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Hi, I’m responding to S. Simon’s questions, placing this interesting tangent in perspective with M. MacDougall’s original question, and then returning us to our regularly scheduled EBM programming! :- ) [2 min read time (add post script = 5-7 min read time)] First, I really appreciate questions. Restated, I will attempt to summarize them as: A) What do I mean by “other ways of knowing”? B) Should CAM therapies like acupuncture be evaluated differently (i.e. not by RCT) or be held to a different standard of proof? In the interest of brevity, I’ll clarify these briefly and provide an in depth explanation as a post script. . 1. With respect to the second question “B,” I argue that - from an allopathic point of view - any CAM therapy/method should be evaluated with the same rigor as anything else we use in scientifically informed practice. Using “some other standard” would be axiomatically hazardous. In short, use the same yardstick! 2. With respect to the first question “A,” the short answer is this: the yardstick doesn’t measure everything we care about as people. *IF* one accepts that premise, then “ways of knowing” is linguistically the best way philosophers have to non-judgmentally compare axiomatically distinct viewpoints (or epistemologies: http://en.wikipedia.org/wiki/Epistemology) of the universe. For example, chi is an entirely different starting point than, say, the atom or F = MA. And I apologize if the way I phrased “…only saying how well it fits” either belittled the importance of evidenced based medicine or suggested some alternative be used to inform allopathic practice. Absolutely not! (And incidentally, I claim no opinion about which study methods best address CAM or when we can say “enough is enough” e.g.,Echinacea, how many negative trials do we need??). My original message was motivated by my belief that - just because much of CAM is unsupported by evidence (and therefore rightfully viewed skeptically if not dismissed outright in evidence-based practice) – it does not mean ipso facto that it is *universally meaningless.* And, I recognize that this argument is not without its critics. And, I detail below that most clinicians already practice with this philosophical plurality in mind whether we recognize it or not. “Art and science of medicine” anyone? And tying this to the original question, which (I’m liberally rephrasing…) is what is EBM’s perspective on CAM? EBM approaches CAM the same way as it does mainstream allopathic medicine: it is studied, graded, and synthesized as people like Sackett et al and others have so well outlined. Outside of this frame, I’ll glibly say EBM usually does not or cannot have a perspective on CAM. (see below) So, with all due respect, I was struck funny by the original question: because for me, this is kind of like me asking my car mechanic for marital advice. (Or asking my math teacher’s advice on my literature homework) Appreciate the dialogue, Patrick --------------------------------------------------------------------------------------------------------- ****Post script: Read on if you’re bored, interested, or otherwise****** --------------------------------------------------------------------------------------------------- Herein I’ll provide a more detailed caution about “universal truths.” And again, this will apologize for any perceived lack of distinction I made between maintaining logical rigor within scientifically informed allopathic medicine and necessarily limiting the scope of our logic. (And speaking about abstractions is inevitably dense.) First, we should expect rigorous logic in medicine. And I view the torch of “evidenced based medicine” as the collective force for that logic, gaining deep facility with the hypothetico-deductive model as K. Hopayian cites, thinking critically about relative utility of tools like RCTs vs. case studies vs. contemporary elaborate variations on the theme of prospective cohort as S. Simon has done. I suspect no one in this audience needs to be convinced of Newtonian science and EBM’s power for understanding observable phenomena within our natural universe. However at least intuitively, most of us recognize that this does not explain “everything” that makes our living experience meaningful. More simply stated, we don’t pretend to be able to know everything about everything. As a clinician, I see this every time I see a patient. I understand the evidence behind epinephrine and direct current for cardiac arrest; but I do not demand the same explanation for why one person wishes for this therapy in the future and another declines it. I don’t ask them to “prove it to me.” But, more often than not, these logical distinctions become implicitly compartmentalized, conflated, or simply ignored. Understanding why that second person would not want to be resuscitated from a cardiac arrest might appeal for “…another way of knowing.” We would use the same distinction as we would for my more hyperbolic example of “love” and arithmetic “pi.” So, what is the implication of utilizing the hypotheticodeductive model to assess something like acupuncture? (At the risk of being flippant), again this exercise tells us if acupuncture “fits” or not. If it doesn’t fit, then we say acupuncture has no evidence of measurable efficacy. And as a clinician, I will not view it the same way I do NSAIDs or back surgery. But our practice hints at disquieting realities beyond the scope of deduction, like the lack of relationship between urinary flow and perception of symptomatology between two different men with benign prostatic hypertrophy. One man’s ‘okay’ is another man’s misery. Medical practice continually gives us hints that life, death, and health in between are not perceived equally for all. And this lives under banners like “bioethics,” “the art of medicine,” “medical humanities” and the like. Simply stated, when we use the cliché “art and science,” we are crudely acknowledging “other ways of knowing.” (And – from my last post - even math and the natural sciences may look beyond the deductive / reductionist model – e.g. chaotic behavior, complex adaptive systems, quantum entanglement, etc.) So, when a patient presents to me with back pain or some other condition, I will continue to offer them evidence-supported opinions that are grounded in the allopathic tradition. And – avoiding the hazards of abstractions – I’ll usually frame my response to the CAM question (like acupuncture) this way. “If it makes you feel better (or healthier) then I’m certainly happy for you and support *your* health goals. (…adding my caveats) But, I’m not an expert in that healing tradition. And I do think it’s important that we continue to see and work with each other for “X” condition (and add any other concerns if there are possible CAM harms etc.) ” Because in the end, things like acupuncture were never designed to affect a scientifically measurable outcome, just as penicillin wasn’t developed to mediate an imbalance between yin and yang. Outside of discovering new remedies, like ACE inhibitors, tamoxfen, and even honey for pediatric cough, using CAM – especially well established epistemologies tradition like traditional Chinese medicine -- and EBM in the same sentence is a comical non sequitur. So restating the highlights: 1. I argue that other philosophies do not replace the logic of scientifically informed allopathic medicine. 2. We can and should subject everything we do as allopaths to logical scrutiny, supporting our scientifically informed practice: foxglove becomes digitalis vs. homeopathy becomes…mostly water. (“Yes, I know grandma or Nurse Nelly ‘in her experience’ thinks simethicone works for your baby’s gas. Well, it doesn’t.”). 3. Newtonian science, the hypotheticodeductive logic, etc does not provide universal truth. And, while I’d need an expert in philosophy to provide backup, I’m rejecting outright the notion of universal truths. (Some ardent atheists or religious fanatics are not on board with this, I realize.) BOTTOM LINE: The trick in medicine is knowing when something is beyond the scope of science, when I’m being asked about “love” and not about arithmetic “pi,” when I can provide allopathic guidance or therapy and when I can’t, because I’m not a shaman, preacher, mother, or best friend. And that’s what I practice J >>> "Steve Simon, P.Mean Consulting" <[log in to unmask]> 9/25/2012 1:55 PM >>> Patrick Burke writes: > By evaluating Chinese medicine like acupuncture with deductive logic > like RCTs, _we are really only saying how well it fits within that > way of knowing_. This is an interesting comment to make on a list about evidence based health. I'm well aware of the limitations of clinical trials, and I got a bit of flak when I wrote in my book that randomization is overrated. I have also argued quite forcefully on this list that the hierarchy of evidence is often applied too rigidly. But quite honestly, I worry about what people have in mind when they talk about other ways of knowing. If you propose that acupuncture might be evaluated without RCTs, what did you have in mind? And would that method of evaluation apply only to acupuncture, or would it be an appropriate way of evaluating traditional medicine as well. To ask the question in a different way, should acupuncture have a different standard of proof than, say, the use of beta blockers. If so, why? Steve Simon, [log in to unmask], Standard Disclaimer. Sign up for the Monthly Mean, the newsletter that dares to call itself average at www.pmean.com/news IMPORTANT WARNING: The information in this message (and the documents attached to it, if any) is confidential and may be legally privileged. It is intended solely for the addressee. Access to this message by anyone else is unauthorized. If you are not the intended recipient, any disclosure, copying, distribution or any action taken, or omitted to be taken, in reliance on it is prohibited and may be unlawful. If you have received this message in error, please delete all electronic copies of this message (and the documents attached to it, if any), destroy any hard copies you may have created and notify me immediately by replying to this email. Thank you. 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