Friday, March 20, 2009

Why NCCAM Reminds Us of Tampons

Women older than, say, fourteen will recognize this scenario:

You're off to school or getting ready to meet friends at the mall or are otherwise engaged in something consuming every ounce of your attention. Suddenly the metaphorical phone rings. It's Aunt Flo! She's letting you know she'll be by a little sooner than expected. You make a quick search of your bags and the bathroom only to realize that you're out of Aunt Flo's favorite euphemisms. So it's a mad dash to the grocery store ASAP.

Standing before a wall of pastel colored feminine protection on isle three, you grab the box you want and head for the checkout.

But wait! Strangely, everyone in the store seems to be glancing in your general direction. A voice overhead announces, "Attention shoppers. Look 'n LOL on isle three. Eighth grade girl getting her period. OMG, how embarrassing! HAHAHA!"

Ok, maybe that part doesn't actually happen.

You have a plan. You put the box of tampons back on the shelf and get a shopping cart. You grab a loaf of bread, a roll of paper towels, a bag of candy, and that box of tampons.

Ah, so much less obvious now. Clearly you're not necessarily getting your period. You might just be picking up a few things for the house.

Homeopathy, subluxations, and energy healing are nutty ideas. Standing up for these notions in a room full of scientists should provoke a sense of mortification, not unlike the embarrassment of a young teen holding onto a box of tampons in public.

Little wonder then, that the CAM proponents of NCCAM defined their scope of practice as somehow including a number of reasonable therapies alongside the wacky bits. Herbal remedies, dietary supplements, relaxation methods such as yoga and meditation are examples of the more reasonable topics commandeered by NCAAM.

Yes, much to the irritation of the pharmacognozy, nutrition, and medical psychology communities, history has been re-written such that none of this stuff was ever studied pre-NCCAM.

How depressing.

The recent NCCAM debates around the blogosphere fit this pattern:

1. Someone says NCCAM causes more harm than good by promoting quackery.
2. Someone else says that lots of Americans spend money on alternative medicine, so we ought to be studying it.
3. The first party feels the second party doesn't get it.

What's going on? Why is communication so difficult?

I think that awful word "alternative" is to blame. It's defined in such a ways as to mire us all in confusing equivocations. It's defined by what it is not: something called "conventional medicine." And conventional medicine is defined as those therapies with evidence of safety and efficacy. But this dichotomy doesn't really work.

Are all therapies lacking evidence of safety and efficacy "alternative"? No, for that huge set would include everything from novel chemotherapy strategies to new surgical devices and more.

Are all treatment decisions by medical doctors based on evidence of efficacy and safety? Not entirely. There's a tremendous amount of trial-and-error within medicine. Group data apply imperfectly to individuals. Even so, the process of starting and stopping trials can be justified rationally, or not. And irrational justifications are very much frowned upon on the conventional side of the fence.

So what separates the conventional world from the alternative world? Not herbs or yoga or meditation or dietary supplements. No, the real fight is more fundamental. The real fight concerns how we set the boundary between that which is plausible and that which is implausible. One side sees this as a political question. The other sees this as a function of the scientific method.


  1. Instead of "conventional" or "mainstream" (or, of course, "Western"), how about "Proven?"

    What are now usually called "alternative" could, in fact, belong in the category of "proven," provided that they have been tested rigorously.

  2. What do we call the many therapies presently under study in all areas of medicine? All the novel chemotherapy regimens? All the new surgical procedures? The new behavioral interventions? Are these "alternative" because they haven't been sufficiently proven to be generally accepted by the medical community?

    Outside of research settings, conventional doctors often try new, uproven therapies for individual patients, provided that

    1. there's no proven therapy available
    2. access to a clinical trial isn't practical
    3. the unproven therapy makes sense
    4. someone else has already tried the unproven therapy and documented benefit in at least one similar case.

    Example: a patient can't tolerate an appoved SSRI for OCD so another SSRI without an OCD indication is selected. Based on our current understanding of the brain, there's no a priori reason to believe the second SSRI should be less effective than the first, as both do the same thing in the body.

    A lot of medical practice remains trial and error. So we can't cleanly separate CAM from medicine on the basis of "proven" and "unproven."

    I'm arguing that CAM and medicine are distinguished thusly: prior plausibility based on science verses prior plausibility based on politics.

  3. Dr B,

    I love your "tampon" essay and I agree with your distinction between pp based on science and pp based on politics. Many in both the "conventional" and "CAM" camps, however, have either not thought about pp at all or have dismissed it because they've been convinced, by the pp lacuna in EBM, that clinical trials always trump pp. For a spectacularly wrong view of this, look at the quotation of Edzard Ernst here (under "Mr. Magoo"):

    That post is the last of a series on pp, EBM, and 'CAM' that began here, albeit with a different title:

    BTW, for yers truly's definition of "CAM," look here:


  4. Dr. A,

    Your critique of naturopathy is perfect cogent rage. Reminds me of Samuel Jackson in Pulp Fiction:

    "And you will know I am the LORD when I lay my vengeance upon you."

    Why aren't those fuckers on the floor bleeding?

    Why didn't you win?

    Heh. Humans, I reckon.

  5. Or, being the 16 year old boy, just having gotten his driver's license, and being sent to the store by Mom to pick up a box of tampons.
    You grab a couple other things as well, and hope none of your buddies is at the store.