific evidence. Opinion has no place in scientific argument.
"Because I am acutely aware of my own insignificance."
So? What does that have to do with the existence of some amorphous, unspecified other way of "knowing."?
No one here is denying that there is alot of crap out there hiding behind the facade of "alternative medicine"
I still believe (in some aspects) that westren medicine is still very "euro-centric" and that things such as Accupunture still has an "exotic" stigma.
Painting "everything" in the alternative realm with the black brush (and denying it has ANY validity) is just as ignorant and mule-headed as the women who think ALL OB/GYN's are control freak, section happy pigs, who just want to get home at 5 pm.
Both are obnoxious and unfounded.
Rated for kicks!
"Many people really and truly believe that alternative medicine works and that conventional medicine is a scam foisted on the gullible by drug companies and physician organizations. That doesn't make it true. The only thing that is happening is that millions of people are wasting their money on snake oil and people who need conventional care are being hurt by refusing it."
Please be sure to find a source that cites the amount of people who are denying traditional medicine who consider traditional care a real option (they have ready access and they know they can afford it). I'm looking for some sort of evidence that there are people in the United States with serious ailments (chronic illness; not a loose tooth or hangnail) who would forego traditional medicine they could afford that they know is effective for alternative medicine (meaning they would never see a physician even though they had the opportunity) .
I would also like to see the statistics on the people who died because of alternative care that would have lived had they sought traditional care (again, care they could have gotten and afforded).
I don't doubt there are plenty of people buying snake oil. How many people have access and opportunity for the real thing?
I've never seen any information on this. I thought alternative medicine has always operated as an inferior good (meaning when the economy slows, people spend more money on alternative medicine like buying Ramen Noodles instead of steak and potatoes).
I think it is important to keep the decision-making process in mind before condemning all the stupid people who are needleessly killing themselves.
In the following examples, I am going to assume that electronic fetal monitoring has a sensitivity rate of 99.9% and a specificity rate of 88.8%. I will also assume that intermittent auscultation has a sensitivity rate of 88.8% and a specificity rate of 99.9%. These are not actual values, but they serve as representations of the trade offs made between EFM and intermittent auscultation...
Wait a second. First of all, you made up the sensitivity and specificity values in your example!
So far there's been no study large enough to show the difference you assume to be present in a non-high-risk population. But you assume that if you studied a million women you would find one! Why should you assume that rather than the opposite?
You've already decided that EFM has a benefit in this population, and you EXPECT a large enough study to bear you out. On what do you base this expectation? Not the existing evidence, surely.
I don't think it's legit to defend EFM on the basis of a guesstimated number yielding a projected benefit. The fact remains that the (multiple, large) studies that have been done do not show a benefit in the population of women specified (notice I excluded high-risk women).
Anyway, the point of this is that EFM was accepted by the medical community BEFORE the studies had been done. The studies have now been done, they don't support the use of the technology in low-risk labors, and yet the medical community still insists on retaining it and enforcing it, even when it makes the patient uncomfortable.
This is an excellent example of modern medicine behaving in exactly the same way as the 'alternative' practitioners you decry: using something because others do, in the absence of evidence (and now in the face of evidence). There are lots of other examples of this that I've seen, and I bet you have as well.
"The fact remains that the (multiple, large) studies that have been done do not show a benefit in the population of women specified (notice I excluded high-risk women)."
Which studies are those?
The example you use is a blanket excuse to posit an alarmist, conservative, over-the-top opinion about something you consider to be invalid. Alternative treatment modalities, including herbals, homeopathy, and naturopathy, are highly effective for many people, for curing many ailments.
Being so stiff-necked, unyielding, and close-minded about any treatments that are not based in so-called "modern science" doesn't serve anyone. I've worked for a lot of doctors, as I've stated here before, and there are good ones, mediocre ones, and those to whom I wouldn't send a dog for treatment because, as the saying goes, they don't know sh*t from Shinola when it comes to practicing medicine.
"M.D." does not spell "God". Your word on this issue is not THE word on this issue. It's YOUR word on this issue only.
I think the reason you disparage and dismiss alternative medicine is because you find it a threat to your safe, sanitized, AMA-approved world. Just think what would happen to doctor's fees if the general public started to become educated about the highly effective treatments out there that DON'T cost thousands of dollars! Not to mention that you and your kind would lose that tight-fisted parental control you exercise over your patients. They would no longer depend on you for permission to breathe in and breathe out. Now that would be truly unbearable, wouldn't it?
Just one example of where alternative medicine could be a good answer is the trouble local Seattle hospitals are having with getting the spread of MRSA under control. They are spending thousands of dollars trying to treat patients by means of mainstream, FDA-approved antibiotics that have become largely ineffective, when the infections could have been treated quickly and effectively with several different herbal antibiotics, with zero side effects or recurrences. It's attitudes like yours that keep people sick, because some physicians and medical administrators don't dare draw outside the lines.
Thanks for the reminder of why I rarely see an M.D. for anything anymore. I see alternative practitioners about 75% of the time, and I'm healthy and quite happy, thank you very much.
And I now know what's behind all these opinion pieces of yours: a tightly closed mind. You'd better get with the program, doc. The world is changing very fast right now, and more and more people are starting to see that they have choices when it comes to seeking help from healers. If you insist on keeping your mind shut to that which is new and different, you will be left behind with the other medical dinosaurs.
Which studies are those?
Here are a couple of meta-analyses:
Blix et al., BJOG December 2005, Vol. 112, pp. 1595–1604
Prognostic value of the labour admission test and its
effectiveness compared with auscultation only:
a systematic review
Meta-analysis of three randomised controlled trials including 11,259 women and 11 observational studies including 5831 women.
Conclusions There is no evidence supporting that the labour admission test is beneficial in low risk women.
Thacker et al., Obstet Gynecol 1995;86.'613-20
EFFICACY AND SAFETY OF
INTRAPARTUM ELECTRONIC FETAL
MONITORING: AN UPDATE
Methods of Study Selection: Our search identified 12 published
RCTs addressing the efficacy and safety of EFM; no
unpublished studies were found. The studies included
58,855 pregnant women and their 59,324 infants in both
high- and low-risk pregnancies from ten clinical centers in
the United States, Europe, Australia, and Africa.
Conclusion: The only clinically significant benefit from the
use of routine EFM was in the reduction'of neonatal seizures.
Because of the increase in cesarean and operative
vaginal deliveries, the long-term benefit of this reduction
must be evaluated in the decision reached jointly by the
pregnant woman and her clinician to use EFM or intermittent
auscultation during labor.
Also here is an interesting editorial from the NEJM in 2006, comparing EFM to the newer fetal pulse oximetry.
http://content.nejm.org/cgi/content/full/355/21/2247
" Intrapartum electronic fetal heart-rate monitoring was introduced with great enthusiasm in the early 1970s. Most cases of cerebral palsy were thought to result from asphyxia during the intrapartum period, and it was hoped that the ability to recognize intrapartum fetal asphyxia and intervene with a timely delivery would reduce the incidence of fetal neurologic injury...
By the end of the 1970s, electronic fetal heart-rate monitoring had become a standard of care, despite the absence of randomized, controlled trials showing any reduction in the rate of long-term neurologic handicaps in the newborns.
When electronic fetal monitoring was rigorously assessed, however, the results provided little support for its use. Initial trials that showed no benefit from intrapartum monitoring were criticized for their small size. Larger trials that showed no benefit, including one involving almost 35,000 patients,1 were criticized because they were conducted in term infants who were at low risk. A study reported in the Journal in 1990 showed no significant differences in the results of neurologic evaluations at 18 months of age among premature infants at high risk for intrapartum asphyxia who were randomly assigned to electronic monitoring and those assigned to intermittent auscultation during labor.2 The accompanying editorial characterized intrapartum fetal monitoring as 'a disappointing story'."
1.Leveno KJ, Cunningham FG, Nelson S, et al. A prospective comparison of selective and universal electronic fetal monitoring in 34,995 pregnancies. N Engl J Med 1986;315:615-619
2.Shy KK, Luthy DA, Bennett FC, et al. Effects of electronic fetal-heart-rate monitoring, as compared with periodic auscultation, on the neurologic development of premature infants. N Engl J Med 1990;322:588-593
Aww, c'mon. Please don't throw studies at me that you haven't even bothered to read.
Here's your original claim: "The fact remains that the (multiple, large) studies that have been done do not show a benefit in the population of women specified (notice I excluded high-risk women)."
1. Blix, et al., BJOG, 2005.
This study isn't even about cEFM. This study is about the value of an INITIAL evaluation of the fetal heart rate on admission to labor and delivery. No one has ever claimed that EFM has the ability to predict fetal distress hours before it happens.
2. Thacker et al., Obstet Gynecol 1995
This is the study that I referred to above when I wrote: "There is NO study that shows fetal monitoring to be without benefit. There are studies that show that fetal monitoring offers no additional benefit beyond that provided by rigorous intermittent auscultation by a trained RN following a prescribed course."
The criteria for intermittent monitoring used in most of the studies discussed in Thacker simply cannot be met in any hospital. It requires 1:1 nursing care during the duration of labor, and that is certainly not economically feasible at any hospital.
Again, you seem to have elided the most important point. This meta-analysis does not claim there is no benefit to cEFM. It only claims that there is no ADDITIONAL benefit to cEFM compared to rigorous intermittent auscultation by a trained RN following a prescribed course.
A recent comprehensive treatment of issues in fetal monitoring, Medical Legal Issues in Fetal Monitoring (Clin Perinatol 34 (2007) 329–343), addresses the medico-legal dimension of fetal monitoring. The review lays out the issues:
"... [EFMs] virtues are disparaged in various "evidence-based" articles that suggest that auscultation is comparable to EFM, or that EFM needlessly increases the operative delivery rate, but offers no benefit in prevention of neurologic injury or perinatal mortality...
...Pertinently, these articles and editorials do not call for the abandonment of EFM.
...Notwithstanding these developments, many lawsuits still involve allegations (and rebuttals) that the obstetrician either failed to recognize or act upon abnormal FHR patterns and that failure resulted in perinatal brain injury that could have been prevented."
The authors, Cohen and Shifrin, widely acknowledged to be experts in EFM, favor EFM over routine auscultation for the following reasons:
"[We] resort to EFM as the primary screening test for intrapartum fetal asphyxia because of the limited predictive value of any other clinical risk factors during labor-including auscultation... EFM permits continuous accurate monitoring, permits using the fetus as its own control, evaluates tolerance of a fetus to stress of the individual uterine contraction, and permits the diagnosis of potentially catastrophic events in a timely fashion... There is no example of hypoxia or death on a monitor without warning. It provides a permanent record, subject to later review. With regard to auscultation, there is no study that supports the contention that auscultation is a reliable determinant of the fetal condition or of the need to intervene. Even those who find EFM useless for the purpose of preventing injury or death concede its ability to detect fetal hypoxia."
The authors conclude with an excellent summary of the current role of EFM in obstetrics and in obstetric malpractice suits:
" Despite the persisting debates over its role and benefits, it is likely that EFM will remain a standard part of obstetric care for the foreseeable future. As such, it will also remain a focus of attention in obstetric negligence lawsuits. It must be remembered that in most cases the monitor pattern does not dictate the timing of intervention, but rather is used to keep mother and fetus out of harm’s way...
There is widespread agreement that improvement in perinatal outcome is possible, that the events of labor can contribute significantly to perinatal hazards, and that reviewing adverse outcomes and making obstetric units more reliable in terms of communication and interpretation of tracings will enhance outcome. (my emphasis) That notwithstanding, we do not yet know the totality of injury related to the intrapartum period irrespective of the mechanism. The estimates of the role of hypoxia vary widely, in great measure due to incompatible definitions and limited follow-up... In this respect, newer developments in pediatric neuroradiology and to some extent a more insightful approach to EFM may indeed help us understand these matters and at the same time improve outcome. It seems that we best protect ourselves in medicolegal matters when we protect the mother and the fetus during labor."
The bottom line is this: Neither doctors nor malpractice lawyers believe that the scientific evidence shows that intermittent auscultation is as effective as EFM, and that, therefore, the standard of care is the use of EFM.
"One day I asked her how it was going and she proudly announced that she had finally put together the right mix: various herbs, accupuncture, large doses of several vitamins... and prednisone."
That's like the testimonials about various alternative treatments for cancer that "work" when used in conjunction with chemotherapy.
"I realize that Amy."
I know. I wasn't suggesting that you didn't. I was merely corroborating your example.
Midwives are becoming the logical choice for a growing number of pregnant women. They're trained, they're licensed, they're flexible about birth venues, and they're reasonably priced.
As fewer and fewer pregnant women choose a hospital venue for giving birth, how will you and all the other doctors decide who gets the patients with insurance plans comprehensive enough to cover the costs of prenatal care and delivery? Will you draw straws? Will you pull seniority? Cut staff? Close entire wings of hospitals?
Most hospitals now demand either proof of insurance coverage and verify on the spot the minutiae of every patient's plan, or want cash up front. As the economy tightens its pincer grip on potential patient's cash reserves, there will be far less "extra" cash to be allocated for medical care. This will result in more and more people turning to other means of receiving the assistance they need.
My mother, who retired from the real estate business at the age of 78, had a sign on her computer that said "Adapt or Die". There are doctors I can think of who might want to make just such a sign for themselves and place it where they can see it every day.
"As fewer and fewer pregnant women choose a hospital venue for giving birth, how will you and all the other doctors decide who gets the patients with insurance plans comprehensive enough to cover the costs of prenatal care and delivery? Will you draw straws? Will you pull seniority? Cut staff? Close entire wings of hospitals?"
At the moment, there are not enough obstetricians to take care of existing patients, and they are giving up obstetrics or retiring altogether at a higher rate than other doctors. When do you anticipate that we will have enough obstetricians to care for existing women, let alone a surplus?
Again, you seem to have elided the most important point. This meta-analysis does not claim there is no benefit to cEFM. It only claims that there is no ADDITIONAL benefit to cEFM compared to rigorous intermittent auscultation by a trained RN following a prescribed course.
Well sure, that's the control condition. I'm not saying EFM is no better than home labor with no supervision, right? It's no better in terms of outcomes compared to a less restrictive alternative that leads to fewer surgical interventions.
A recent comprehensive treatment of issues in fetal monitoring, Medical Legal Issues in Fetal Monitoring (Clin Perinatol 34 (2007) 329–343), addresses the medico-legal dimension of fetal monitoring.
"... [EFMs] virtues are disparaged in various "evidence-based" articles that suggest that auscultation is comparable to EFM, or that EFM needlessly increases the operative delivery rate, but offers no benefit in prevention of neurologic injury or perinatal mortality...
...Notwithstanding these developments, many lawsuits still involve allegations (and rebuttals) that the obstetrician either failed to recognize or act upon abnormal FHR patterns and that failure resulted in perinatal brain injury that could have been prevented.
Translation: the real reason we use EFM is not because it improves outcomes, but because it reduces medicolegal liability.
I understand why that's done, but I wouldn't pretend it's scientifically based.
"[We] resort to EFM as the primary screening test for intrapartum fetal asphyxia because of the limited predictive value of any other clinical risk factors during labor-including auscultation... EFM permits continuous accurate monitoring, permits using the fetus as its own control, evaluates tolerance of a fetus to stress of the individual uterine contraction, and permits the diagnosis of potentially catastrophic events in a timely fashion... There is no example of hypoxia or death on a monitor without warning. It provides a permanent record, subject to later review. With regard to auscultation, there is no study that supports the contention that auscultation is a reliable determinant of the fetal condition or of the need to intervene. Even those who find EFM useless for the purpose of preventing injury or death concede its ability to detect fetal hypoxia."
Right. So there are a lot of reasons to *expect* EFM would be a useful alternative to auscultation, but when we actually look at the outcomes we don't find a difference. Surprising, but that's what the studies are telling us.
" Despite the persisting debates over its role and benefits, it is likely that EFM will remain a standard part of obstetric care for the foreseeable future. As such, it will also remain a focus of attention in obstetric negligence lawsuits.
Translation: Even though there's no clear evidence of benefit, we're going to keep using it. This will help protect us from the lawyers.
Like I said, I understand the practical aspects of the approach but it's not defensible *strictly* on the basis of the available evidence for medical benefit.
FYI, as long as you keep posting things that make you sound like a stringer for the National Enquirer, the very unsubtle sexual (vaginas? Cosmo articles?) and/or otherwise sensationalist stuff (fetal parts? thousands die?) you've been offering your readers lately, I'll keep making comments reminding you that trash news disguised as authoritative medical discourse is behavior unbecoming.
How massive? Perhaps ..... a 100% death rate? Leaving out epidemics, which don't have much to do with medicine and a great deal to do with public health measures, the death rate around the world is pretty steady: one death per person. Guaranteed. Maybe sooner, maybe later -- and almost always sooner than we want -- but one each.