A founding father of quackademic medicine speaks

It's been a while since I've written about Brian Berman. We first met him when he somehow managed to insinuate a "case report" of chronic low back pain into The New England Journal of Medicine in which he recommended acupuncture for this patient. Dr. Berman also happens to be a founder of quackademic medicine on par with Andrew Weil. True, he's not as famous to a lay audience as Weil is, but his influence on quackademic medicine over the last couple of decades has been enormous. It's not for nothing that David Freedman picked Berman as the main subject of his pro-"integrative medicine" propaganda piece for The Atlantic entitled The Triumph of New Age Medicine. So harsh was the criticism of that article that it caught the author's attention and even led the usually polite Steve Novella to be unusually harsh in his assessment. No wonder Dr. Berman is so high on the food chain in so-called "complementary and alternative medicine" (CAM), lately reborn as "integrative medicine," or, as I like to put it, "integrating" quackery with science-based medicine! So high on the CAM food chain is he that he is on the advisory council for the National Center for Complementary and Alternative Medicine (NCCAM). The only slot higher on the quackademic medicine food chain than that would be to be the director of NCCAM.

Maybe Berman will get that job one day.

So it was with some interest that I read a long interview with Dr. Berman in Topics in Integrative Health, in which a fawning chiropractor, Daniel Redwood, sticks his nose so far up Dr. Berman's posterior that they could share an olfactory bulb. At around 6,000 words the interview is longer than even the average Orac post. Since I'm kind of tired as I wrote this and yesterday's post was plenty long, I think I'll cherry pick the parts that interest me. (Look for me to be quote mined about "cherry picking" sometime in the near future.) The interview is as self-serving a load of tripe as I've ever seen from an advocate of quackademic medicine, full of typical CAM tropes and the apologia for pseudoscience that we've all unfortunately become so used to. However, it does provide a bit of insight into how Dr. Berman got to where he is.

The first thing that's depressing to learn is that pseudoscience and quackery can sell. Berman is highly funded from NCCAM, having "earned" $30 million in grants from NCCAM over the last 14 years and currently serving as the principal investigator of two NCCAM specialized center grants to study traditional Chinese medicine (TCM). As many of you know, he is also the director of the integrative medicine program at the University of Maryland (where there is reiki in the ICU). Under his guidance, the University of Maryland has been turned into Hogwarts, with the difference being that in the fictional world of Harry Potter magic works. Over the last couple of decades, Dr. Berman managed to introduce core curriculum and elective courses in integrative medicine and established research and clinical fellowships in integrative medicine magic. Yes, Dr. Berman has quite a list of achievements in quackademic medicine.

So Redwood asks Berman why he became interested in integrative medicine quackademic medicine. Parts of his rather long answer include:

After my medical training, it was very clear to me that I had been taught excellent skills for acute problems but didn’t have enough answers for my patients who suffered from chronic disorders. I had people who I knew weren’t well but all the tests were showing things were fine. I would tell them that there’s nothing that shows up on the tests so maybe we can refer you to the psychiatrist. That didn’t seem like enough so I started to look around and see what else was there.

We hear this a lot. Because scientific medicine doesn't always do so good with chronic diseases or chronic pain conditions, that must mean that woo works! Or it must mean that it's justified to try woo. So Berman looked for that "something different" and, like a sign from God, he found it:

I said to my wife, why don’t we leave the meeting and go for a walk on the beach. And so we did, and walking along I saw this sign for the ARE, the Association for Research and Enlightenment. I remembered that one of my classmates at Columbia was into Edgar Cayce, and I seemed to recall this has something to do with that. We went in there and I picked up a couple of books. One was on drugless therapies, by Harold Reilly.

The ARE? Seriously? We're talking Edgar Cayce here! Seriously. We've met this guy before when his philosophy inspired Abraham Cherrix to abandon conventional medicine for his cancer. Cayce was known for for falling into trances and giving readings on topics as varied as Hitler, astrology, the existence of Atlantis, ESP, ancient Egypt, and others. today, the ARE lists many forms of quackery, including craniosacral therapy, reflexology, lymphatic drainage, reiki, and many others. Let's just put it this way, I wouldn't look to Edgar Cayce for any sort of inspiration or example of how to improve medicine, but that's exactly what he did, because Harold Reilly's book was actually called The Edgar Cayce Handbook for Health Through Drugless Therapy, and it includes credulous discussions of hydrotherapy, colon cleanses, and other forms of quackery.

Yet this is what inspired Berman to go to the ARE clinic in Arizona in 1983 to study at the feet of Gladys and Bill McGarey and this:

When we were out in Arizona, I had the good fortune to meet a German homeopathic doctor who was practicing in Prescott. I went up there once a week. It took me months before I realized that there was something different happening there, which was that people were starting to get better. People that had chronic diseases, from chronic hepatitis to cancer to many other problems. I had never seen that before.

Yes, Berman was credulous towards the purest form of quackery, homeopathy. The only thing that shocks me here is that he's so willing to admit it.

From then, Berman went on a veritable world tour to seek out and master every form of woo that he encountered. OK, it wasn't worldwide, but he did spend nine years in England, setting up a practice in London and getting involved with a psychiatrist who used homeopathy, acupuncture, and diet to treat patients. Through it all, Arizona and England and all, Berman said:

Acupuncture seemed very natural to me to learn. I took many more courses in acupuncture and Traditional Chinese Medicine, the Eight Principles approach. I found that the energetic approach of homeopathy really complemented that.

And so a quackademic was born.

This tendency then leads Berman to be somewhat dismissive of Cochrane (which isn't necessarily a horrible thing in that I sometimes criticize Cochrane for methodolatry), but the underlying attitude seems to be that Berman is unhappy because Cochrane finds the woo that he likes to be either probably ineffective or to have insufficient evidence. This leads Berman to answer a question about Cochrane finding most CAM to be marginally effective at best:

That is so. It has a very high bar, for all of medicine. I don’t think it’s a bad thing to have a high bar. What it does is to say okay, here’s what we know, here are the gaps, and here’s what we still need to find out. It helps us in that way. What it doesn’t always help with is to tell the practicing clinician what to tell the patient in front of us. Are we to tell the patient that there are some studies that say such and such, and the methodological quality may not be perfect? Clearly you have to do some interpretation. As you say, a Cochrane review is very rarely going to say that something has overwhelmingly been shown to be effective. In a sense, we can say that Cochrane reviews are building a house of evidence.

Oh, dear. Dr. Berman seems to find it distasteful to be have to admit to his patients that, taken as a whole, evidence doesn't support the use of most CAM therapies. Not liking that, he resorts to special pleading, rather than trying to point out specifics of how, why, and where Cochrane gets it wrong, as skeptics do when we find Cochrane reviews that we disagree with. Instead, he blithely dismisses Cochrane reviews in general as never being willing to say that there is strong evidence for a therapy.

All of this leads to the perfect summation of the CAM attitude towards evidence:

Efficacy is the extent to which a specific intervention or treatment is beneficial under ideal conditions. In efficacy research, we narrow down the focus of who we allow into the study. So in the case of osteoarthritis and acupuncture, it might only be people between the ages of 40 and 60, and maybe it’s only women or people who are not obese. Then you give the treatment under relatively ideal conditions. With effectiveness, it’s a measure of the extent to which the intervention does what it’s intended to do in routine care. You’re not narrowing it down; you’re using the treatment as it’s practiced in the real world.

Here's the deal. Berman is basically correct in describing the difference between efficacy and effectiveness. However, like most CAM apologists, he misunderstands the problem with his preference for effectiveness research. I've discussed how CAM advocates prefer less rigorous "pragmatic," "real world" trials to those nasty randomized clinical trials. It turns out that pragmatic trials are a two-edged sword. Treatments that definitely work in RCTs not infrequently turn out not to work as well in "real world" situations. The reasons can be legion. For one thing, clinical trials have very rigorous inclusion and exclusion criteria that mandate which patients are eligible to be in the trial and which ones are excluded. Such criteria exist in order to minimize variability and maximize the likelihood of seeing a positive signal, if one exists. Once a drug or treatment is FDA-approved and "released into the wild," so to speak, doctors inevitably apply the treatment to patients who were not represented in the original RCTs that led to the approval of the treatment, a process sometimes called "indication creep." Another issue is that patients out in the community are rarely monitored as closely as the subjects of clinical trials are. Also, for more advanced or complex treatments, there is often a learning curve. Academic medical centers have largely passed the learning curve before they do the RCTs. As a procedure or treatment trickles out into the community, it might take a long time for doctors who don't see a lot of patients who might benefit from the treatment to go through the learning curve. Many other reasons come to mind, all of which point to why, in the case of treatments with good RCT evidence to support them, "pragmatic" trials, which are generally uncontrolled and not randomized, can be helpful to get an idea of the "true effectiveness" of a treatment.

Now, let's contrast that situation to something like acupuncture or other CAM treatments that rely mainly on placebo effects to give the appearance of efficacy or effectiveness. For such treatments, "pragmatic" trials will be likely to exaggerate the apparent effectiveness, because gone are the double blinding, the randomization, and all the other controls in RCTs designed to minimize the chance that placebo effects will give the appearance of efficacy. Unlike the case for treatments that have convincing RCT evidence for efficacy, where pragmatic trials will frequently reveal less effectiveness than would be expected from the RCTs, in the case of placebo treatments favored by quackademics like Berman, effectiveness research and pragmatic trials are likely to show an effect, whether there is one or not, particularly for subjective outcomes such as pain relief or anxiety relief.

As Steve Novella and I have pointed out before, no wonder quackademics love "pragmatic" trials so much! Steve quite rightly points out that doing "pragmatic" or "effectiveness" studies on treatments that haven't already been shown by high quality RCT evidence to be efficacious is pointless. The normal order of research goes from small pilot trials to larger phase II trials, finishing up with large phase III trials. If the treatment under study survives that progression, then pragmatic studies make sense. As Steve Novella has also pointed out, acupuncturists and CAM believers, having failed to demonstrate efficacy for their favorite woo above and beyond placebo effects in larger trials, are either leapfrogging straight to "pragmatic" studies or backtracking to the sorts of smaller, less rigorous trials that are done earlier in the process of investigating a new treatment. The reason for the strategy is obvious and implied right in the interview. With the full implementation of the Affordable Care Act just around the corner, comparative effectiveness research will take center stage. In this, CAM has one final shot to gain the appearance of legitimacy. After all, in effectiveness research, treatments with real efficacy will appear less effective in the "real world," while placebo treatments will appear more effective. And you can't tell me that CAM apologists aren't aware of that.

I could go on and on. There's enough material in this interview with Dr. Berman to do two or three Orac-length posts. However, I'm tired, and I think that you are all quite capable of deconstructing the rest of Berman's CAM-speak. I'll just conclude by pointing out that this interview makes a compelling case that Dr. Berman, not Andrew Weil, could easily be The One Woo To Rule Them All.