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Snake Oil Science

For my first blog entry, I wanted to write about something important, and I couldn’t think of anything more important than a recent book by R. Barker Bausell: Snake Oil Science: The Truth About Complementary and Alternative Medicine. If you want to understand how medical research works, if you want to know what can lead patients and scientists to false conclusions, if you have ever used complementary or alternative medicine or have wondered why others do, if you value evidence over belief, if you care about the truth, you will find a treasure trove of information in this book.

Some of the treatments encompassed under “complementary and alternative medicine” (CAM) have been around for a long time. Before we had science, “CAM” was medicine. Back then, all we had to rely on was testimonials and beliefs. And even today, for most people who believe CAM works, belief is enough. But at some level, the public has now recognized that science matters and people are looking for evidence to support those beliefs. Advocates claim that recent research validates CAM therapies. Does it really? Does the evidence show that any CAM therapy actually works better than placebos? R. Barker Bausell asks that question, does a compellingly thorough investigation, and comes up with a resounding “NO” for an answer.

Bausell is the ideal person to ask such a question. He is a research methodologist: he designs and analyzes research studies for a living. Not only that: he was intimately involved with acupuncture research for the National Center for Complementary and Alternative Medicine (NCCAM). So when he talks about what can go wrong in research and why much of the research on CAM is suspect, he is well worth listening to.

He describes his acupuncture research in great detail. It involved patients with pain from dental surgery. Before designing the experiments, he searched the literature and found an article that reviewed 16 previous trials of acupuncture for dental pain and concluded that it was probably effective. But on the Jadad scale, a simple 5-point measure of quality, none of those 16 studies scored higher than 3 (which is considered barely adequate) and 5 of them incredibly scored zero. Bausell’s group set out to resolve the question with research of much higher quality. For instance, a low dropout rate is one measure of quality; they only had 3 subjects drop out during the course of the study, and those 3 were people the researchers sent home because of a snow storm!

They compared “true” acupuncture to the most credible “sham” acupuncture they could devise. There was no difference in outcome: both were equally effective in relieving pain. When they looked more closely at their data, they found some surprises. The placebo control was not perfect, and some subjects had been able to guess which group they were in. Knowing you really got acupuncture should have increased the placebo response, and knowing you didn’t should have decreased it – yet even so, there was no difference between the groups. So the results were even more negative than they appeared. Even more fascinating, patients who thought they got real acupuncture reported much more pain relief than those who thought they got the sham, regardless of which they actually got!

Bausell points out that penicillin cures pneumonia even if you’re in a coma, but alternative medicine only seems to work when you are awake. You have to know (or think) you’re being treated. And penicillin works by well-understood scientific principles, while much of alternative medicine is based on “entire physiologic systems or physical forces that the average high school science teacher already knew didn’t exist.” If any alternative treatment clearly worked as well as penicillin, prior plausibility wouldn’t matter: science would adopt it and worry about how it worked later. Under the circumstances, prior plausibility is an important consideration.

He tells his mother-in-law’s story. She had knee pain from osteoarthritis with fluctuating symptoms. Every time the pain increased, she would try something new she had read about in Prevention magazine and every time it would seem to work as the pain naturally decreased again. And eventually it would seem to stop working as the pain naturally increased again. She would phone every couple of months to tell him about the wonderful new treatment she had discovered. She was not ignorant or stupid, but she underestimated the power of the placebo and didn’t realize how the natural fluctuations of her pain led her to false conclusions.

She had fallen for the most common human error: the post hoc ergo propter hoc fallacy. The fact that pain relief follows treatment doesn’t necessarily mean that the treatment caused the pain relief. This is only one of the many impediments to correct thinking that plague our fallible human brains. Bausell describes some of those other impediments. He shows how patients, doctors, and researchers are all equally likely to fool themselves, and why the most rigorous science is needed to keep us from reaching false conclusions.

Bausell’s thorough discussion of the placebo phenomenon is illuminating and invaluable. He covers the history of research on placebos and tells some fascinating anecdotes. He argues that placebo response is not just imagination. It is a learned phenomenon, a conditioned response. You respond to a placebo pill because you have previous experience of being helped by pills. Morphine injections in dogs cause a side effect of salivation: after a while, you can inject water and they will respond with salivation. Physiologic effects from placebo are always smaller than with the real thing, but apparently they do occur. The evidence for objective physiologic effects may not be entirely convincing, but it is certain that pain and other subjective symptoms respond to placebos. And there is even research suggesting a mechanism: the release of endogenous opioids, pain-relieving chemicals produced by our own brains. If you counteract those chemicals with a narcotic antagonist like Narcan, you can block the placebo response.

He shows that the act of taking a pill may really relieve pain, but that the contents of the pill may be irrelevant. Research shows a hierarchy of placebo response: injections work better than capsules and capsules work better than tablets. The color and size of the pill and the frequency of dosing all make a difference. And intriguingly, patients who have responded to a placebo have distortions of memory: they remember the pain relief as greater than it actually was! Bausell points out that

“…just because someone with a PhD or an MD performs a clinical trial doesn’t mean that the trial possesses any credibility whatsoever. In fact, the vast majority of these efforts are worse than worthless because they produce misleading results.”

The book includes valuable lessons on how to tell credible research from the other kind. Even the most experienced researchers will find food for thought here, and for the layman it will be a revelation.

Research is full of pitfalls. Negative studies tend not to get published (the file drawer effect). Research done by believers and pharmaceutical companies tends to be more positive than research done by others. Studies from non-English speaking countries are notoriously unreliable for various reasons – 98% of the acupuncture studies from Asia are positive, compared to 30% from Canada, Australia, and New Zealand. The researcher may delegate the actual research to others, who may make undetected mistakes or deliberately skew results to please their boss. Double blind studies may not be truly blind: subjects may have been able to guess which group they were in. Subjects who are not responding may drop out. People who believe in homeopathy are more likely to volunteer for homeopathy studies. Researchers may put a positive spin on their findings or reach conclusions that are not justified by the data. Even if the research is impeccable, we arbitrarily use p=.05 as the measure of statistical significance, and this means there is a 5% probability that the results will appear falsely positive just by chance. There are more pitfalls, and Bausell covers them all.

When you come right down to it, no experiment is beyond criticism, and most published research is wrong. So how can we decide which studies are credible? We now have published guidelines such as the 22 item Consolidated Standards of Reporting Trials (CONSORT) checklist to assess the quality of randomized controlled trials, but Bausell offers some simpler criteria that can rule out the worst offenders:

  • Subjects are randomly assigned to a CAM therapy or a credible placebo
  • At least 50 subjects per group
  • Less than 25% dropout rate
  • Publication in a high-quality, prestigious, peer-reviewed journal

Using this simple 4-item checklist, he reviewed all the CAM studies published in The New England Journal of Medicine and The Journal of the American Medical Association from 2000-2007. 14 met the criteria, and all were negative. When he expanded his search to include the Annals of Internal Medicine and Archives of Internal Medicine, he ended up with 22 studies, only one of which was positive (exactly what you would expect from the 5% rule if none of them worked).

Since different studies have conflicting results, we now use meta-analyses or systematic reviews to try to reach a reliable conclusion. In fact, we even have systematic reviews of systematic reviews! After explaining why systematic reviews are subject to several pitfalls of their own, Bausell goes on to examine the high-quality systematic reviews from the Cochrane collection. Cochrane’s independent reviewers take the quality of studies into account and try to evaluate all the published evidence without bias. Of 98 CAM reviews in the Cochrane database, 21 were positive. When he subtracted those that lacked confirmation by studies in English-speaking countries, those with suspect controls, and those that were subsequently trumped by more definitive high-quality studies, the percentage of positive studies dropped to that familiar 5%.

A highly touted non-Cochrane review of homeopathy concluded that the clinical effects of homeopathy were not just due to placebo. But strangely they also concluded that there was insufficient evidence to show that any single homeopathic treatment was clearly effective in any one clinical condition. A re-analysis of the studies they had reviewed showed that when only the highest quality studies were considered, the alleged positive effect for homeopathy disappeared.

What all this amounts to is that advocates can point to plenty of “snake oil” science that apparently supports various CAM treatments; but when examined critically, the entire body of evidence is compatible with the hypothesis that no CAM method works any better than placebo. True believers will never give up their favorite treatment because of negative evidence; they will always want to try one more study in the hope that it will vindicate their belief. They see science as a method they can take advantage of to convince others that their treatment works. They don’t see it as a method of finding out whether their treatment works. Bausell says,

“CAM therapists simply do not value (and most, in my experience, do not understand) the scientific process.”

He doesn’t try to tell us what to think, but he educates us in how to think critically about medical claims and about medical research. He doesn’t aim to dissuade anyone from using CAM. He just doesn’t want anyone to choose it for the wrong reasons, to be fooled into thinking there is credible evidence where there isn’t. He emphasizes that CAM nourishes hope, and its placebos work, if only for symptoms that would eventually resolve on their own anyway. The comfort CAM brings can be valuable, as long as it is not used in place of effective treatments for serious conditions – and most of the time it isn’t, despite the occasional horror story of a patient who refuses effective cancer treatment and dies using a worthless remedy. Bausell ends his book with advice on how to choose an effective placebo therapy!

Posted in: Book & movie reviews, Clinical Trials, Science and Medicine

Leave a Comment (37) ↓

37 thoughts on “Snake Oil Science

  1. jonny_eh says:

    That was an excellent article!
    All that’s missing is a link to go purchase the book that was mentioned.

  2. fls says:

    Thank you for an informative review. I just wanted to add that copious endnotes provide references for the information he presents.

    Linda

  3. jeffthefish says:

    Great resource! I just ordered this book from Amazon. I can’t wait to read it. Coincidentally, today is my company’s “wellness” fair, featuring homeopathy, naturopathy, and agriculture!

  4. jeffthefish says:

    Wait, agriculture? I mean acupuncture. That’s the funniest mistake I’ve made in a while.

  5. Pingback: Snake Oil Science
  6. Snorklefish says:

    One of the problems with discussing CAM is that it encompasses an incredibly diverse number of “treatments.”

    I like to think of complementary medicine as helping individuals cope with their conditions without promising to help cure or directly effect the underlying disease. Support groups and therapy for people experiencing stress as a result of their condition might not help people overcome their disease, but it could surely help them face their condition with a more rational or positive attitude.

    Now… support groups and therapy are hardly “alternative”, but they are often ignored by doctors more focused on direct treatment. I would label such “treatments” as complementary. This is especially true given that many oncologists and fertility doctors neglect to refer their patients to doctors and therapists trained to help people cope with their conditions. Isn’t such treatment “complementary” and yet thoroughly reasonable and helpful to living with a condition (as opposed to curing it).

  7. mike stanton says:

    Wow! Another excellent post. As soon as I have finished reading Arthur Allen’s book, “Vaccine: the controversial story of medicine’s greatest lifesaver” I will be ordering this book. If you are looking for another book to review I can heartily recommend Paul Offit’s biography of Maurice Hilleman, “Vaccinated.”

  8. Beauzeaux says:

    I just finished reading this book. It’s excellent but not a “soft” read. It’s rigorous. I now have a much better understanding of how to recognize a study that may actually mean something.
    Unfortunately, the title “Snake Oil Science” makes it sound like a much lighter book and some buyers will be bitterly disappointed when they realize how much work is required to understand it.
    The book is also set in a typeface that is extremely difficult to read. It’s a lovely font but whoever decided upon it for an entire book should be forced to read a six point sans serif in dim light for the rest of their miserable lives.
    All that said, I’m glad I bought and read it because it makes no assertions without detailed evidence and it makes clear just how difficult it is to design and carry through a truly randomized trial.

  9. kstults says:

    I really like what you folks have achieved with this blog.

    Great subject matter and great writing.

    I forward to reading this blog on a regular basis!

  10. Harriet Hall says:

    Snorklefish said, “I like to think of complementary medicine as helping individuals cope with their conditions without promising to help cure or directly affect the underlying disease.”

    Of course. And the placebo effect of alternative medicine can do the same. We are all in favor of anything that increases patient comfort. I have no objection to people using any kind of complementary or alternative medicine as long as they know the facts and can give informed consent.

    What I object to is misinformation and misrepresentation – telling patients there is good science to support a treatment when there isn’t, offering false hope under pseudoscientific pretenses, alleging that water can remember, or that energy fields can be smoothed by hand-waving, or similar imaginary nonsense. Good evidence-based medicine practiced with compassion can offer real hope for a better life even when it can’t cure; there is no need to resort to belief-based medicine or create false hopes.

  11. Ex-drone says:

    In March 2005, Ipsos-Reid did a national survey for Health Canada. The federal department’s National Health Products Directorate (NHPD) (similar to NCCAM) uses this survey, in part, to justify its promotion of NHPs:

    http://www.hc-sc.gc.ca/dhp-mps/alt_formats/hpfb-dgpsa/pdf/pubs/eng_cons_survey_e.pdf

    Based on the survey, NHPD makes statements like “A recent survey shows that 71% of Canadians regularly take … NHPs”. However, when you look at the survey carefully, you see that the “71%” refers to those who “have used” NHPs, as in “have ever used”.

    When asked what NHPs the survey participants have used, 58% said “vitamins/minerals”; the next NHP down the list is echinacea at only 15%. Therefore, NHPs are declared prevalent in part because 58% of Canadians have taken vitamins/minerals at some point in their lives.

    It is also interesting to note that, when survey participants were asked what NHPs are, a significant number offered answers that ranged from “herbal teas” to “organic food” to “healthy products”.

    It is tempting to conclude that CAM is being institutionalized in the federal government here because Canadians consume multi-vitamins and organic groceries. A facetious statement perhaps, but it seems that woo treatments (e.g., homeopathy, chiropractic and therapeutic touch), which are defined as CAM, will sneak through the door of legitimacy under the cloak of NHPs, because they are also defined as CAM.

  12. Dennisr says:

    Snorklefish said :”Support groups and therapy for people experiencing stress as a result of their condition might not help people overcome their disease…”

    In fact, this study: Emotional Well-being Does Not Predict Survival in Head and Neck Cancer Patients, James Coyne et al., suggests it won’t. And Blues musicians will tell you sometimes letting yourself feel blue is the best way out.

  13. Skeptic says:

    Looks like an interesting book but ditto on the horrible choice of font for the body text. It appears to be Delargo DT Light. Use fancy, hip fonts for long-form body text an your peril.

  14. apteryx says:

    A study examining the likelihood that CAM studies are positive in only four high-end journals is meaningless. There are hundreds of medical journals whose positive papers are used to justify the prescription of pharmaceutical drugs! Is it not possible that the editors and reviewers of JAMA prefer CAM studies that have negative results? (I can tell you for a fact that some of the negative studies recently published in the journals mentioned used inappropriate test materials, or materials so badly characterized that it is impossible to know their quality or composition. If a positive study had been so sloppy, these journals would have rejected it or included an editorial telling us how the results couldn’t be applied to any product actually available to consumers. Certainly the studies in German journals that more regularly publish studies of botanical medicines display a >5% positive rate. After a single plant has a couple dozen positive placebo-controlled studies to its credit, I’m hard pressed to say there is no evidence it’s better than a placebo.

  15. HCN says:

    I just finished the book, and ran it back to the library since it is due today. Funny, when I checked it out three weeks ago there were several available and I did not have to wait for it… But since my reading time has been interrupted by homework required for a class, I put off finishing the book, only to find almost 20 holds were on the book. So I finished the book (in the school cafeteria after class, while at son’s orthodontist appointment and while he was shopping for shirts).

    Fortunately a couple of the latter chapters were listings of studies and their results. I did not have much problem with the font since it reminds me of reading blogs, like this one (though it may be a factor in my reading it in short bits over three weeks).

    Beauzeaux said “I just finished reading this book. It’s excellent but not a “soft” read. It’s rigorous. I now have a much better understanding of how to recognize a study that may actually mean something.”

    While that may be true, he does take pains to explain many concepts like the “Hawthorne effect”. Plus he throws in several snarky comments, like the “answer is ‘C’”, which may have included the choice of the experiment on magnetic shoe inserts effected by the participants stepping on leeches (okay, from memory, I had to return the book to the library before it closed!).

    Now I have to see if the library has Christopher Tourney’s Conjuring Science book (I read Voodoo Science by Park years ago).

  16. BillyJoe says:

    If that IS a good summary of what I can expect to find in the book, I’ll have to get a copy. The copyright page lists Melbourne, so I guess I should have no trouble.
    It’s about time we had all this information in the one place.

  17. Harriet Hall says:

    Apteryx said “A study examining the likelihood that CAM studies are positive in only four high-end journals is meaningless. ”

    I agree. If that were all Bausell did, we could disregard him. I urge apteryx to read the book, and to try to understand Bausell’s entire argument.

  18. apteryx says:

    Dr. Hall, I’ll presume that “try to understand” was not meant to be snarky. Still, if you have accurately summarized Bausell’s conclusions, there would be a big difference between “understanding what he is claiming” (which would be easy) and “agreeing that his argument is correct” (which sounds impossible to me). You represent him as saying that while Western medicine “works even if you’re in a coma,” CAM “only seems to work when you’re awake,” implying that its results are purely due to the placebo effect, or to use a broader and perhaps less pejorative term, culturally based “meaning responses.”

    I’d respond that firstly, meaning responses provide part of the benefit of Western medicine as well. Both patient belief and clinician attitude influence the pain relief provided by either allopathic drugs or placebos, just as was seen in the one (negative, so acceptable) acupuncture study cited above. It might make more sense to acknowledge and utilize humans’ innate emotional responses than to condemn them and pretend that they don’t exist in our superior system. Secondly, while there is a fashion to label CAM benefits as placebo-related even when demonstrated in placebo-controlled studies, you noted that the placebo effect is related to the endogenous opioid system. What happens when an herbal product improves cardiac ejection fraction, or displays a hepatoprotective effect, or prevents infections? Can endogenous opioids produce those effects? If so, maybe we should all take a sugar pill every day. Thirdly, such benefits, plus others that haven’t been or won’t be studied in humans, are frequently also observable in animal studies. How can the animals getting the botanical have better coronary blood flow or faster wound healing than the animals getting vehicle alone, if you “have to be awake” to benefit? Animal subjects are “not awake” in that they have no way of knowing that either treatment is supposed to benefit them.

    The conclusion I draw: Bausell must either be ignorant of a great deal of research, or willing to reject it wholesale by casting suspicion on the competence or integrity of every scientist involved in generating that diverse body of research. (Does that tactic sound familiar?) I have some sympathy for the “anti-quack” fanatics, since there is some real lunacy out there being hyped with highly irritating pseudo-scientific blather. But the backlash response some doctors display of calling everything they didn’t learn in med school “woo” or the equivalent is not helpful. They are the exact counterpart of those CAM devotees who, instead of rejecting only the many unproven Western treatments (statins and episiotomies all ’round!), reject them all wholesale and encourage people not to get their kids tetanus shots. Both types of extremist give the appearance of arguing at least in part from emotion and economic self-interest, leaving the consumer without a good foundation for picking sides, much less choosing the rational middle ground. If your site really wants to promote science-based medicine, I hope you will encourage readers to examine the research and other evidence regarding both novel and traditional treatments with a critical eye, rather than cheering only for positive or only for negative results depending upon what treatment is at issue.

  19. HCN says:

    apteryx, what is your opinion of the the list of Cochrane reviews he summerized in the book? There were dozens.

  20. The problem with discussing this issue is that “alternative” is a false category. One cannot make many meaningful statements that apply to such a broad and disparate groups of modalities.

    For example, comments made about homeopathy, which is demonstrably extremely implausible, cannot also be applied to botanicals, which are plausible and should not be considered in the same category as homeopathy.

    I agree that everyone looks at the literature with a biased eye (some more than others). The goals is to use a set of criteria ahead of time that minimizes the effects of bias, and Bausell set out to do that. He is not the only one who has found a consistent pattern that when dealing with highly implausible claims there is an inverse relationship between the quality of the studies and the size of the effect.

    Regarding the placebo effect – Apteryx has based his comments on what I feel are common misconceptions about this effect. First, it is not one effect, but many, and some contributions to placebo effects are not dependent upon belief (they can be introduced by observers and therefore can occur in animals). Here is a more thorough discussion of the topic.
    http://www.theness.com/neurologicablog/index.php?p=46
    and
    http://www.theness.com/neurologicablog/index.php?p=38
    and
    http://www.theness.com/neurologicablog/index.php?p=92

  21. Harriet Hall says:

    Apteryx,

    I did mean to be a bit snarky, because your response didn’t even take into account everything I wrote in the review, much less the more detailed, nuanced discussion in the book itself.

    Bausell is well aware of the hundreds of medical journals with positive findings, and he explains why he distrusts the majority of those findings. I mentioned in my review that he shows that the rate of positive studies varies wildly according to which country they are published in, yet you cite the higher rate of positive findings in Germany as if that meant more than Bausell thinks it does.

    Yes, placebo effects occur in scientific medicine. Bausell in no way “condemns” them. In fact, he gives advice on how to benefit from them. I think I made it clear that he does not discourage the use of CAM either. He just wants us to understand whether claims are backed by good science.

    As Dr. Novella pointed out in his “Plant vs Pharmaceutical” article, herbs have medicinal effects and should be evaluated by the same standards as pharmaceutical drugs. There are problems with the way they are promoted by alternative medicine: the evidence is often of poor quality, and even when there is good evidence, we may not have reliable products (because of the DSHEA), and we often don’t have good safety data or good comparisons with other treatments.

    Everything in Bausell’s book applies to critical analysis of conventional medical claims as well as to alternative claims. It’s interesting that you mention episiotomy and statins as examples of “unproven” Western treatments. I remember getting in big trouble in my internship for omitting an episiotomy when I didn’t think it was needed. Conventional medical research has finally gotten around to finding that routine episiotomies are not indicated, and doctors have responded by changing their practices. As for statins, there has been a lot of misinformation and misunderstanding of what the science really says. I think statins are supported by good evidence. I’ve had long discussions with a member of the International Cholesterol Skeptics who thinks otherwise. Perhaps that should be the topic of a future blog entry.

  22. apteryx says:

    Dr. Hall: I didn’t intend to address your whole review, nor the book itself, only a single small point. If I had the time to write something that lengthy, you would probably not appreciate getting it in your comments page. (BTW, statins are useful for some people, but my understanding is that for primary prevention, they have not been proven to do more good than harm in some of the population subgroups who are encouraged to take them.)

    For HCN, I have not seen the book and do not know what Cochrane reviews were included. Dr. Hall’s review states that 21 of 98 were positive. This does not mean that the other 77 reviews found evidence that the treatments were no good. Suppose that the published studies of a botanical for a given use almost all show significant benefits, but the studies are not very large (as is common when funding is limited) or use more than one product type. Cochrane will say that the evidence for efficacy remains insufficient. That does not mean that there is no evidence.

    Then, according to Dr. Hall’s review, which was meant to be favorable, Bausell managed to drop the percentage of positive Cochrane reviews from 21% to “that familiar 5%” by “subtract[ing] those that lacked confirmation by studies in English-speaking countries, those with suspect controls, and those that were subsequently trumped by more definitive high-quality studies.” This is highly suspicious. The whole point of a systematic review is to have an unbiased reviewer amass the existing studies, no one of which can be definitive, assess their quality and comparability, and come up with an estimate of how solid the evidence for the treatment is. Such a reviewer can and does omit studies whose methodological quality is too poor to justify inclusion. Someone who has not reviewed the underlying studies in detail cannot just waltz in afterwards and announce that you can’t draw (favorable) conclusions based on science done by non-Anglos (is it any wonder the rest of the world doesn’t like us?). Likewise, a single recent negative (“higher-quality”) study may have had any number of flaws that limit or invalidate its results – or may have been one of the 5% we should expect to be negative just by chance, right? That’s why we like to see systematic reviews instead of leaping back and forth with each new study that comes out.

    Incidentally, Dr. Hall refers to the remaining 5% of positive Cochrane reviews as “the percentage of positive studies,” and it is implied that we should assume this is due to chance at the p=.05 level and conclude that even those remaining positive reviews Bausell can’t explain away (including top-quality Anglo studies, with no countervailing research whatsoever) should be rejected as being statistical accidents. I’m no statistician, but this is not true. What you are left with there is not a group of STUDIES of a single treatment, of which 5% are positive with significance at the .05 level. It’s a group of REVIEWS of unrelated treatments, of which 5% remain positive. Each of those positive reviews is based on multiple positive studies, each with results significant at the .05 level; and almost all of the high-quality studies available had to be positive, otherwise the review would have said “inconclusive” rather than “positive.” The chances of that happening by accident, if the treatment has no activity, are certainly less than 5%. It is, also, no more fair to judge reviews of “CAM treatments” as a statistical group than it would be to judge reviews of “allopathic treatments” as a group. If there are ten negative studies of reflexology, say, and someone hands you a new positive study, you certainly should keep the negative studies in mind when considering the positive one. But it is insupportable to suggest that a negative review of reflexology should influence your judgement of a positive review of horse chestnut for CVE. That is like saying that if calcium channel blockers don’t work as advertised, it should affect your opinion of bunion surgery.

  23. Harriet Hall says:

    Again, the book itself is more nuanced. I hope you will read it.

  24. cloudskimmer says:

    Dr. Hall,
    First, thank you for your articles, which are always informative and frequently hilarious.

  25. cloudskimmer says:

    Second, you mention (positively) Bausell’s recommendation to try CAM methods. Since they are correlated to the placebo effect, this amounts to giving money to quacks, but also, for those of us who are skeptical, the placebo effect won’t work–or at least not as well–as if you actually believe. So what is left for those of us who don’t want to give our money to charlatans, but have something like chronic pain which is not well addressed by modern medicine?
    And, to invite dueling experts, I have read Dr. Sampson’s contention that there is no such thing as the placebo effect; that the phenomenon is simply a correlation of many factors. Bausell seems to clearly demonstrate that there is such an effect which seems to be related to operant conditioning and self-induced endorphins. So is the placebo effect simply us fooling ourselves, in which case, doing acupuncture–if we don’t believe in it–would be totally worthless? And do you have any reservations to Bausell recommending any therapy sufferers want, despite his demonstration that any improvement would be illusory and temporary?

  26. Harriet Hall says:

    The placebo effect is a combination of factors including suggestion, distraction, and conditioning. Bausell says, “Neither a placebo nor a CAM therapy is going to cure anything that wil not resolve itself or that the body does not have the capacity to deal with. Both a placebo and a CAM therapy that appeals to you, however, are equally capable of relieving pain if it isn’t too severe.” The trick is to find something that appeals to you. For instance, I have a personal aversion to acupuncture needles, but I might be willing to try hypnosis. When people are suffering, even the most rational person may sometimes suspend disbelief and try something he knows is irrational.

    All Bausell can do is evaluate the existing evidence; he doesn’t rule out the possibility that some CAM methods might eventually prove effective, especially herbal remedies. I don’t think he really “recommends” CAM. He accepts the inevitability that patients “will” try CAM and he recommends ways to do so safely.

    I would never recommend a therapy like homeopathy or acupuncture, but if a patient suggested it and wanted to try it, I wouldn’t object. I would tell him that it was not supported by acceptable scientific evidence, but that some people did “believe” it had helped them, and that I would like to continue monitoring his care while he tried it.

    I can’t object to any improvement in patient comfort, even if it is illusory and temporary – as long as other necessary care is not compromised.

  27. HCN says:

    apterix wrote “For HCN, I have not seen the book and do not know what Cochrane reviews were included”

    Thank you for admitting that you have not even seen the book.

    Go to your local library or book seller to get a copy to read. Come back after you have read it.

  28. jmorris@cim says:

    Dr. Hall- thanks for the Blog. I’ve ordered copies for my exam rooms. I’d like to find well written patient info pamplets on various CAM (or SCAM, as Mark Crislip describes them). Do you know of any in print? Thanks

  29. Harriet Hall says:

    I know of lots of books, but I don’t know of any pamphlets. If anyone else does, please tell us.

  30. Carl Bartecchi says:

    I feel that Snake Oil Science is an outstanding text. Among it’s many strengths is the authors background and the fact that he is not a physician. It’s other strengths have been well noted.
    I understand the author’s suggestion, that a patient who is not doing well with what we are prescribing or recommending, might try to find some alternative medicine therapy to achieve a possible placebo effect, that might at least give the poor suffering individual some chance or hope of relief. However, in my 40 years of medical practice, seeing many such frustrated and often depressed patients, I have found a very successful alternative to sending them off to an alternative medicine practitioner. I suggest to these patients that we seek a “second opinion” from a recognized expert in the area of the patient’s physical or mental involvement. I utilize specialists at our medical school, the Mayo Clinic, or other recognized specialty centers. I have found that patients are delighted that you would do this for them. I make all the arrangements, which involves a lot of time and effort contacting the right person and sending a detailed description of the problem, attempted treatments, and copies of all the laboratory tests, X-Rays, etc. One might say that this is like a placebo equivalent, but it is reassuring to the patient that you are not missing the rare disorder that is causing their problem and comforting to me that I have not missed the one in a thousand possible explanation for their problem. Forty years of practice makes one humble and able to realize that all of us can make a mistake.

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