A little over a month ago, I wrote about how proponents of “complementary and alternative medicine” (CAM), now more frequently called “integrative medicine,” go to great lengths to claim nonpharmacological treatments for, well, just about anything as somehow being CAM or “integrative.” The example I used was a systematic review article published by several of the bigwigs at that government font of pseudoscience, the National Center for Complementary and Integrative Health (NCCIH) about CAM approaches for the management of chronic pain. You can read my whole post for yourself if you want the details (and read Edzard Ernst and Steve Novella for more), but the CliffsNotes version consists of two main points. First, the review didn’t really show that any CAM approach worked, given how the authors included so many studies with no placebo or sham control and didn’t systematically assess the quality of the studies. Second, this study is the best publicized example of how NCCIH, looking for a reason to justify itself, has latched on to the opioid addiction crisis in this country and gone “all in” with CAM for chronic pain. Of course, the problem is that none of the real “alternative” treatments show any convincing evidence of efficacy; so NCCIH has to claim exercise (in the form of yoga and Tai Chi, for instance) and various other modalities that aren’t really “alternative” as being part of CAM. True, the authors did try to claim that acupuncture works for back pain and osteoarthritis of the knee, but the flaw of including mostly studies with no placebo/sham control completely undermined that claim. Basically, taken in its entirety, the NCCIH’s systematic review failed to find convincing evidence that any CAM therapy really works for chronic pain.
So I wrote my post, noting also how this review article and its framing of CAM as equivalent to any nonpharmacologic treatment were clearly in line with the last two NCCIH strategic plans, perused the comments our readers left, and pretty much forgot about the study, because fortunately, it didn’t seem to get much traction. (Releasing it right before the Labor Day weekend probably didn’t help NCCIH much.) However, there is one person who did not forget, and that person is John Weeks. Last week, he published a response to the criticisms of the NCCIH review in the Journal of Alternative and Complementary Medicine (JACM) entitled “Polarization-Based Medicine: Protests Against the Mayo-NCCIH Pain Guidance Evoke the Bigotry of the Political Season.”
As they say, it’s on.
Meet the new editor of JACM
About a month ago, I received by snail mail at work a letter from a reader. Now, as I frequently say, it’s rarely a good idea to send me a snail mail at work, at least if you hope for any response, because it’s frequently several days before I see it, sometimes longer, and I don’t generally respond to such messages because it’s kind of a pain. However, this letter intrigued me. It was someone pointing out an announcement by Mary Ann Liebert, Inc, the publisher of JACM, about the new editor of the journal. That editor is John Weeks. (A PDF of the flyer is available online here.) The announcement reads thusly:
Mary Ann Liebert, Inc., publishers is pleased to announce that John Weeks will assume the role of Editor-in-Chief of The Journal of Alternative and Complementary Medicine, effective immediately. John has been deeply imbedded in this field in many capacities for over three decades – see his brief bio below – guiding and stimulating dialogues and initiatives in multiple areas, including research.
John is a present or past colleague of many of our authors and on JACM‘s editorial team. He is developing a core group of editors who will join him in guiding this next phase while ensuring that the Journal continues to maintain a high level of quality and integrity in the peer-review process. Among these will be Richard Hammerschlag, PhD; Heather Boon, BScPhm, PhD; Peter Wayne, PhD; Aviad Haramati, PhD; Leonard Wisneski, MD; and Pamela Snider, ND. Our Managing Editor, Susan Jensen, will remain in her role to ensure continuity.
Some of you may recall that at the banquet night of the 2014 International Research Congress on Integrative Medicine and Health in Miami, John was the recipient of a Lifetime Achievement Living Tribute award, complete with a book of testimonials from 150 leaders. In one, Josephine Briggs, MD, the director of the NIH National Center for Complementary and Integrative Health, called John “a provocative voice, but a welcome one, one of the most insightful in current healthcare discussions.” We are excited to have his voice, experience and growing network on board to shape this next phase for JACM.
“Provocative”? I’m not sure that’s the word I would have used. My choice would have been a word like “telling.” Why telling? Well, first JACM is a CAM journal. If the publishers wanted to try to convince people that CAM is legitimate from a scientific standpoint, you’d think that they’d have chosen someone in CAM who at least has some scientific credentials. Lorenzo Cohen and Barrie Cassileth, for instance, come to mind. They didn’t. Instead, they promoted a full-throated booster of CAM who describes himself on his blog as a “writer, speaker, and change agent.” More importantly, Weeks has no discernable scientific or professional background relevant to being Editor-in-Chief of a biomedical scientific journal. Sure, he clearly has the skills to edit a magazine, but being the editor of a scientific journal is not the same thing.
Of course, maybe this is appropriate. After all, JACM, being a CAM journal, isn’t really a scientific journal at all. It’s more like a tooth fairy science journal, and I expect that it will become even more so under Weeks’ leadership. So, in a way, I guess appointing Weeks as Editor-in-Chief isn’t as crazy as it sounds on the surface. The journal wasn’t scientific to begin with; so a physician or scientist wasn’t required. Just look at a few of the headlines under Featured Press Releases and Editorial Content:
You get the idea. Good science was never a major concern at JACM. No doubt what Mary Liebert, Inc. sought in Weeks was his promotional skills, given that the 2015 Impact Factor of JACM is only 1.395. It’s a bit misguided, though. The Impact Factor, as imperfect as it is, estimates how influential a journal is by how many times other scientific journals cite its articles. The way to get a higher impact factor is to publish better, more interesting science. On the other hand, given how CAM works, maybe all it requires is publishing more…interesting…CAM articles, regardless of the science.
In any case, Weeks and I (and many other skeptics) have a bit of a history. He has not liked some of the things I’ve written about CAM in the past. Indeed, he singles out in particular this post I wrote about his defense of alternative medicine. To get a taste of where he’s coming from, it’s worth citing the article I criticized:
The movement from “alternative” to a new language of “complementary” and “integrative” when it arrived in the mid-1990s was partly what would, on the street, be called a “suck-up” gesture. I participated, and still do. We were trying to find a way to play inside the power-centers of the juggernauts, world views, and abiding priorities that daily generate the BMJ outcomes.
You see, Weeks likes the term “alternative,” although he tried mightily to redefine it to something different than what it had always meant: Medicine outside of the mainstream of medical practice, in essence medicine not scientifically proven to work or scientifically proven not to work. Rather, he wanted the “alternative” in “alternative medicine” to mean an “alternative” to the way the business of medicine runs now. Good luck with that reframing. Once a word comes to have a meaning, it’s devilishly difficult to change it.
He also mentioned his impending appointment, although from the context it appears that he hadn’t accepted yet:
I was asked a month ago, out of the blue, if I would like to become editor-in-chief of the first peer-reviewed, indexed journal in what is now the “integrative health and medicine” field. The journal was born 20 years ago when — as my father would have put it — “integrative medicine” was hardly a gleam in anyone’s eye. The publication is the Journal of Alternative and Complementary Medicine.
I was told that renaming is on the table. Do we keep the name as is? Do we add “integrative”? Do we, as a federal research agency and an academic collaborative have recently chosen, lose the “alternative”?
Amidst the politics of pleasing Father — or not — what do you think says it best? Do we want an “alternative” to our present way of doing business, and prioritizing treatment?
I do like how Weeks admits things about integrative medicine that I’ve been saying all along, such as how it’s a marketing term more than anything else. It reminds me of what Glenn Sabin says about integrative medicine, how it’s a brand, not a specialty. Of course, he doesn’t say these things the way I say them, and he says them as though they were a good thing when they are not.
So what’s eating Mr. Weeks about the reaction to the NCCIH review on chronic pain?
In which SBM advocates are likened to Donald Trump…
Mr. Weeks is upset. He’s so very, very upset at criticism of the NCCIH review on CAM approaches to chronic pain. He lets us know this right at the beginning of his article when he tells us that colleagues were asking him why on earth he would write such an article, becoming more than a little pretentious in the process, when, after having quoted Robert Graves’s poem To Lucia at Birth, he writes:
Why would I give any measure of visibility and credence to the transcontinental vitriol that greeted a September 1, 2016, pain guidance from the National Center for Complementary and Integrative Health (NCCIH) at the U.S. National Institutes of Health (NIH)? The language and approach of this antagonism to anything “complementary” or “integrative” or “alternative” would seem to have come from the same playbook as the U.S. presidential campaign season this year. General consensus is that no U.S. campaign has ever been as polarized, riddled with lies and half-truths, punctuated by namecalling and bigotry, or as hateful as the campaign for the presidency of Donald Trump.
The ugly tenor of the nominally scientific dialogue of these unrelenting opponents of the NCCIH reminded me of this centripetal pulling apart of civil discourse in the present political battle. The parallel is all the stronger because the stakes, in both arenas, are so high. For instance, we have a “war” against opioid addiction that, as I shared in my last column, could be moderated via enhanced collaboration.
Ah, yes, the time-honored political practice of drawing oneself up straight and portraying oneself as above the fray (the bit about his colleagues asking him why he’s bothering to respond), expressing indignation at the insults coming from one’s opponents and then throwing back similar insults; e.g., comparing them to Donald Trump and accusing them of nasty tactics. Yes, I do routinely refer to The Huffington Post as that “wretched hive of scum and quackery.” It’s a bit of an in-joke that I’ve used many times. Any Star Wars fan would recognize the exact scene that line riffs on. Truth be told, I have been thinking of no longer using that line, at least no longer applying it to HuffPo. Compared to its founding and several years after, HuffPo hasn’t been nearly as bad when it comes to promoting quackery and antivaccine pseudoscience as it was several years ago, a history that led me to portray HuffPo as being at war with medical science.
One thing I couldn’t help but notice Mr. Weeks, for all his protestations otherwise, is pretty good at the political name calling game. He even admits that that’s what he’s doing:
While the most outspoken group of detractors in the United States dubs its outlet “science-based medicine,” I have chosen in my writing to reference them only as “polarization-based medicine.” The good news is that there are recent models of respectful scientific dialogue between NCCIH and some who don’t always agree with the agency’s promulgations.
With Mr. Weeks’ indignation at all the nasty name calling dealt with, along with his decision to engage in the same, let’s move on to the substance, if it can be called that, of his complaints.
The (quackademic) empire strikes back
Reading Mr. Weeks’ piece, I became acutely aware of the need to disabuse him of an idea he seems to have, namely that all of his critics are somehow linked to this blog. His introduction speaks of SBM, but then his first volley of self-righteous fury is directed at, well, take a look:
Here is a taste of the response. An Australian medical doctor immediately characterized the synopsis as “one of the most blatant examples of quackacademic confabulation I have seen in ages.” (The pejorative is a favored description of the scientists who are members of the Academic Consortium for Integrative Medicine and Health, and elsewhere around the world, who are integrating complementary and integrative approaches into their research, education, and in some institutions, clinical practices.) The members of the NCCIH team are portrayed by the same writer as “sincerely deluded cranks.”
Actually, no. Mr. Weeks doesn’t know what he’s talking about. In actuality, “quackademic” medicine is a far more general term than that, originally coined by Dr. Robert W. Donnell in 2008 to describe the infiltration of quackery into medical academia, both research and education. As such, the term describes much, much more than merely ACIMH members; it describes a general phenomenon. This brings me to another aspect about Mr. Weeks’ article, and that’s his refusal to name those criticizing him. Come on, Mr. Weeks. That’s just childish. I name you when I criticize something you wrote. You could at least do me (not to mention the two others you criticize) the same courtesy. I mean, seriously. One of the critics of the NCCIH review was Edzard freakin’ Ernst, for cryin’ out loud! There is no critic of CAM more well-known than he that I’m aware of.
In any event, the article Mr. Weeks quotes was written by Michael Vagg, Clinical Senior Lecturer at Deakin University School of Medicine. He’s also a bona fide pain specialist, a Fellow of Australasian Faculty of Rehabilitation Medicine (RACP) and a Fellow and Board Member of Faculty of Pain Medicine (Please can we give up on complementary, alternative and ‘integrative therapies’ now? carries considerable weight. It’s also a very good article. One wonders if he’d be willing to do a post or two for SBM on science-based pain modalities. (Hint, hint, Dr. Vagg, if you’re reading this.)
Yet another irritating aspect of Weeks’ article is that nowhere does he actually convincingly rebut on substance anything that any of us has written. His entire article is primarily one massive piece of tone trolling. For instance, about my post on the NCCIH article, Mr. Weeks writes:
In a separate column, the same USA academically based surgical oncologist noted above dismisses the NIH’s guide from the 105 RCTs as “tooth-fairy science.” He condemns the process by association: two of the NIH’s team, each with research doctorates, were separately educated as doctors of chiropractic and naturopathic medicine, respectively. He writes, “If you want to know why NCCIH supports so much pseudoscience, look no further than it having chiropractors and naturopaths in high ranking positions.” He restates his definition of “integrative medicine” as “integrating pseudoscience and quackery into medicine.”
Notice the logical fallacies, such as the appeal to authority. It’s the NIH team. How dare I criticize its results? Yes, I did mention chiropractors and naturopaths, but, unlike the impression that you get reading Mr. Weeks’ criticism, you’d think that was all I did. In fact, those were small parts of my post cherry picked by Mr. Weeks while he ignored all the substantive criticisms I had about the article. Notably, Mr. Weeks can’t rebut and doesn’t even mention a single one. Yes, I did write those things, and I stand by them, but I also wrote so much more that described the NCCIH article’s shortcomings in detail based on science and methodology.
Now, regarding Edzard Ernst:
From England, also within days of the NCCIH’s publication, a blog post from a medical doctor and former professor who has written for two decades against integrative care was titled: “Why that study about alternative therapies relieving pain is worthless.”12 The NIH team is portrayed as “actively misleading” the public with “exaggerations, sloppy research and misleading conclusions.” The name calling— and particularly the routine attributions of quackery—recall Trump’s epithets placed on each of his opponents, for example “Crooked Hillary.”
Again, this is Edzard Ernst here. At least use his name. As for insults, methinks Mr. Weeks doth protest too much. Likening an opponent to Donald Trump, particularly a British opponent, is pretty loaded language, as is Mr. Weeks’ portrayal of Prof. Ernst as hopelessly biased. In any case, here is Ernst’s blog post, “Unacceptable pseudo-science from the NIH.” Judge for yourself. Also notice that nowhere—nowhere!—in his post does Prof. Ernst use the words “quack” or “quackery.” In fact, in tone, Prof. Ernst’s post is less inflammatory than my post or Dr. Vagg’s post. Prof. Ernst does, however, accuse the NIH of what is bordering on scientific misconduct:
A summary of this nature that fails to take into account the numerous limitations of the primary data is, I think, as good as worthless. As I know most of the RCTs included in the analyses, I predict that the overall picture generated by this review would have changed substantially, if the risks of bias in the primary studies had been accounted for.
Personally, I find it lamentable that such a potentially worthy exercise ended up employing such lousy methodology. Perhaps even more lamentable is the fact that the NIH (or one of its Centers) can descend that low; to mislead the public in this way borders on scientific misconduct and is, in my view, unethical and unacceptable.
One notes that Prof. Ernst backs up every charge he makes with a detailed list of the review article’s shortcomings. Mr. Weeks even admits that some of Prof. Ernst’s criticisms have merit. There was a point that Mr. Weeks made that at first I thought might have validity, namely where he says that Prof. Ernst “denigrates the team for not knowing the difference between efficacy and effectiveness” and then writes that this is “the fact that the data tables available to the target audience through links in the article separate them out.” Then I went to the supplemental data tables. Let’s just say that I would…disagree…with Mr. Weeks’ characterization of the tables. To me it was very unclear where efficacy and effectiveness were being separated out. One wonders why, though, Mr. Weeks didn’t rebut any substantive criticisms by either Dr. Vagg or myself and only tried to do so with Prof. Ernst. It couldn’t be that we did better than Prof. Ernst, and Mr. Weeks’ couldn’t find anything to rebut other than our tone, could it? No, even I’m not that egotistical.
The “birther” movement is invoked
For someone who is so very, very offended by inflammatory language and has a penchant for likening his critics as being akin to Donald Trump, Mr. Weeks sure does pull a couple of Trump-like moves. For instance, he accuses the critics of NCCIH of the logical fallacy of poisoning the well:
An additional reason that the article is deemed “worthless” is particularly resonant with the strategies of candidate Trump. Trump has led “a five-year long smear of the nation’s first black president” by questioning the right to office of current president Barack Obama through suggesting—despite hard evidence to the contrary—that Obama wasn’t born in the United States. Here is the echoing language from the British antagonist to the NCCIH: “The article is from the National Center for Complementary and Integrative Health, a part of the NIH which has been criticised repeatedly for being biased in favour of alternative medicine.” By its birth in the NCCIH, the work is damned. Or, as the surgical oncologist suggested, if doctors of chiropractic or naturopathic medicine are involved, it must be worthless. Such logic is akin to racial profiling. Condemnation due to origin or tribe.
Wow. First, that birther analogy is really, really strained, particularly when Mr. Weeks stretches it to encompass racial profiling. Pointing out that quacks are in high ranking positions in NCCIH and using that to point out the bias in NCCIH is akin to “racial profiling”? Histrionic much, Mr. Weeks?
Of course, poisoning the well can be a logical fallacy, particularly if the only argument used is to point out negative aspects of a person or institution espousing a viewpoint one is critical of. However, it’s not always illegitimate to criticize the source of a viewpoint if that criticism suggests bias or incompetence. Indeed, criticizing the source can be valid when it is used as part (and not the main pillar) of an overall argument that is relevant to demonstrating why that viewpoint is not valid. Not surprisingly, Mr. Weeks eschews answering most of the substance of our criticisms and zeros in like a laser beam on the tone issues and what he perceives as poisoning the well. Also, one notes another big difference between criticizing NCCIH and racial profiling. A person can’t do anything about his or her race. A person is born that way. Criticizing actual behavior is much different. A better analogy would be behavioral profiling, not racial profiling. Based on what chiropractors and naturopaths do when they practice medicine, it is not at all unreasonable to be more skeptical of a purportedly scientific paper they’ve written because of their embrace of pseudoscientific systems of medicine that are not based in science or even reality.
Two tribes go to war
Now here’s the fun part. After having whined on and on about how nasty and tribalistic skeptics are, Mr. Weeks draws a contrast between the purported virtue of “his” tribe compared to “our” tribe. Noting that many CAM practitioners are not happy with the pronouncements of NCCIH on the efficacy of various CAM modalities, he brings up examples of “civil” discourse. One is by a naturopath named Michael Traub, who wrote a rebuttal to a less than enthusiastic article on the efficacy of CAM approaches to skin disorders, citing literature. That’s nice. We do the same thing when appropriate. The other is from a chiropractor, William Meeker, who wrote to Mr. Weeks with the preface of “I am biased,” which leads Mr. Weeks to exult:
Perhaps I am biased. What a welcome, humble perspective! In fact, in a context in which a third of what is done in regular medicine is unnecessary, in which quality science is still attached to but a fraction of what is done, and in which frightening levels of morbidity and mortality are endemic to medical delivery in the United States, such self questioning serves us all.
Of course, as usual, Mr. Weeks invokes some common CAM tropes here, exaggerating how little of regular medical practice is supported by good science, for instance, and pointing to problems with morbidity and mortality in medicine. Of course, I like to respond to such tropes with the observation that it is not CAM practitioners who discovered these problems, who quantify them, or who work on solutions to them. It is physicians and scientists in “conventional medicine.” That’s why I laughed when I saw the title of the paper asking whether CAM can reduce medical errors. So did Prof. Ernst, by the way.
Near the end, Mr. Weeks destroys my irony meter. Again:
Medical integration challenges us as humans. Achieving the form of justice known as optimal patient-centered care is a delicate balance scientifically, clinically, politically, and economically. Convened are historically separate and unequally resourced professions, guilds, and tribes. We need to bring our best selves to the table. In this diplomacy, we are served to apply the serenity prayer to decide where and how we spend our energies to find the optimal common ground. Wisdom leads us to the place that my colleague, at the top of this article, suggested I go, which was to not write this column. British poet Robert Graves provides us guidance: “Hark how they roar, but never turn your head/Nothing can change them, let them not change you.”
Yet, Mr. Weeks wrote this article anyway. I also take him at his word that he hasn’t been “changed.” I rather suspect that he’s been just this self-righteous and good at mud slinging all along. He’s also particularly good at the flounce. Having portrayed himself as having dirtied himself by getting into the mud with his critics despite the advice of his colleagues not to, he quickly pivots to the old “I have better things to do” ploy:
Now then, back to the challenging work of engaging and publishing the research that will best support us in “making use of all appropriate therapeutic and lifestyle approaches, healthcare professionals and disciplines to achieve optimal health and healing.”
That’ll show us! Would that that’s what Mr. Weeks were doing. Unfortunately, perusing recent issues of JACM, where I find credulous articles on cupping, associating body types in traditional Chinese medicine with hypertension, patient satisfaction with the National Acupuncture Detoxification Association Protocol in a community mental health setting, craniosacral therapy for low back pain, individualized homeopathy for psychotherapy, and grounding, I have a hard time accepting Mr. Weeks’ assertion that he’s doing anything of the sort. There’s even an article by Mr. Weeks credulously swallowing the utterly dubious case series touting the Bredesen protocol for Alzheimer’s disease, which both Steve Novella and I discussed and found to be sorely lacking in anything resembling scientific rigor.
Believe it or not, I am more than happy to engage in civil discourse with CAM practitioners. However, I do admit to bias. (Look for that sentence to be quote-mined.) In fact, I make no bones about our bias. I am biased in favor good science and against bad science. In contrast, no matter how much he deludes himself otherwise, Mr. Weeks’ bias is so much in favor of CAM, integrative medicine, or whatever you want to call the pseudoscience and quackery that these new medical specialties are “integrating” into medicine that he fails to recognize just how bad the science is supporting it. If that’s “polarization,” so be it! Not all polarization is bad, and certainly in this case some degree of polarization is necessary.
The way to win skeptics over is not to whine about how very, very mean we are, because there are a lot of us who are actually not very mean at all and go out of our way to be civil, for example, Steve Novella. I can easily counter Mr. Weeks’ bruised feelings from a bit of sarcasm and a few insults by pointing out that I’ve had CAM advocates go far beyond simply calling me nasty names on the Internet to trying to get me fired from my job on multiple occasions over the last 12 years, to reporting me to my state medical board for my writing, to complaining to the FBI about me. (I kid you not about those last two.) So, Mr. Weeks will excuse me if I don’t leap to apologize for a bit of sarcasm and snark here and there. His tribe is as tribal as mine. No, his tribe is even more so.
Of course, Mr. Weeks can easily silence that sarcasm and snark. All it would take would be consistent good science from well-designed, well-executed preclinical laboratory and animal experiments and clinical trials on CAM to demonstrate their value, something he is now in a position to provide. I won’t hold my breath waiting, however, because I was probably too blithe about saying how easy it would be for Mr. Weeks. After all, you can’t publish what doesn’t exist. Well, actually you can, and I expect that that’s what Mr. Weeks will continue to do at JACM.