M EDI C I N E
THURSDAY, AUGUST 13, 2015 • THE BULLETIN
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'Atei.native Me icine' a es on't mattei. T e science oes. By AaronE. Carroll • The Net York Times
he University of Toronto recently stirred up a bit of controversy by offering an uncritical
dass on "Alternative Medicine." A variety of bloggers and journalists brought up many valid concerns about the curriculum, but there is a much larger problem: No one is sure how best to teach that subject.
The dichotomy, however, between alternative and traditional medicine, or between Eastern and Western medicine, is a false one. We would be much better off if we could reframe the issue. People often think of Eastern or alternative medicine as more "natural." Many feel that Western medicine is built around technology and products produced in a lab. They' re not entirely wrong. Many of the gains that have been made in traditional medicine have been the result of innovation in laboratories. But that doesn't mean that
COMMENTARY everything doctors are taught in medical school involves a drug or device. I talk to pa- chronic pain. They found tients all the time about diet that not only did acupuncture and exercise. I don't do this work better than no-acupuncbecause there's a company ture control groups, but there making money off it. I do it were also significant differbecause both of these things ences between acupuncture have been proven to be im- and sham acupuncture. This portant for health. suggests that not all of the Nor do all medications get benefitsare placebo effects. cooked upin a lab.We recomPeople have been treating mend folic acid, which is a B many mental health problems vitamin, for pregnant women with therapy for years. Full because research has shown disclosure: I'm one who has that it reduces the risk of ma- been treated. I' ve never takjor birth defects in newborns. en any of the long-term psyWe all know that adequate chotropic drugs, and many intake of vitamin C prevents scurvy and that vitamin D prevents rickets.
patients prefer not to if possible. Austin Frakt, my Upshot
co-contributor, wrote recently about the evidence supporting controversial to p h y sicians. cognitive behavioral therapy We recommend them all the for insomnia, as well as for a time. That's not because they host of other health problems. None of these things are
were developed in the West-
Even mindfulness, or medita-
ern Hemisphere. It's because tion, has been studied extenthey have been subjected to sively, and found to be pretty the rigor of scientific inves- effective in treating anxiety tigation — and found to have and mood problems. I' ve been merit. convinced enough by this T here ar e
m a n y o t h e r evidence to t r y
m e d itation
forms of n o ntechnological myself. medicine that have the weight I would argue that all the of scrutiny behind them. In a therapies I mention here armeta-analysis published just en't considered complemena few years ago, researchers tary therapies — they' re oflooked at all the accumulated ten just considered therapies. randomized controlled trials That's because they' ve been examining how acupuncture studied, and they' ve proved to fared in treating people with work. Too often, though, those
Scorecards Continued from 01 ProPublica reporter M a r-
shall Allen said he believes the general public can understand Surgeon Scorecard's limitations. "It's a starting point for much more mean-
ingful conversations with doctors," he said. Patients should ask, "What's your total com-
plication rate?" He continued, "You know what's crazy is a lot of these
people don't even really know. A lot of surgeons do not track their complications."
St. Charles Health System and Bend Memorial Clinic each track complication rates
and are willing to share data on doctors who appear in Surgeon Scorecard. Only one local doctor, Timothy Beard, was deemed to
have a "high" complication rate for gallbladder removal in Surgeon Scorecard. But
Surgeon Scorecard's rate was based on 26 procedures, the number of in-hospital surgeries Beard performed on Medicare patients. With such a
Edel Rodriguez/The New YorkTimee
The dichotomy between alternative and traditional medicine is a false one. The value of a treatment, regardless of origin, should be whether it has been subjected to the rigor of scientific investigation and found to have merit.
s m all s am-
ple size there's a chance that Beard's overall complication rate is actually "medium," and
it's possible it could be "low," according to the database. Cochran, the statistics profes-
sor, doubted that most people would understand the nuance. "They' re not going to understand how l i ttle confidence
we really should have in this result."
Most gallbladder removal surgery is out-patient, and Pro Publica will update Surgeon Scorecard to reflect those larger numbers, Allen said. It could make a difference for
Too often, though, those who consider themselves supporters of alternative medicine disdain the idea that any of their
munity refuses to change its tension-type headaches, that behavior. My Upshot articles acupuncture and acupressure are littered wit h e x amples didn't reduce pain caused of this, including potentially by HIV-related peripheral treatments need to be studied. They make too-widespread mammogra- neuropathy and that the supphy screening, advanced life plement Garcinia cambogia an appeal to the fact that their medicine is and many surgical did not help with weight loss. more natural; has been used for long periods support procedures. Supporters of However, the same issue conof time; or has the support of many people in Western medicine are often tained studies that showed blind to their own prejudices. that yoga-based interventions other cultures. Butterbur, a plant extract, improved carpal tunnel synhas been found in m edical drome more than wrist splintwho consider themselves sup- forms o f co m plementary studies to be as effective as ing, that the Chinese practice porters of alternative medimedicine as ineffective. Just antihistamine s i n t r e a ting of moxibustion significantly cine disdain the idea that any a few months ago, the ¹ allergic rhinitis, without the increased fetal activity and of their treatments need to be tional Health an d M e dical sedatingside effects conven- fixed breech presentations bestudied. They make an appeal Research Council of Austra- tional drugs often have. Horse fore delivery and that Chinese to the fact that their medicine lia released a report in which chestnut seed extract appears herbal medicine appeared to is more natural; has been used it fully reviewed 225 studies to be safe and effective in improve symptoms in some for long periods of time; or has of homeopathy, the practice the short-term treatment of patients with irritable bowel the support of many people in of treating sick people with chronic venous insufficiency. syndrome. Although some of other cultures. small amounts of substances Peppermint oil can be used this research has been continOf course, not long ago, all that cause similar symptoms to relieve the symptoms of ued, to my knowledge neither therapies could be described in healthy people. They found irritable bowel syndrome. I sideofmedicine has changed in this way. The application no well-designed studies that know of few physicians who p ractices o r b e l iefs m u ch of modernscience allowed us found it to outperform a pla- promote these therapies as based on this work. In an accompanying edito devise and conduct trials cebo or function as well as often as they do prescription that could prove or disprove a any conventionall y approved or over-the-counter drugs. torial, Phil Fontanarosa and treatment's efficacy or harm. therapies. Their conclusions Granted, that could be b e- George Lundberg, two of JAMany of the drugs we use to- echoeda previous reportfrom cause it's potentially hard to MA's editors, wrote: "There day had natural origins. Dig- Britain, and those found in be sure of supplements you' re is no a l ternative medicine. italis comes from foxglove, many Co chrane systematic buying, but there are ways to There is only scientifically quinine from cinchona bark, reviews. overcomethoseproblems. proven, evidence-based medpenicillin from bread mold My friends who believe in In 1998, The Journal of the icine supported by solid data and aspirin from willow tree homeopathy don't really care. American Medical Associa- or unproven medicine, for bark. Conventional medicine Those who favor conven- tion published a theme issue which scientific evidence is may have improved our abil- tional medicine, though, can on alternative medicine for lacking." ity to purify these substanc- be just as blinded. Too often, common c h r onic m e d ical I'd change this only by addes, but it acknowledges that w hen confronted with e v i - conditions. The randomized ing, "There is no conventional many natural therapies hold dencethat advanced technol- controlled trials within it of- medicine." value. ogy might not be providing fered evidence that s p inal Yet science rejects many benefits, the m edical com- manipulation did not improve
Beard, who did 190 gallblad- patient readmissions at 3,004 der removals at Bend Surgery hospitals and found that high Center over the same time surgery volume and low morframe considered by ProPubli- tality rates are associated ca, 2009 through 2013, and with lower rates of surgical had just two complications, a readmission. rate of I percent, BMC Chief ProPublica points out in Medical Officer Dr. David Hol- a paper on its methodology loway said. that among the readmissions Holloway said he would fa- counted in Surgeon Scorevor making BMC's doctor-spe- card, the average length of cific performance data public. stay is five days, "more than "I think that's where all of this one would expect if a patient ends up, with total transparen- was simply hospitalized as a cy," he said. "Where I would precaution." like to see us go over the next Holloway supports transseveralyears isto become re- parency of quality metrics, ally transparent in a way that but he said a single doctor makes sense to the public." shouldn't shoulder the responSurgeon Scorecard also sibility. "The state of medicine prompted executives at The anymore, it's really a team Center, an o r t hopedic and sport. Things are so complineurology specialty practice, cated, it really is a team." to consider whether to publiDoctors have also worried cize its outcomes. "What can that ratings will discourage we publish that will be useful them from taking on difficult for the general public?" CEO cases. Mike Gonzalez said.
Dr. Kathleen Moore, an or-
The medical community thopedic and spine surgeon has also blasted ProPublica for with Desert Orthopedics, is trying to measure surgeons' one ofseveral local doctors performance from Medicare doing lumbar spinal fusion, billing records on hospital re- and whom Surgeon Scorecard admissions. Gonzalez pointed listed as having a "medium" out that one of The Center's complication rate. Moore said surgeons, Dr. Timothy Bol- the database doesn't reflect lom, had three complications the fact that she and her partamong 187 Medicare patients ner are the only local doctors undergoingknee replacement, who take on complex scoliosis a rate of 1.6 percent. Further- cases. more, Gonzalez said, two of She said many of her pathose patients were readmit- tients are older, and that ted for fever, something that' s leaves them prone to complinot necessarily related to cation, but their other option surgery. is to live with a lot of pain, Despite doctors' complaints, and possibly heart and lung hospital readmission rates problems, she said. "It really continueto be used to measure skews the data tremendously quality, and a study published when you have practices that in the New England Journal of are very different," Moore Medicine in September 2013 said. "Those physicians who supports that practice. The au- are willing to do the toughthors looked at nearly 480,000 er work are going to look
worse."
data that's even more reliable
And comparisons among doctors who are all ranked in the same category may not mean much in Surgeon Scorecard. All of the local compli-
than Medicare billing records.
cation rates for lumbar spinal
fusion were based on 30 or fewer surgeri es. Moore said
"We know there's other data
out there, held by the American College of Surgeons," she said. "It's not available to the public." — Reporter: 541-617-7860 Izmclaulzhlin@bendbulletin.corn
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she does 75 to 100 fusions per
year.For alltypes of surgery, she said, her complication rate is around 2 percent. Dr. Darrell B rett, w h om
Surgeon Scorecard listed as one of the best-performing spine surgeons in Oregon, doesn't have a problem with the Surgeon Scorecard. "They have a right to know," he said of patients.
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Brett said he doesn't do sco-
liosis cases."However, I do a lot of difficult reoperations," on people who had prior surgery with a different doctor, Brett said in an emaiL He added, "I take all-comers so I cer-
tainly don't 'cherry pick.'" On his website, Brett says
he does about 750 spine surgeries a year, mainly on the lumbar and cervical spine with "clinical outcomes" in the
top I percent of national peers and an infection rate of less than.01 percent.
Doctors are extremely competitive, yet they' re sensitive
to being called out, said Doris Peter, director of Consumer
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Reports' Health Rating Center. Even within institutions, it
can be controversial to share individual performance data,
she said. Peter applauded ProPublica for shedding light on what many people have suspected, which is that individual doctors affect patients' outcomes.
She hopes it will push the medical industry to release
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