| It seems to me that it is impossible to construct a true, effective placebo intervention for studies on physical medicine — chiropractic, massage therapy, acupuncture, physical therapy and so on. And yet we find our research community challenged to live up to the so-called “gold standard” of a placebo-controlled, randomized trial.
Right. We are holding a workshop on just this problem later this spring. I totally agree with you. It is also important to have some clarity on what the question is. So if the question is, “Does massage therapy get people back to work faster than standard care?” then the placebo may not be relevant. If the question is, “Do needles on the meridians have a different effect than needles that aren’t on the meridians?” then you may be able to develop an appropriate sham. But I know that within the chiropractic community, we’ve had a number of grant applications, and in fact have funded some, on sham controls for spinal manipulation. But I’m not at all sure that this is making total sense. Because the patient who has experienced these kinds of therapies before may know what’s happening and the subjective experience may be an important part of the way these interventions are working.
Every so often, usually when budgets are being considered, I read an opinion piece in the Washington Post urging that NCCAM be completely defunded because none of its research has proven to be of any value. On your website, however, I see reports of NCCAM-funded studies, as well as other CAM research, which show positive results from CAM procedures. Among those currently highlighted are positive studies on acupuncture for low back pain and for arthritis of the knee. Do you personally have to spend much time fending off those who want this research shut down?
It’s a hard question. We are, of course, unhappy when we hear critical comments about us. I am more worried about the criticism, which I view as unjustified, that the research isn’t rigorous scientifically. Sometimes it’s positive and sometimes it’s negative — that’s the way science is. And I think that these [CAM] practices are important, people are finding them to be of benefit and we’ve got to learn more about how they work and in what settings they’re most useful. So I don’t worry as much about the criticism that the research isn’t always turning out positive. I do worry a little about the perception, which I consider incorrect, that the work isn’t rigorous. We worry about that and we do our best to counter it.
In terms of being trained in rigorous scientific methods, can you share with us something of your background before your appointment to NCCAM?
I’m a kidney doctor and I have spent a lot of my career taking care of people with chronic kidney disease. They’re people with very substantial illness. A number of our patients are either on dialysis or transplant-dependent. High-tech medicine often leaves people feeling pretty unsupported by the health care system. Before I took on this job, I worked a lot with my predecessor, Steve Straus. We co-chaired a conference on the placebo and I was struck by how impressive the effects of reassurance and a placebo pill were on a lot of symptoms. It’s a fascinating area of medicine. So I came to this with both interest in the science and with a real feeling that high-tech medicine didn’t have all the answers. And I am finding this to be a very interesting responsibility. I’m learning a lot from the CAM practitioners I talk to, a number of whom seem to be very committed clinicians who are working very hard to take care of their patients.
What can you tell us about plans for NCCAM’s future? I know that you are now in the process of formulating a five-year plan.
It’s our third strategic plan, for the next five years. We are very much in the middle of it. We anticipate that it will be published at the end of 2010, with all of the spring months being devoted to getting further input from the community. We’ve had a lot of response to the preliminary documents we’ve posted. We’re digesting that and we’re presenting that to our council.
I guess if I had to point to some of the areas we’ll be emphasizing, one is the role of CAM in symptom management. Back pain and pain in general are among the main reasons that people are turning to CAM practitioners and CAM modalities. I think this is an area which is really important. One of our critics criticized some comments I made, and said that CAM modalities are only good for things like hot flashes and back pain. I responded pretty adamantly to that by saying, “No, symptoms really matter.” And if we can help people with common discomforts, that’s really important. |
