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A formal request for retraction of a Cancer article

I am formally requesting that Cancer retract an article claiming that psychotherapy delays recurrence and extends survival time for breast cancer patients. Regardless of whether I succeed in getting a retraction, I hope I will prompt other efforts to retract such articles. My letter appears later in this post.

In seeking retraction, I cite the standards of the Committee on Publication Ethics (COPE) for retraction. Claims in the article are not borne out in simple analyses that were not provided in the article, but should have been. The authors instead took refuge in inappropriate multivariate analyses that have a high likelihood of being spurious and of capitalizing on chance.

The article exemplifies a much larger problem. Claims about innovative cancer treatments are often unsubstantiated, hyped, lacking in a plausible mechanism, or are simply voodoo science. We don’t have to go to dubious websites to find evidence of this. All we have to do is search the peer-reviewed literature with Google Scholar or PubMed. Try looking up therapeutic touch (TT).

mind-over-body

I uncovered unsubstantiated claims and implausible mechanisms that persisted after peer review in another blog post about the respected, high journal-impact-factor (JIF = 18.03) Journal of Clinical Oncology. We obviously cannot depend on the peer review processes to filter out this misinformation. The Science-Based Medicine blog provides tools and cultivates skepticism not only in laypersons, but in professionals, including, hopefully, reviewers who seem to have deficiencies in both. However, we need to be alert to opportunities not just to educate, but to directly challenge and remove bad science from the literature.

A brief history

You may recall my previously blogging about the article that I am now requesting be retracted. I described how the authors unsuccessfully attempted to block publication of a criticism of their study. They then refused to respond when the criticism was published. The article spun faulty analyses and avoided simple analyses that showed that giving cancer patients breathing exercises and encouragement of healthy behaviors does not forestall recurrence or extend their lives.

But earlier papers from the same project did some spinning as well. For instance, one paper tested the more reasonable hypothesis that psychological interventions can reduce emotional distress, improve health behaviors and dose-intensity, and enhance immune responses.

There is no evidence that any changes in the immune parameters that were studied would be clinically significant or that there exists any plausible mechanisms by which recurrence and survival might be affected. But why wouldn’t we expect a support group intervention to affect mood and health behavior in the way that was hypothesized?

The abstract claimed uniformly positive results in terms of effects on anxiety and improved dietary habits, smoking, and adherence, with no negative results mentioned. However — and here I draw on my past blog post — the authors cast a wide net, with the methods section revealing assessment of at least:

  • 9 measures of mood (there is evidence from other articles that there are even more measures of mood assessed that were not reported in this article);
  • 8 measures of health behavior;
  • 4 measures of adherence;
  • 15 measures of immune function.

Turning to the actual results, only 1 of the 9 measures of mood was significant in time-by-treatment interactions. The intervention seemed to have had a significant effect on “dietary behavior” (although it is unclear why the results for very different individual dietary behaviors were not individually provided) and smoking, but no effect on exercise. As is often the case with early breast cancer patients, rates of adherence to chemotherapy were too high to allow any differences between the intervention and control groups to emerge.

In terms of immune function, results were not significant for counts of CD3, CD4, or CD8 cells, or six assays of natural killer cell lysis.

These overall results suggest that what we were told in the abstract represents a gross confirmatory bias — the suppression of negative results and the highlighting of positive ones likely to be due to chance.

Claims about biomedical outcomes such as recurrence and death need to be evaluated as such. It is unlikely that claims about a new form of chemotherapy or radiotherapy would be accepted if they were based on faulty post-hoc analyses of a study with such a small sample size, and with results contradicted by more straightforward, appropriate analyses. But for a variety of reasons, claims about psychological interventions improving survival are often given special consideration not only in the media, but in scientific journals.

Let us get real. Given the effectiveness of current treatments for early breast cancer, an effort to demonstrate an improvement over results obtained in guideline-consistent routine care would have to involve thousands of patients, not the 227 recruited for this study. In the U.S. the 5-year survival rate for women with localized breast cancer is now 98.5%. And then of course there is the lack of plausible biological mechanism by which group therapy could slow recurrence and extend survival.

Mind over cancer

The idea that the power of mind can triumph over physical illness is deeply rooted in Western folk culture and has its roots in classical Greek and Roman thinking. Yet, we showed in a systematic review of the literature, that “No randomized trial designed with survival as a primary endpoint and in which psychotherapy was not confounded with medical care has yielded a positive effect.”
Investigators who had undertaken ambitious, well-designed trials to test the efficacy of psychosocial interventions but obtained null results echoed our assessment with reviews declaring “Letting Go of Hope” and “Time to Move on.”

I provided an extensive review of the literature concerning whether psychotherapy and support groups increased survival time in an earlier blog post. Hasn’t the issue of mind-over-cancer been laid to rest? I was recently contacted by a science journalist interested in writing an article about this controversy. After a long discussion, he concluded that the issue was settled — no effect had been found — and he would not succeed in pitching his idea for an article to a quality magazine.

But hold on.

Considering the question open is vital to continued federal funding of the field of psychoneuroimmunology (PNI). Without having established that psychological interventions actually improve survival of cancer, PNI seeks to explain how these interventions succeed. It is classic tooth fairy science.

tooth-fairy

The NCI in particular provides financial support to efforts to promote psychoneuroimmunology in articles in special issues of journals and symposia that exclude any anyone who might express skepticism. As an example, see an extraordinary 2013 article, “Psychoneuroimmunology and cancer: a decade of discovery, paradigm shifts, and methodological innovations published by McDonald, O’Connell & Lutgendorf in Brain, Behavior, and Immunity (30, S1-S9).
The article celebrated a decade of NCI support for psychoneuroimmunology, starting with a 2002 conference and resulting 2003 monograph. The three authors were a NCI program officer, a science writer paid by NCI, and a proponent of Therapeutic Touch. The 2013 article introduced a collection of carefully selected invited reviews:

This [2003] seminal volume captured state-of-the-science reviews and commentaries by leading experts in psychoneuroimmunology (PNI) and served as a catalyst for biobehavioral1 research conducted in a cancer context. In the decade prior to the NCI commissioned supplement, Brain, Behavior, and Immunity published only 12 cancer-relevant articles. Since the 2003 supplement, the journal has featured 128 cancer-relevant papers that have generated 3361 citations (data from SCOPUS, retrieved November 1, 2012), relative to 55 papers on PNI and cancer, published in other peer review journals during the same time period. These bibliometric data highlight Brain, Behavior, and Immunity as a leading scholarly outlet for research on the biology of psychological and social experiences and the integrated mechanisms associated with cancer as a complex disease process. The current volume celebrates the 10-year anniversary of the 2003 supplement. This collection of invited reviews and research articles captures important discoveries, paradigm shifts, and methodological innovations that have emerged in the past decade to advance mechanistic and translational understanding of biobehavioral influences on tumor biology, cancer treatment-related sequelae, and cancer outcomes.

This paragraph can be interpreted in different ways. B, B, & I’s editorial board is a tight club of PNI researchers , many of those with NIH funding. The journal rarely has an article without positive findings and seldom is seen a skeptical word about PNI. The journal could represent the success of NIH funding for PNI research, particularly NCI, or the poor reception of PNI research in the larger scientific literature. Outside the incubator, PNI mostly does not survive peer review.

In 2014, a NCI program officer placed solicitations on a listserv for free training in Cancer to Health (C2H), supported by a NCI R-25 grant. The evidence mustered for the R-25 application is the project from which the Cancer article came.

At a 2014 meeting of the Society Behavioral Medicine, the NCI supported a symposium with a NCI program officer as a discussant. The author of the article for which I have requested a retraction renewed her claims of the powers of her intervention and solicited applications from professionals interested in free training with support from the NCI R-25 training grant.

In August 2014, the author of the Cancer article will fly to Groningen, the Netherlands, with another NCI program officer and again present her claims at the International Congress of Behavioral Medicine.

For political reasons, not science, the NIH is interested in keeping this line of research alive, even if it is on life support. The idea is that behavioral interventions can extend life, not just improve its quality. And to study exactly how requires not only investigator-initiated R01s but larger program grants. When the author of the Cancer article refused to respond to our critique, the task was accepted by Peter Kaufmann. He is the Deputy Chief of the Clinical Applications and Prevention Branch of National Heart Lung and Blood Institute (NHLBI) and at the time his commentary was written, President of the Society of Behavioral Medicine.

As I note in my earlier post:

candle

Subtitling his commentary “To Light a Candle,” Kaufmann conceded that my colleagues and I had raised valid criticisms about the design and interpretation of the C2H intervention trial. However, he took issue with our recommendation that clinical trials of this kind be suspended until putative mechanisms could be established by which psychological variables could influence survival. Quoting our statement that an adequately powered trial would require “huge investments of time, money, and professional and patient resources,” he nonetheless called for dropping a “preoccupation with mechanisms and secondary aims,” and instead putting the resources to increasing the sample size and quality of an intervention trial.

Wow, so we should ignore the lack of evidence for biologically-plausible mechanisms. Kaufmann suggests we should pour what would have to be millions of dollars into a trial to test whether psychotherapy and support groups extend the lives of cancer patients.

The call for retraction

May 7, 2014

Fadlo R. Khuri, MD, FACP
Editor-in-Chief, Cancer

Dear Dr. Khuri:

This open letter formally requests retraction of a 2008 Cancer article

Andersen, B. L., Yang, H. C., Farrar, W. B., Golden-Kreutz, D. M., Emery, C. F., Thornton, L. M., … & Carson, W. E. (2008). Psychologic intervention improves survival for breast cancer patients. Cancer, 113(12), 3450–3458.

According to the Committee on Publication Ethics (COPE; http://tinyurl.com/kd5q28o), journal editors should consider retracting an article if

they have clear evidence that the findings are unreliable, either as a result of misconduct (e.g. data fabri­cation) or honest error (e.g. miscalculation or experimental error)

I call your attention to the basic data reported in the flow chart in Figure 2 of the cited article. Analyses that can be readily performed but that are not provided in the article directly contradict the claims that are stated in the title, get amplified in the abstract, and are repeated throughout the text. When simple 2×2 chi-square calculations are performed on raw recurrence and death events from the figure for intervention versus control group, differences do not approach significance for the proportion of women experiencing a cancer recurrence in the intervention (25.4%) versus control conditions (29.2%; Odds Ratio = 0.83, CI = 0.46 – 1.48, p = .525). There is no difference between the proportion of women who died in the intervention group (21.1%) versus the control condition (26.5%; Odds Ratio = 0.74, CI = 0.40 – 1.36, p = .332). Similar results are obtained if one examines only those deaths due to breast cancer.

My colleagues and I previously published a commentary in Cancer arguing that the authors’ data failed to support their conclusions.

Stefanek, M. E., Palmer, S. C., Thombs, B. D., & Coyne, J. C. (2009). Finding what is not there. Cancer, 115 (24), 5612-5616.

Our commentary was originally submitted as a briefer letter. It was first rejected, with a previous editor citing a standing policy of not accepting critical commentaries if authors refused to respond. This policy essentially allowed authors to suppress criticism of their work, regardless of the validity of criticism. We asked the editor to re-evaluate the policy and reconsider the rejection of our commentary. The editorial board reconsidered and invited the extended commentary that was published. However, the authors still refused to respond, a choice which many would consider extraordinary.

Our criticisms would have been directly addressed if the authors had simply provided a report of positive findings for standard, unadjusted outcomes, such as a Kaplan-Meier estimate of the survival function. We indicated strong reasons why such analyses would not be significant. Regardless of their choice not to respond to our letter, the authors had a responsibility to provide these data.

Instead of results for unadjusted outcomes, the authors had provided in the article dubious multivariate analyses with a high risk of spurious findings. Both unadjusted and adjusted analyses should have been provided. When positive results are obtained with unadjusted outcomes, readers’ confidence in them are increased when findings persist after adjustment for possible confounds. However, when positive results are obtained with unadjusted outcomes, contradictory findings after adjusting for confounds warrant special scrutiny. Interpretation of adjusted outcomes assumes complete specification of possible confounds and measurement without error, assumptions that are not typically tested or met. Analyses with adjusted outcomes are not necessarily more generalizable than those with unadjusted outcomes. On the contrary: Positive findings with adjusted outcomes may variously reflect overfitting, residual confounding, incomplete specification and imperfect measurement of covariates, and covariate selection procedures that capitalize on chance.

The multivariate analyses presented in Anderson et al.’s article control for initial group differences in a number of potential confounds. This is remarkable because the authors also reported ‘‘no significant differences between study arms in sociodemographics, disease, prognostic factors, type of surgery received, or adjuvant treatments.”

The authors relied on a backward elimination procedure to select control variables from a larger pool of at least 15 candidate variables. Eight to ten of these factors were retained as covariates in analyses predicting time to recurrence, death from breast cancer, or death from any cause. Aside from capitalizing on chance, the number of covariates was simply too high relative to the number of events being explained (i.e., recurrences, breast cancer deaths, other deaths). Anderson et al. consistently violated the general rule that predictors should not be added to the equation if the ratio of outcome events to predictor variables is not at least 10:1. For instance, the final model for recurrence-free survival included 11 predictors for 62 events: a ratio of 5.6:1.

You may ask why a claim for retraction is occurring at this time. First, the authors have continued to cite this claim in other publications without acknowledging objections to the analyses. Second, this paper continues to be widely cited and specifically as evidence that psychosocial intervention prolonged survival, a claim that does not otherwise have support. Third, this particular paper served as the basis for federal funding to disseminate training in this intervention. The paper is specifically cited in solicitations (http://tinyurl.com/n2den7g) for training at Professor Barbara Andersen’s Training Institute For Empirically Supported Biobehavioral Interventions for Cancer Patients.

Claims about time to recurrence and cancer-specific and all-cause mortality are claims about biomedical outcomes. I seriously doubt that had such claims concerning chemotherapy or radiotherapy based on flawed analyses in a small sample in a study in which survival was not a predesignated outcome been made, they would go unchallenged. I believe that these authors’ claims should be held to the same standards as other biomedical interventions.

The American Cancer Society website (http://tinyurl.com/l2f63c7) has posted a statement

The research is clear that support groups can affect quality of life, but the available scientific evidence does not support the idea that support groups or other forms of mental health therapy can by themselves help people with cancer live longer.

This is in response to widespread beliefs among patients and their families that persons with cancer can somehow boost their immune system and thus extend their chances of survival if they attend such groups.

The Andersen et al. Cancer article that lends credibility to these groups stands in direct contradiction to that statement by the ACS. Either the statement should be revised or the finding should be retracted.

Thank you for your consideration. I await your response with interest.

Sincerely,
James C Coyne PhD
Professor Emeritus of Psychology in Psychiatry
Perelman School of Medicine of the University of Pennsylvania
Professor of Health Psychology
University Medical Center, Groningen

Posted in: Cancer, Clinical Trials, Neuroscience/Mental Health

Leave a Comment (132) ↓

132 thoughts on “A formal request for retraction of a Cancer article

  1. FastBuckArtist says:

    Censorship and science do not go well together. I am not sure what offended you in this study so much that you are calling for retroactive removal of the material.

    4-6 people out of 227 is not a convincing number, but there could be something there, a person with a positive attitude is more likely to make lifestyle adjustments leading to improved body health and therefore improve their survival chances in case of cancer recurrence.

    The auithors could have toned it down and said the results show a small improvement in survival. Seems like they put an overly positive spin on the conclusions in hopes of getting published. Who wants to publish a boring study that showed nothing significant?

    1. FastBuckArtist says:

      A look at another study with a larger group that also finds a link between mental issues and post-cancer survival, but are more modest in their conclusions:

      Influence of psychological response on survival of breast cancer patients

      For 5-year event-free survival a high helplessness/hopelessness score has a moderate but detrimental effect. A high score for depression is linked to a significantly reduced chance of survival; however, this result is based on a small number of patients and should be interpreted with caution.

      1. WilliamLawrenceUtridge says:

        …and if Andersen et al. had a similar disclaimer, the framing of the article and its use as an ongoing launching pad for an entire field of research would be properly contextualized. Not to mention, deaths are all-cause mortality in the Watson paper from 1999 that you cite, not specifically cancer deaths. Further, do you know if there was matching for things like staging, clinical presentation, etc? In other words – did more people die because they were depressed and felt helpless, or were depressed and helpless-feeling people more likely to have a more severe clinical presentation?

        You don’t know, because it’s not a raondomized controlled trial.

        1. Earthman says:

          Just the point I was about to make. Are those who have been told they are in a worse medical condition (you have 3 months!) more likely to be depressed than those with a more open prognosis? There is serious risk of getting cause and effect back to front, especially if you go in with the assumption that mood can affect disease.

    2. James Coyne says:

      The Committee on Publication Ethics indicates that articles making claims not backed by the data are suitable for retraction. I don’t think they believe they are in the business of censorship, only ensuring the integrity of the literature.

      The comment “Who wants to publish a boring study that showed nothing significant?” seems to encourage a strong confirmatory bias and justification for a spinning. Presumably most of us don’t accept this justification, although the practic is rampant.

      1. Sawyer says:

        Dr. Coyne, I’m sure we all appreciate your effort in responding, but you’re wasting your time with FBA. Not one person here has ever had a successful conversation with him about any topic, and his name choice seems to be his only attempt at honesty.

        1. David Gorski says:

          Indeed. I’m only disappointed that FBA was the first commenter on your article. He is uneducable.

          1. FastBuckArtist says:

            Love you too David :)

      2. Earthman says:

        I was always taught that a negative result was equally as valid as a positive one. It is good to disprove something, even if you set out to verify that proposition. Whether journal editors like to publish negative results is an entirely different matter.

    3. Sawyer says:

      I am not sure what offended you in this study so much that you are calling for retroactive removal of the material.

      Who wants to publish a boring study that showed nothing significant?

      FBA, please provide us with a shred of evidence that you even understand the concept of a peer-reviewed, scientific journal.

      These journals have been around since the formation of the Royal Society of London. With over 300 years of history and mountains (literally) of papers, there’s no shortage of material to draw upon and learn about this topic. Despite healthy disagreements in the scientific community about the standards journals should employ, no educated and ethical person should ever be making the statements you just made.

      I would have liked to see more discussion on the biological underpinnings of psychological effects on cancer proliferation, but you’ve already hijacked the topic with nonsense. Thanks.

    4. WilliamLawrenceUtridge says:

      Censorship and science do not go well together. I am not sure what offended you in this study so much that you are calling for retroactive removal of the material.

      It seems more that Andersen et al. were trying to censor criticisms of their paper through an attempt to game the journal’s protocols on criticisms by providing no reply. Further, even retracted papers are kept available – they’re merely heavily annotated as “retracted”, in an extremely public manner.

      4-6 people out of 227 is not a convincing number, but there could be something there, a person with a positive attitude is more likely to make lifestyle adjustments leading to improved body health and therefore improve their survival chances in case of cancer recurrence.

      Wouldn’t that suggest that mood has nothing to do with it, efforts are to be put towards lifestyle adjustments?

      And what proof is there that lifestyle adjustments will help with cancer recurrence? If you’ve already got DNA damaged badly enough to cause cancer (and if a recurrence, then have a patch of cells already capable of evading the immune system and resisting chemotherapy), why would lifestyle changes make any difference?

    5. Harriet Hall says:

      “4-6 people out of 227 is not a convincing number, but there could be something there”

      This is a common criticism of RCTs, and it is worth addressing. There could be a minority of patients who actually respond to a treatment when the great majority of patients do not. Unless we can figure out which ones are likely to respond, what are we to do – treat everyone despite the fact that few will respond? We test for statistical significance because in every study a “trend” will be seen: the number of patients who respond will not be exactly the same in the treatment and non-treatment groups. What are we to do with that information when it doesn’t reach statistical significance? It could be that a minority actually responded, but it could just be “noise” in the data. Meta-analyses can help, but they are all too often impaired by the GIGO principle.

      To put this criticism into perspective, I think the critics would protest vigorously if the FDA approved a prescription drug based on this kind of results.

  2. James Coyne says:

    The Lancet study concerned fighting spirit. Here is what I have written about that literature.

    Coyne, James C., and Howard Tennen. “Positive psychology in cancer care: Bad science, exaggerated claims, and unproven medicine.” Annals of Behavioral Medicine 39.1 (2010): 16-26.

    Note that the quote expressing relief that “fighting spirit” is considered discredited comes from the paper [12 below] that you cite :

    An early study [11] was widely interpreted as demonstrating that patients having a fighting spirit were more likely to be disease-free and to survive to 5 and 10 years post-assessment. However, these claims were based on a small investigation that used a brief open-ended question assessment in a sample of 57 early-stage breast cancer patients and which lacked statistical control for node status. A later, larger study (n=578) that used a self-report measure failed to find a prognostic value for fighting spirit [12]. The investigators expressed relief: “Our findings suggest that women can be relieved of the burden of guilt that occurs when they find it difficult to maintain a fighting spirit” ([12], p.1335).

    1. FastBuckArtist says:

      Coyne, James C., and Howard Tennen. “Positive psychology in cancer care: Bad science, exaggerated claims, and unproven medicine.”

      Would it be fair to say mental comorbidities like depression have a negative effect on survival of cancer patients? There is some more recent evidence that improvement in depression symptoms also improves cancer survival.

      When dealing with depressed patients, I see that their physical health suffers as well, they isolate themselves, dont leave the house as much, the eating and exercise habits deteriorate, I can see how this would lower their chances in case of cancer recurrence, you need to be strong enough to survive the ordeal of surgery and radiotherapy, mentally strong and physically strong.

      Your review suggests that modern treatments for depression are not very effective in helping these people, the counseling offered by conventional medical practice does fall short on that front.

      1. dw says:

        You really don’t appear to know what you are talking about.

  3. Michael Finfer, MD says:

    As a cancer patient. myself, I have to say that some combination of optimism and determination is necessary to get through treatment that can be quite unpleasant and have significant sequelae, and that alone can confound studies like this. However, to say that a genetically abnormal cell population can be controlled with one’s mind to me is akin to a Vulcan mind meld.

    1. FastBuckArtist says:

      I dont believe the Andersen et al were suggesting anything about controlling cell growth with mind power.

      The benefits of being in a solid mental shape are not magical, they start from mundane attendance of the followup screening tests, something a severely depressed person will just skip.

      Good luck with your fight, hope you make a full recovery.

      1. MadisonMD says:

        The benefits of being in a solid mental shape are not magical, they start from mundane attendance of the followup screening tests, something a severely depressed person will just skip.

        This could explain difference in survival, perhaps*, but not difference in recurrence. Actually, increased screening paradoxically would be expected to increase rate of apparent recurrence (more detected).

        I would make the argument that the benefits of being in a solid mental shape, as you say, have intrinsic value regardless of survival. So, I would want to know if the intervention improved the outlook and decreased depression in this cohort. It likely should be targeted at patients most in need of the intervention… which is standard of care now.

        *Only early detection of local recurrence could improve survival, and most recurrences are metastatic– so this is unlikely.

        1. Earthman says:

          I was always taught that a negative result was equally as valid as a positive one. It is good to disprove something, even if you set out to verify that proposition. Whether journal editors like to publish negative results is an entirely different matter.

        2. Earthman says:

          Sorry that my comment below is a copy of my previous one, something screwy went on.

          I get a little fed up of the media constantly referring to people with cancer as having a battle, war, fight, struggle, whatever, as if we are beating off the disease with a stick. In my case the main factors that have given me 32 years in remission are:-

          1) Really skilful surgery with very sharp knives
          2) Really powerful drugs that half kill you
          3) Fantastic surges of radiation that burned their way though my body
          4) The British NHS that meant I was not financially ruined by the cost of it all.

          As for my mental state – no nothing to do with it actually.

          Sorry – this is anecdotal evidence and therefore does not count.

  4. WT says:

    How do the authors get from 30 deaths in control group vs. 24 in treatment group to a hazard ratio of .44?

  5. James Coyne says:

    WT: How did they get there? By the magic you can do by using inappropriate multivariate analyses and hoping that no one asks for or reconstructs basic unadjusted associations.

  6. Cervantes says:

    Obviously, behavioral interventions can extend life if they get people to, say, in the case of HIV take their antiretrovirals and attend medical appointments. Cancer patients who have self-management requirements related to outcomes can plausibly benefit from interventions that address their motivation and self-efficacy. If investigators would focus interventions on these plausible mechanisms there could be real value in it, and yes, they could still get grants and publish (more widely respected) papers. Why we have to believe in magic eludes me.

  7. Frederick says:

    It is clear that peoples need psychological support during ordeal like cancer, to accept going through treatment and everything. But to claim that he can heal them, that’s way out of line. It can lead to dangerous false interpretation, some might actually belive they can replace a part of their treatment by a positive attitude.
    I totally agree with that retraction request.

    1. dw says:

      People just need emotional support to get through tough times. We don’t really need any research to prove that.

      The other thing that disturbs me about studies such as this is, are we saying that if it DOESN’T extend their lives or reduce their chance of recurrence, therapy is wasted on cancer patients? Surely not. We do not NEED for therapy or other forms of emotional or practical or behavioral support to be extending survival times in order for it to be worthwhile! We should not throw research dollars away on foolish questions.

  8. egstras says:

    Part of the problem with crap like this is that it conveys the idea that one must deny “negative” emotions in order to survive. See Ehrenreich’s book , Bright Sided.

    Years ago, I had a client who was facing cardiac surgery for some sort of congenital malformation. Her surgery was to be with the world expert, who had done twelve of them. My client was scared and had things she wanted to say in case she didn’t survive.

    Her family, however, had bought into the cheerful = survival stuff and kept shushing her.
    She came in with her husband. she talked, we all cried, and the surgery went just fine.

    1. goodnightirene says:

      Bright Sided is a terrific book that very nicely discusses the history of magical thinking as expressed in the “positive thinking” bandwagon. Sadly, Ehrenreich has recently published some awful memoir about “visions” she had in her youth, which she apparently interprets rather unscientifically.

      1. dw says:

        I know, now THAT’S depressing (Ehrenreich’s mystical turn; reminds me of Kubler-Ross).

  9. Windriven says:

    Dr. Coyne, You are performing an invaluable and desperately needed service in asking for this retraction. There has been an erosion of rigor in a number of journals and this, arguably, can lead to the squandering of scarce and precious research funds in the pursuit of blind alleys and feel good initiatives that ultimately diminish rather than advance patient care.

    The editorial content of journals should shape the direction of further inquiry in part by excluding results that are weakly supported by data that has been contorted by inappropriate statistical devices to confirm some predisposed notion. Using the power of editorial judgment to point in spurious directions does a disservice to all involved.

    I hope you will be successful. But successful or not you are shining light in a dirty corner that desperately needs attention.

  10. James Coyne says:

    Thank you very much for the encouragement, Windriven.

  11. Ed Whitney says:

    The study in question allocated groups by minimization, not by randomization. There seems to be some debate about whether minimization studies should adjust their analyses for factors used in the minimization. The unadjusted analyses were not significant. The adjusted analyses appear to have been. There may be a risk of misleading results if adjustment is not made in the analysis.

    I am fairly certain that some reader of this website has some actual knowledge of the values and pitfalls of minimization, and of whether adjustment controls for error or only introduces additional sources of error. I hope that someone can link to a reader-friendly discussion of this issue.

  12. James Coyne says:

    I am not an expert on minimization, but based on consultation with experts, here is what we said in our published commentary.

    “The authors justify the use of covariates on the minimization method that was used to assign patients to groups, indicating that ‘‘adjustment should always be made for the minimization factors when analyzing data from a trial using this method.’’1 The authors of the review that was cited5 to support the analysis, however, presented a more nuanced discussion of the topic, noting that adjustment can lead to concerns about the validity of results. We note that Andersen et al. used 4 minimization factors, far fewer than the 8 to 10 variables they included as covariates. In addition, the authors did not find it necessary to covary these minimization factors when presenting data from the same trial in 2 earlier reports,3,4 begging the question of precisely which criteria entered into the decision to adjust findings in this report, rather than other reports of the same trial, given the absence of significance for unadjusted results.”

    1. Ed Whitney says:

      That is why, when I become president of the One World Government, the first thing I will do (after taking away everyone’s guns and forcing them to gay marry), is to require that any study in a peer-reviewed journal shall furnish a data supplement with the raw data, stripped of identifiers, so that readers can explore the data and find out if any analyses were likely to have been influenced by the authors’ looking at the data. This may control the amount of black magic that can be performed in the analysis.

      As it is, trial registries like clinicaltrials.gov require designation of a primary outcome, but not of the analytical methods which will be used when the study is completed. I understand that you may not know whether your data will have a numerical distribution appropriate for a pre-planned analysis until you have it in hand, so maybe I should defer imposing that requirement pending further consultation with my advisors.

      1. dw says:

        But do go ahead with the gun ban and the forced gay marriage thing :)

  13. etatro says:

    It is incredibly frustrating because there are legitimate areas of research respecting the interactions between the neuroendocrine, immune, and central nervous systems, which affect behavior and mental health. They do not need to make up these grandiose claims. I attended PNI’s conference in 2012 and was not invited back (and really had no interest in it). I see really bizarre stuff coming from the same people ….. like neuroimaging for mediums who communicate with dead people ….
    ————————————
    Regarding publishing of crap papers and the peer review process …. I recently had a pretty crazy experience as a peer reviewer. I suggested that the title of the paper exceeded the scope of the findings, and that the major conclusions in the Abstract, Intro, and Conclusions exceeded the scope of the experiments done (but the experiments were done well, the results valid, just the conclusions grossly overstated their generalizability) …. and the authors were hostile in their response, tweaked the title slightly but still maintained the over-reaching scope; and spent several paragraphs defending the claim in the Response to Reviewers letter.

    I am an Assistant Professor …. and I never, ever imagined responding to “accept with revisions” that way…. I thank my lucky stars and make the darned revisions. Anyhow … So I had to spend my time, re-reading the paper, looking for their edits, responding to their responses … explaining my position about the scientific scope of the experiments vs. the scope of their title and conclusions. It came back a SECOND time … this time the letter was extremely (condescendingly) thankful and praising my superb scientific acumen …. while skirting around the fact that they STILL kept the scope of the conclusions to exceed the experiments.

    I gets exhausting dealing with big egos (and frankly … sociopathatic personalities). When the second revision came around and the title had become convoluted but still over-reaching, I was tempted to just recommend rejection and tell the journal I didn’t want to see it again. But I need to maintain a good relationship with journal editors …. and I know there’s some post-doc or some student who’s job applications and future prospects are being held up because this paper’s been under review for 6 months …. all because the graybeard senior investigator won’t tone down the importance of his work. Now I am the one who feels petty getting into a back-and-forth with a childish-acting oldie about the nuances of some obscure paper in a second-tier journal that I have zero interest in but I have already donated my time to trying to keep up to high standards.

    Swimming upstream.

    1. etatro says:

      I guess I just wanted to relate my story to explain how crappy stuff gets through peer review. Authors recommend reviewers … likely junior people in the field who may appear to be sympathetic to the need to publish in order to advance …. and then respond persistently and vigorously until the reviewer gives up in exhaustion/frustration … we get very VERY little recognition or credit for serving as peer reviewers, and we want to make it as quick and painless as possible. It maybe goes on a line on our CV’s that no one will read … what only matters for advancing is bringing in grant money, professional service & high scholarly standards be-damned. I am a proponent of open peer review, or a system where the reviewers’ names are attached to the article; and one should be judged also on the publications you review as well as those you publish. That’ll probably never happen, though.

      1. JD says:

        I too am a big proponent of open peer review, and I love the way PeerJ has been going about publishing. Specifically, they require open availability of the data and try to publish the review history next to every manuscript (still an option to decline).

        But, this study has some methodological problems

        1. Etatro says:

          The BMC journals are doing an open review now. I have one under revision at BMC-ID, and I like the process. pLOS One is now requiring raw data to accompany papers. A year ago, I tried to submit raw data as a supplement to a society journal (ASMicrobiology), and the reviewers thought it was unnecessary and my coauthors thought I was crazy. I thought it would have made for a good teaching data set, and I was applying for teaching jobs at the time and hoped to incorporate teaching / research. Alas, some old guard academics don’t see the benefits of transparency.

  14. JD says:

    Happy to see things like this being called out, lets me know that methodology still matters to some. Very surprising that unadjusted hazard ratios were not reported and that the outcome was not additionally analyzed as dichotomous. Bearing in mind that the sample size calculation was based on time to event, providing these in an author response would be an easy way to quell the levied criticisms. Even if the results were discordant, this would open a dialogue and show transparency. At least the unadjusted should be provided, as we have no way of knowing what this would be without the data in hand.

    The 10 events per covariate rule of thumb has great bearing on logistic regression models. In the time to event framework, this matters, but is only one aspect. If you consider what goes into a good power and sample size calculation, the probability of event is required, but one also needs to think about follow-up and (if possible) the survival distribution. So, for Cox models, all of these factors play a role in the ability to detect a difference within a given model.

    Your critiques are valid, but I would suggest one more that is a pet peeve of mine. The authors state that they assessed proportional hazards, but these results are not shown. It is unclear whether only the intervention was assessed or if covariates were also examined. This can wreak havoc on your models if not appropriately dealt with, maybe to a greater extent than having a relatively small number of events. Also, they show predicted cumulative incidence curves, and I am not sure whether or not these were predicted from the Cox model. If they were, then they tell us nothing about proportional hazards. A Kaplan-Meier plot would be free to cross and can show large violations.

    1. Ed Whitney says:

      For several years, JAMA had a requirement that industry-sponsored trials be analyzed by an academic statistician not involved in industry, but this was changed last year because the editors apparently decided that major threats to validity had been ameliorated by recent reforms in the reporting of trials.
      I am wondering:
      Was JAMA right to make this requirement in the first place?
      Was JAMA right to reverse its policy last year?
      Did any other journals follow JAMA in imposing this requirement, or was JAMA all alone in doing what it did?
      Would such a policy prevent journals like Cancer from publishing studies, whether industry-sponsored or not, which were analyzed in an unsound manner?
      Industry sponsorship appears not to be the only risk factor for biased analysis of study data.

      1. JD says:

        I think this might be a fair requirement for pharmaceutical or device manufacturers, to require independent analysis in an attempt to avoid selective reporting. I think the struggle is how you handle clinical trials that aren’t run by such companies. The Resuscitation Outcomes Consortium is a good example and has what I feel to be a nice model. EMS agencies across a number of sites participate and teams are randomized to various care modalities. What is useful is that all data storage and analysis occurs through a data coordinating center, with participating sites running all analyses through the center. Many other trials use the same strategy.

        In the ROC case, biostatisticians would not be considered independent, as they are part of the consortium and receive some level of funding through their participation. I wouldn’t consider that to be a risk to validity or fair reporting though, as I don’t perceive that there is a substantial motivation to massage data or selectively report findings. It is pretty clear that this would help no one, monetarily or scientifically.

        So the JAMA requirement is probably a good one in some cases, but it may be a better approach to increase transparency and accountability. A good start would be to make the de-identified data freely available, but that would be a pretty big request.

  15. qetzal says:

    Is it just me, or is Fig. 3 in that paper total misleading and inappropriate. All three panels show a large apparent difference between arms that doesn’t seem to jive with the actual numbers they report in Fig. 2. I note that the Fig. 3 legend says “Predicted cumulative survival….” Does that mean they’re presenting survival curves based on their multivariate model, rather than on the actual data? That seems to be consistent with this line from the paper:

    Multivariate analyses (see Table 2) confirmed that patients randomized to the Intervention arm had a significantly lower risk of disease recurrence (HR of 0.55; P = .034), as shown in Figure 3a.

    Is that really what they’re doing? Showing when people “should” have died according to their multivariate model? That can’t be considered a valid way to present data, can it?

    To me, it looks like they deliberately included these survival curves to give the obvious visual impression that there was an actual, real survival difference between their groups, and deliberately downplayed that these are hypothetical.

    1. JD says:

      Its common to report “predicted survival” in this manner, by fitting a multivariate Cox model and back-calculating survival or cumulative incidence (you can’t directly obtain the survival function from cox models, so we estimate). The problem is that I cannot tell if this is the case from looking at the graph alone and their description, in that I can’t tell if the steps are fixed or not. It could go either way. By not being clear in the methods and footnote, it becomes difficult to retrace their steps.

      To compound the problem, when you back-calculate survival, you have to assume values for each of the covariates. The default is usually the mean, which doesn’t make sense for categorical variables. If specified correctly, the curves would then represent the survival for a woman <35, who had chemotherapy, and had radiotherapy etc. There is nothing methodologically wrong with this approach, in that the statistics have been worked out to make this conversion, but it needs to be made clear what the curves represent. A simple statement in the footnote would make a world of difference.

  16. James Coyne says:

    Reply to 14 etaro I quite agree that there are important PNI claims that are quite legitimate. Some of of Barbara Andersen’s colleagues at Ohio University are Ron Glaser and his wife Janice Kiecolt-Glaser who have done incredible experimental work concerning effects of stress on wound healing. The results are robustly replicable, even if the mechanism remains controversial. Ron Glaser also has a very credible model of certain skin cancers that are not life-threatening, but nonetheless have traceable PNI effects.

    They were once listed as collaborators of Barbara Andersen, but when I asked Ron, he simply said that that was no longer true.

  17. James Coyne says:

    Reply to JD. Thanks for your comments. If you really want to take on the granddaddy of all claims that psychotherapy promotes the survival of cancer patients, see David Spiegel’s 1989 Lancet article. It has over 1000 citations, but claims begin to fall apart when you give a close look at the survival curves that are in the paper. No one can replicate the survival in the control group, but much of subsequent work replicates the survival curves for the intervention group for both intervention and control conditions. Furthermore, when results for appropriate median survival time, not mean survival time, they are not significant. It all comes down to some an unexplained clustering of four deaths in the control group.

    I provided a critique at this link here, but I will bet you can extend it.

  18. CrankyEpi says:

    Dr. Coyne, first let me say that philosophically I am right there with you. I am skeptical that psychological interventions can increase survival via “boosting the immune system.” The immune system is extremely complex; how do you measure it? However, I would interpret the COPE standard,

    “they have clear evidence that the findings are unreliable, either as a result of misconduct (e.g. data fabri¬cation) or honest error (e.g. miscalculation or experimental error)”

    to mean either outright cheating or basic mechanical errors such as “2+2=5” or “we thought we were using Sprague-Dawley rats but they turned out to be rats from the sewer.” I don’t believe your request will be granted because you are essentially arguing that the authors’ results are unreliable due to poor methodology and cherry-picking of results. If the latter is the case, the vast majority of the peer-reviewed literature should be retracted (I could be persuaded that this is in fact the case).

    Some specific observations:
    1. Many journals limit the information the authors can provide, so this would be an easy “out” for any author not including all results that could be of interest.
    2. Simple 2X2 chi-squared tests for recurrence or death are not seen as appropriate statistical tests when the follow-up times differed among patients. Did all patients have the same follow-up time?
    3. Relying on the p-value to tell you whether “there is a difference or not” is not sufficient. Absence of evidence does not equal evidence of absence; the power of the statistical test also needs to be established and the difference which would be considered “no different” needs to be established. An odds ratio of 0.74 is not very close to 1.
    4. “When positive results are obtained with unadjusted outcomes, readers’ confidence in them are increased when findings persist after adjustment for possible confounds. However, when positive results are obtained with unadjusted outcomes, contradictory findings after adjusting for confounds warrant special scrutiny.” This is an oversimplification. It all comes down to the myriad details of how the study was designed and executed. Even statistical analyses that are “perfectly” done cannot stand by themselves, especially considering the possibilities of selection bias (yes, a randomized trial can have selection bias) and information bias. I agree with the rest of your paragraph, but those points are not a basis for retracting an article.
    5. To Ed Whitney’s point, I have seen it recommended that analyses of data from minimization studies should be adjusted rather than unadjusted.
    6. A ratio of 5.6 observations to each event is not conservative but also not completely out of line.

    The authors found some pretty large differences between study groups which I do agree is surprising.

    1. Ed Whitney says:

      Thanks, Cranky. Do you happen to know if p values in minimization studies have the same interpretation as in randomized studies? If those conventional frequentist interpretations only apply to random samples, then what do they mean in minimization samples?

      Pretty arcane stuff but it may turn out to affect the way we evaluate evidence.

      1. CrankyEpi says:

        Hi Ed, I am going to confess to you that I am not an expert in this area. I can tell you that I have read that permutation tests should be done when an allocation method like minimization has been chosen instead of simple randomization. Meaning, as I read it, the distribution of the test statistic needs to be estimated through generating many samples which reflect the null hypothesis. So you’re right, it’s pretty arcane because under randomization the distribution of the test statistic is known through statistical theory.

      2. CrankyEpi says:

        I should have added that when the distribution of the test statistic is derived using statistical theory, one of the assumptions used is that the data are from a random sample.

  19. James Coyne says:

    CrankyEpi: I cannot predict whether our call for a retraction will be successful. However, our previously published detailed commentary warranted a response any provision of the data they could have readily settled the matter. Instead the authors attempted to block publication of our commentary and actually wrote to our institutions complaining that we were taken issue with important findings.

    We really need to see the data and I do not understand why it is not available.

    Please note that this trial did not preregister survival as an outcome. Given the survival rates of patients with early breast cancer, an effect on survival is quite implausible with a sample of this size. And the 11 year follow-up period is not prespecified and seems quite arbitrary.

  20. James Coyne says:

    Thanks all for your comments. I am sorry that I am not a always able to keep up in responding to them, but here goes another reply.

    I have no doubt that depressive symptoms are correlated with subsequent mortality if the depressive symptoms are assessed after the onset of cancer. The problem with depressive symptoms is there nonspecificity. They are so highly correlated with various aspects of physical condition including pain and fatigue and overall physical symptom burden that one cannot readily tease out a specific residual that resembles anything that we would think of as depression.

    I tried to make light of this serious issue in a talk entitled “”Why do we keep stalking bears when we only find scat in the woods?” The title refers to continually assuming that depressive symptoms are a risk factor when the ultimately turn out to only be a risk marker. You can find the slides for that talk HERE.

    The only study I know that is cited as demonstrating that improvement in depression care is associated with better improvement in the mortality of cancer patients is an extremely flawed BMJ article based on post hoc analyses. At the BMJ website, I left a challenge to the authors to produce some simple data needed to back up their claims. They have never responded, but you can see my challenge HERE.

  21. Michele says:

    Have you considered posting your concerns on PubMed Commons, PubMed’s ‘social media’ option? Not sure how user friendly the system actually is, but it seems like a sadly underused resource for drawing attention to problem papers.

  22. PMoran says:

    As I once tried to explain somewhat cumbersomely here — http://www.users.on.net/~pmoran/cancer/on_sustaining_hope.htm

    – a really pernicious effect of mind-body myths in cancer is that it actively discourages plain speaking within CAM circles.

    Within an “alternative” cancer mailing list or blog there will be some people who might think that, say, Hulda Clark was a seriously deluded old woman, but who won’t speak up because others may be staking their life on her advice and need to be protected from “negativity”.

    It is often also touch and go as to whether wise decisions are made in relation to the acceptance of mainstream care and the general mushiness of discourse creates an atmosphere of “choose your own poison”, so to speak.

    1. Windriven says:

      “[A] really pernicious effect of mind-body myths in cancer is that it actively discourages plain speaking within CAM circles.”

      Or any circles. This is an interesting comment coming from you, Peter. I hope that doesn’t sound confrontational because I honestly don’t mean it that way.

      In some of your earlier comments you seem to have taken a softer view of some ‘alternative’ therapies than some of the others here. But the present example instantiates why that can be problematical. When we stop calling BS for fear of alienating someone or treading on toes or casting doubt on some treatment imbued with a dying patient’s hopes, we really do no one a service.

      Are you suggesting some balance that is not intuitive clear – at least to me?

      1. PMoran says:

        W: “In some of your earlier comments you seem to have taken a softer view of some ‘alternative’ therapies than some of the others here.”

        Fair questions.

        You presumably have in mind those occasions when my misgivings about the quality and style of material published here was trivialised as “clutching at my pearls” at “meanness towards CAM”? (Even though visitors not uncommonly express somewhat similar sentiments and at least one regular commenter has said she would not refer her friends here).

        Intriguingly, the snark, condescension, ridicule, etc. were defended as being justifiable ways of getting certain points across about science and medicine.

        Yet when I lapsed into similar styles of debate, as we nearly all do at times, I was “putting people off” and generating “more heat than light”, even with this sophisticated and battle-hardened enclave.

        That, of course, was MY point. I am prepared to admit that I WAS sometimes guilty in that regard and that I will probably not always be free of those tendencies in the future when engaged in the to-and-fro of debate.

        I still think it is arguable whether it is desirable for such tendencies to be so prominent on a site named in such a way that people will come to expecting the calm, confident, cautiously precise, qualified voice of science, perhaps hoping for concise, easy-to-find information, and finding something else altogether.

        If I can explain my views further, it should be clear by now that while the usual medical sceptic sees CAM as a somewhat uniform shade of black with a little grey at one edge, and with only some exaggeration a threat to civilisation as we know it, and as an utterly disposable phenomenon, I see a great range of activities that stretch from fairly white in their native settings down to a small black deep where wholly evil people knowingly deceive very ill people. .

        The white is when CAM-based activities satisfy certain kinds of human needs, including limited medical needs, in a reasonably safe manner and in ways that are not necessarily always readily or as safely obtained within the mainstream. Science does not preclude this, while making it pretty certain that no form of pseudoscience is involved by offering plenty of more likely explanations for any benefits observed.

        Also, quackery is not a property of methods, as such. It applies to claims that might be made concerning them. A single method might be encased in numerous claims with varying degrees of validity or invalidity (?).

        I also see CAM use as partly a response to certain limitations and characteristics of the mainstream, which are not going to change overnight. That changes how I want to talk about it to that part of our audience that is only too acutely aware of those limitations.

        In summary, I am inclined towards a discriminatory and proportionate response. We don’t want to risk being misunderstood and dismissed as a zealots or extremist by getting too excited about matters having the cosmic significance of a cosmetic commercial. . I also favour a main focus upon where the real dangers lie, because that is easy for everyone to understand. I favour consciously working towards regaining lost public trust, which means putting at least as much energy into setting our own house in order.

        1. Windriven says:

          Peter, I don’t always agree with you but I always enjoy – and am often influenced – by reading you.

          ““more heat than light””

          I think that was me. And to be fair, I believe I used that phrase to characterize some of the exchanges between you and Drs. Gorski and Pavlov when they got more embittered than enlightening.

          “Also, quackery is not a property of methods, as such. It applies to claims that might be made concerning them. A single method might be encased in numerous claims with varying degrees of validity or invalidity (?).”

          Accurate. But I’m trying to decide if it is also true. Consider acupuncture; among the less black of the sCAM modalities. It is difficult to separate acupuncture from the overblown claims made for it. Are you not saying in effect that astrology is fairly harmless; that it is the money-grubbing astrologers who make unrealistic claims for its abilities that mark the evil?

          “We don’t want to risk being misunderstood and dismissed as a zealots or extremist by getting too excited about matters having the cosmic significance of a cosmetic commercial.”

          That is a great line. But again, is it accurate? Where is the line between the serious and the insignificant? Steven Rodrigues and his magic needles strike me as being decidedly on the serious side of the line. Others perhaps not.

          “I also favour a main focus upon where the real dangers lie, because that is easy for everyone to understand. I favour consciously working towards regaining lost public trust, which means putting at least as much energy into setting our own house in order.”

          Hard to disagree. But where do the real dangers lie? I certainly agree that it is easy enough to waste fire on meaningless targets. But I’m struggling to think of a meaningless target that has been addressed in these pages recently.

          There are lots of gray areas in medicine. But the range of practices from acupuncture to reiki are a dark enough shade of gray to be indistinguishable from black, absent some new and breathtaking evidence. Isn’t our time better spent sorting out those things that really are gray than pretending that, say, homeopathy might be a little gray if you hold it in the light just so?

          “In summary, I am inclined towards a discriminatory and proportionate response. ”

          Mea culpa. Kinda.

          Thank you for a reply more thoughtful than I sometimes deserve. And keep working on that guest blog. It will be great fun to read. And it might set a new record for number of comments ;-)

          1. DevoutCatalyst says:

            > Consider acupuncture; among the less black of the sCAM
            > modalities.

            Where does one buy this less than black variety of acupuncture? Skimming acupuncture blogs reveals a realm indistinguishable from chiropractic in the zeal for making the $$ green stuff out of the black stuff.

            1. Windriven says:

              A valid point, DC. But compared to, say, homeopathy or reiki, acupuncture is slightly less unbelievable. I’m not sure which sCAM modality I could have chosen that would have been less-blacker ;-)

              1. MadisonMD says:

                [C]ompared to, say, homeopathy or reiki, acupuncture is slightly less unbelievable.

                …and to weigh against that greater sliver of possibility, it has slightly more risk [Ernst][MacPherson et al.][Yamashita and Tsukayama]

            2. Windriven says:

              @Madison

              Thanks for the dope slap. Having reread my remarks I regret having chosen any sCAM as an exemplar of the less black. BS is BS. BS that doesn’t stink particularly badly is still BS.

              1. PMoran says:

                “Thanks for the dope slap. Having reread my remarks I regret having chosen any sCAM as an exemplar of the less black. BS is BS. BS that doesn’t stink particularly badly is still BS.”

                Oh, W, and you were so close to a less simplistic point of view!.

                Why would this supposedly medically educated, even “science-based”, group be unable to distinguish between the various questions that the practice of acupuncture raises? The urge to quash Chinese medical theories, that hardly anyone else is taking too seriously, is addling your brains.

                Here is some homework for you all. Explain why SBM authors and commenters can generally accept that that spinal manipulation is effective for some types of back pain, but not that acupuncture is effective for anything.

                My point is not to endorse or “debunk” either, but to point out that the evidence for both, including their ability to exert various non-specific physiological and psychological therapeutic influences, is almost identical. Yet one is being held to be white or only slightly off-white and the other jet black, in terms of SBM’s simplistic categories for “quackery” or “BS”.

                The above two are almost exactly comparable scenarios, with some uses of spinal manipulation, and some explanations as to how it might work also qualifying as deep quackery.

                I stand behind my “thought for the day” as stated above.

                “Also, quackery is not a property of methods, as such. It applies to claims that might be made concerning them. A single method might be encased in numerous claims with varying degrees of validity or invalidity (?).”

              2. Andrey Pavlov says:

                The urge to quash Chinese medical theories, that hardly anyone else is taking too seriously, is addling your brains.

                You’re right. The Cleveland Clinic is not serious. Nor is their in-house TCM herbalist center. Thanks for reminding us that nobody needs to be taking TCM seriously in order to make an entire herbalist center at a world-renowned academic facility based on it.

                Explain why SBM authors and commenters can generally accept that that spinal manipulation is effective for some types of back pain, but not that acupuncture is effective for anything.

                Well, gee. That really is a head scratcher.

                Let’s see. Because there is no direct mechanism unique to acupuncture that could be the mechanism by which to effect improvements in LBP, whereas in manipulative therapies there is.

                Because SMT is not inherently placebo but can be misused as placebo for indications that are unrelated to it, whereas acupuncture is always inherently placebo.

                Because using SMT for asthma is just as much quackery and operates by the same mechanisms as using acupuncture for LBP.

                Because there is no indication for which acupuncture can be used that isn’t fundamentally quackery and entirely reliant on placebo effects.

                Because mechanical issues are amenable to mechanical intervention, and SMT is intrinsically an active mechanical intervention. Tiny needles that of themselves and intrinsically do not elicit any sort of physiological or mechanical response make no logical sense to use for LBP or any other indication, any more than waving your hands and chanting does.

                My point is not to endorse or “debunk” either, but to point out that the evidence for both, including their ability to exert various non-specific physiological and psychological therapeutic influences, is almost identical.

                No Peter. You are dead wrong here. Acupuncture is only and solely 100% “various non-specific physiological and psychological.” Manipulative therapy is that plus direct physical action on the affected tissues in a manner that is consistent with the presenting problem. If you have a muscle that is spasming pushing on it actually directly does something in addition to all the non-specific effects. If you stick a needle in your ear even the same muscle that is spasming the needle does not directly do anything to the muscle.

                The evidence is not the same. The rationale is not the same. And to call them “nearly identical” is to stray very far from what the science actually tells us in order to entertain your fantasy of utility for acupuncture specifically as a distinct entity.

              3. WilliamLawrenceUtridge says:

                Explain why SBM authors and commenters can generally accept that that spinal manipulation is effective for some types of back pain, but not that acupuncture is effective for anything.

                Well, spinal manipulation has a mechanism of effect that is sensible, and specific tests for specific types of back pain have found specific effects.

                I don’t think anyone here would claim that acupuncture is not effective for anything, I think that’s a straw man. I think we would note that it lacks a meaningful and proven mechanism of effect beyond placebo, that there is no specific indication that well-designed research has proven it to be effective for (particularly over long time periods, and in a reliable manner), that the mechanics of it (needling location, manipulation, depth) have proven to be meaningless, and that the diagnostic system behind its conception and use (traditional Chinese medicine) is a prescientific modality of thought that has essentially no relation to the modern understanding of the body and therefore there is no expectaiton that it would, could, or should work. It’s not up to “us” to prove that acupuncture doesn’t work, it’s up to proponents to show that it does. And in a reasonable world, that recognizes the limited time and resources of society and scientists, reasonable people would agree that further research isn’t warranted since the results to date have been disappointing and prior probability is incredibly low.

                But if nothing else – acupuncture is probably effective for lancing boils and hemochromatosis.

                How’s that guest post coming along by the way?

  23. James Coyne says:

    “When we stop calling BS for fear of alienating someone or treading on toes or casting doubt on some treatment imbued with a dying patient’s hopes, we really do no one a service.”

    Wow, Windriven, That is seriously profound and I think a lot of us should start with it being our thought for the day. Thanks

    1. goodnightirene says:

      “When we stop calling BS for fear of alienating someone or treading on toes or casting doubt on some treatment imbued with a dying patient’s hopes, we really do no one a service.”

      No detraction from the brilliance of Windriven intended, but I say this to my altie acquaintances all the time. They usually grimace a bit and say something about, “well, it can’t hurt…..” or “health freedom”. Sigh. They know I’m right, but it goes against everything they’ve been thinking–just like religion.

  24. Etatro says:

    I think that john Sheridan’s animal model at Ohio State is an interesting example of neuroendocrine – immune – central nervous systems interaction re behavior & stress. He is in a different department than Anderson (whom I’ve never met). I think that Sheridan published previously a little bit in BBI but recently two papers went to J Neuroscience. At the 2014 Conference on Retroviruses and Opportunistic Infections (CROI), Ed Hammond gave an interesting presentation on major depression and CSF viral load in HIV patients, though the audiences raises the chicken/egg question and audibly guffawed at over reach on his perceived impact. http://www.croiwebcasts.org/portal;jsessionid=0F279B974018AC5793DA125EF788C7BA

  25. Ed Whitney says:

    A classic paper from 1980 by Lee
    et al “randomized” patients with proven coronary artery disease into “treatment” 1 (receiving the number 1) and “treatment” 2 (receiving the number 2). Patients were then followed for 5 years to ascertain survival and its association with “treatment group.” Overall the survival was equal, but patients in group 2 with three-vessel disease and an abnormal left ventricular contraction pattern did better than similar patients in group 1. When stratified on a prior history of congestive heart failure, the patients with three-vessel disease, an abnormal baseline left ventricular contraction pattern, and no prior history of CHF, the “treatment” effect was even greater, and remained statistically significant after adjustment for multiple prognostic variables.

    This paper should be remembered from time to time for discussions such as this one. It should be read by all medical students. The title is “Clinical Judgment and Statistics.”

    1. Ann says:

      Thanks so much for this link!

  26. Michael Stefanek says:

    Jim and others-very interesting discussion about the call to retract and issues related to mind over body claims in general, and those in the cancer domain in particular. I noted a few years ago (Handbook of Cancer Control and Behavioral Science)
    “perhaps it is not now too much to ask of researchers in this field to clearly articulate the model forming the basis of their research; develop distinct hypotheses to be tested; test these hypotheses with sufficient power to detect significant differences” and “it would be comforting to hope that researchers have at last reached a level of scientific maturity that allows them to listen to the now decades-old lessons of (Bernard) Fox (1978). ” Oh, well hope springs eternal. In a recent invited piece by David Spiegel (Br J Hlth Psych, 2013), the statements are made that “eight of 15 published trials indicate that psychotherapy enhances cancer survival times” and that “There is evidence from 15 RCTs indicating that effective psychosocial support improves quantity as well as quality of life with cancer.” The first, a clumsy and unsophisticated box score approach and the latter simply inaccurate. The entire article addresses not one criticque of findings and the body of work related to psychotherapy and cancer survival. That is not science-that is proselytizing-and there is far too much of this, unwillingness to engage in scientific discourse with those holding contrary views, and acceptance of lack of rigor in studies examining survival and increased survival. I suspect I am a bit more optimistic about this work than Jim, but my optimism requires me to be a cautious skeptic. Until we learn more about the complexity of the many purported mechanism of the mind-body link (dysregulation of the HPA axis, modulation of natural killer cell number and function, DNA repair, etc) it is very premature to leap to clinical trials….and there are many doing work in this area of much more basic and translational science-including many noted in this blog-the Glasers, Sheridan, some of Steve Coles work at UCLA that have and might contribute more of such knowledge. Thanks to all for a very engaging discussion.

  27. James Coyne says:

    Thanks, Michael for weighing in and well put.

    Some of you may recognize Michael as an author on the commentary on this paper to which Andersen refused to respond and on the systematic review of the larger literature.

  28. Ann says:

    My layperson thoughts…

    I squirm at the clamor for more and more woo in medicine. I am mystified at the number of my friends who are adding ever more varieties of CAM to their routines. I think that in some cases this is due to frustrations with aging bodies and niggling little complaints not worth discussing in our limited appointments with MDs. In other cases, I see this as related to general disenchantment with everything big and/or corporate. People tend to be blind to the bigness of alternative medicine. What they experience is more time with practitioners who give them lots of high touch (both literally and figuratively) and more time.

    A worry: as we begin to require people in the US to participate in health insurance schemes, will the demand for coverage for CAM increase (reasoning: you can’t make people pay for care they don’t believe in and deny coverage for care they do believe in)? There is so much of regular medicine that is unproven, still, isn’t there?

    Re: need for plausible mechanisms before pouring lots of time and money into research… Is this really the way it works? I can’t imagine that over the course of human history people understood mechanisms before learning useful things. Yes, there are countless silly correlations, but don’t some productive investigations come from curiosity about observations of correlations prior to understanding mechanisms whereas other research follows on detection of a promising mechanism?

    1. Harriet Hall says:

      We don’t require plausible mechanisms; preliminary indications that something actually works would be sufficient. We started using penicillin long before we understood its mechanism of action. Implausible things like acupuncture and homeopathy have been studied because they appeared to work, but studies showed that appearance was misleading. They have been sufficiently studied now that there is no need for further study, not because they are improbable, but because there is no convincing evidence for their efficacy.

      1. Only paid operatives would stoop this low. I must say you are biased, misguided, and have no concept of the discipline of Acupuncture or needling.

        5000 yrs + implausible do not match mathematically. You or yall need to reassess the studies and data. There is a truth in the discipline, a lot of us in CAM know it. You will feel ashamed when we find out who is paying you to maintain this stance with all the evidence.

        1. Harriet Hall says:

          No one is paying me. Your unfounded insults are becoming very tiresome.

          1. Chris says:

            I just ignore SSR, and don’t even read the comment threads that he hijacks. I am amazed at the patience of those who do chose to engage in any form of discussion with him.

            Though I keep wondering when patience on this blog will run out, and he will go the way of a select few like Thingy.

            1. Andrey Pavlov says:

              I just ignore SSR, and don’t even read the comment threads that he hijacks. I am amazed at the patience of those who do chose to engage in any form of discussion with him.

              Same here Chris. But, as you may remember, when I first came around to this blog (a surprisingly long 4 years ago!) I actively engaged Thingy and the other resident trolls. I found it to be a valuable exercise to cut my teeth on. Now, I find it much more a waste of my time than anything else, hence why I simply ignore SSR entirely. But there are others for whom there is still value and I would argue that the exchanges are valuable for others reading as an example of different schools of thought. The juxtaposition of legitimate attempts at rational discourse with the incoherent ramblings of a quack can provide a stark example to then better see more nuanced differences.

              In other words, like learning the “classic” presentations of disease and then using that as a foundation for learning the other various presentations and recognizing them for what they are.

        2. Dave says:

          “5000yrs + implausible do not match mathematically”

          I wonder if the ancient Mayans or the Druids in Europe would have said the same thing about human sacrifice to avert natural disasters.

          1. Exactly!! You are applying the same logic and reasoning to human sacrifice and the weather, as Acupuncture being implausible.
            Blinded by a higher power, you dogmatically think that Acupuncture is debunked. NOT so!

            Because there is an inherent truth in the “procedure” of placing a metallic needle into flesh/muscles to effect a cure as it relates to pain and neurovascular dysfunction.

            In reality “acupuncture” can save lives, pain and suffering, hospitalizations, surgeries etc!

            Not adopting “acupuncture” results in higher health care cost and subject people to torture and death.

            I know that is a true statement for reasons that you choose not to understand.

            So YES your logic and reasoning is as barbaric, illogical and superstitious as the Mayans!!!

            1. Dave says:

              The point, SSR, is that just because an activity has historically been used for a long time, does not mean that htere is any validity in the activity. Yet you continually use this argument to justify accupuncture.

              1. “validity in the activity.”

                Is exactly why you guys are misusing the term “science. ”
                You know we don’t have valid mechanism of action for many treatments we offer in medicine. Especially in this group who wish to discount innate healing.

                Can you prove that Acupuncture does not work??

              2. MadisonMD says:

                Can you prove that Acupuncture does not work??

                Toothpick study.

              3. WilliamLawrenceUtridge says:

                Is exactly why you guys are misusing the term “science. ” [snip]Can you prove that Acupuncture does not work??

                It’s amusing that you attempt to lecture others on the definition of the word “science” then follow that up with a commont that shows you don’t understand the principle of falsifiability. I mean really, it’s almost Poe. One never proves something doesn’t work – instead, the person claiming it does work must provide evidence for this fact. One can’t prove that unicorns don’t exist, those who claim unicorns do exist must provide evidence for this assertion in order to be taken seriously.

                The lack of perfect knowledge doesn’t imply that you can fill in the gaps with whatever nonsense most appeals to you.

                You know we don’t have valid mechanism of action for many treatments we offer in medicine.

                It’s true that in many cases the exact mechanism is not understood – but two things argue for there to be a mechanism once sufficiently investigated. First, there is good evidence that the treatment does work – take to groups, give one the new treatment and the other the old, then watch what happens with careful counting. If they end up the same, then that’s evidence that your treatment doesn’t work and you should stop wasting time and money on it. Second, many treatments involve general principles like “chemicals act on cells”. There is no need to adopt hitherto-unrecognized anatomical structures or laws of physics. Even if we don’t know the specific protein acted upon by the specific chemical, we still know that there is an effect and it is probably chemical.

                Especially in this group who wish to discount innate healing.

                Straw man – nobody here discounts innate healing. In fact, it is probably the most invoked reason for why patients appear to get better when they try things like acupuncture, chiropractic and particularly homeopathy. People try these modalities when symptoms are at their worst, which means innate healing gets ignored and the SCAM takes the credit. It is part of the placebo effect and part of the reason why your claims of “it worked for my patient” are ridiculed.

                A point you continue to fail to grasp.

            2. Windriven says:

              “In reality “acupuncture” can save lives, pain and suffering, hospitalizations, surgeries etc!”

              So where is the evidence, Steve? Your repeated assertions, no matter how heartfelt, aren’t evidence. Acupuncture has been studied ad nauseum so where is the evidence?

        3. WilliamLawrenceUtridge says:

          Only paid operatives would stoop this low. I must say you are biased, misguided, and have no concept of the discipline of Acupuncture or needling.

          Yes, my god, only a paid pharma shill would dare ask for well-controlled studies demonstrating objective benefit before asking patients, governments or insurance companies to pay money for something. How evil!

          5000 yrs + implausible do not match mathematically. You or yall need to reassess the studies and data. There is a truth in the discipline, a lot of us in CAM know it. You will feel ashamed when we find out who is paying you to maintain this stance with all the evidence.

          Prayers have been used for 5,000+ years, to a multitude of gods, spirits, angels and ancestors. When we substituted “hey, let’s count how many people die” for prayer, life expectancies rose and child mortality fell.

          Maybe we should go with something other than “but it’s really old” as our criteria.

  29. DClarke says:

    We should be careful not to move from saying that people going through hard times could do with additional support, to saying that people going through hard times should therefore be provided with psychological interventions. Often people’s friends and families are preferable providers of emotional support to those being paid to provide care within a medical system. As with any medical intervention, we should have good evidence that the benefits of intervention outweigh the harms before recommending it. Some people quite legitimately find the medicalisation of the psychosocial aspects of their lives to be an unsettling intrusion.

    1. n brownlee says:

      “Some people quite legitimately find the medicalisation of the psychosocial aspects of their lives to be an unsettling intrusion.”

      Yes, absolutely; what an excellent point.

  30. DClarke says:

    (That was intended to be a reply to 8. Frederick and dw)

  31. PMoran says:

    “I don’t think anyone here would claim that acupuncture is not effective for anything, I think that’s a straw man.”

    They do and it’s not. There is very rarely any overt acknowledgement of potential benefits.

    Steve Novella, who otherwise adopts a unadorned scientific style of writing which makes his pronouncement more forceful, makes bald statements like, “it doesn’t work”. Mark Crislip says: “Since SCAM effect = placebo and placebo effect = nothing, therefore the SCAM effect = nothing”.

    Andrey, plausibility is a semi- subjective judgement, and also one not so easily applied to complex interventions such as acupuncture, that may be invoking a variety of additive non-specific therapeutic influences in those for whom it is culturally acceptable.

    About a week ago I sent a rather long blog post to Dr Gorski. It was hastily put together, but probably conveys some idea of what I am getting at and why.

    1. Andrey Pavlov says:

      They do and it’s not. There is very rarely any overt acknowledgement of potential benefits.

      I’ll agree with you (and disagree with WLU). I think it is fair to say acupuncture doesn’t work and it is not effective for any condition. The ritual of it recruits placebo and other non-specific effects for some subjective amelioration of certain symptoms. The reason it is reasonable and scientific to say “it doesn’t work” (as Dr. Novella accurately does) is that “it” is a direct object referring to acupuncture and it is everything except “acupuncture” that has any effect and even then that effect is small to maybe moderate and only in certain specific cases under certain specific circumstances.

      There are no potential benefits of acupuncture unless you mangle the definition of it to mean “any random collection of things, with or without needles, or using any other of a number of random “tools,” using any number of entirely random approaches with any number of random “points” on the body that are happened to be called acupuncture.” A definition so broad that literally anything someone wishes to simply call acupuncture is. In which case the term becomes meaningless since I could then play dice on my patient’s back (with some nice candles and music in the background, of course), call it acupuncture, and claim “it works!” when my patient reports a modest improvement in subjective pain. And then charge them $60 for the privilege.

      Andrey, plausibility is a semi- subjective judgement, and also one not so easily applied to complex interventions such as acupuncture, that may be invoking a variety of additive non-specific therapeutic influences in those for whom it is culturally acceptable.

      Sorry Peter, physically pushing on a sore muscle vs inserting (or not!) a needle so thin as to be not felt in a distant location does not exactly lend much room for subjective analysis as to mechanism and plausibility of intrinsic efficacy.

      You are reaching deep to conflate ideas and continue on with these mystical and undescribed “variety of additive non-specific therapeutic influences” as your get out of jail free card.

      About a week ago I sent a rather long blog post to Dr Gorski. It was hastily put together, but probably conveys some idea of what I am getting at and why

      Can’t wait.

    2. WilliamLawrenceUtridge says:

      They do and it’s not. There is very rarely any overt acknowledgement of potential benefits.

      Of course not, for the same reason the placebo benefits of thalidomide are not discussed. Good medical care should inherently provide a placebo effect. If it does not – that’s a reason to improve the placebo-delivering skills of the medical practitioner, not a reason to pretend placebo effects are worth delivering in isolation. If you think they are, well, I think that’s exasperatingly short-sighted of you. I certainly don’t think those placebo effects are worth the pernicious criticisms of real medicine that CAM always brings to the table, and I think it’s a dangerous, slippery slope for real doctors to try to deliver placebo effects alone. Perhaps we part company here – I can see how someone could hold this belief, I just think it’s dumb.

      1. WilliamLawrenceUtridge says:

        Ah, though I should recognize that I am not and have never been a doctor. So my purely theoretical knowledge and opinions totally uninformed by real-world experience are of questionable merit. If I had to deal with years of vague complaints and antibiotic-demanding earaches, I might change my tune.

  32. PMoran says:

    Andrey, I think the “we define acupuncture thus, therefore — ” approach is an embarrassment, given your scientific pretensions.

    For the purposes of practical medicine and also for further exploration of the theory and substance of therapeutic interactions there are a variety of general concepts of “acupuncture” and it is the interaction of those, various practices that arise from them, and individual patient requirements and inclinations that will determine medical outcomes with symptoms and psychosomatic states.

    That is, unless you want to take ancient TCM theory far more seriously than I do, and more than many acupuncturists do.

    Interest in this will go on regardless of how a reclusive order of scientific monks defines “acupuncture”, so as to be able to write down “it doesn’t work” in their gospel and then attempt to convert the rest of the world to what is almost certainly a grossly simplistic point of view. It even has to dispose of some of the evidence by being presumptuous enough to as to say that the level of averaged benefit constantly reported in a certain kind of study is too small to be of use to patients with chronic pain.

    WLU, you illustrate how the committed sceptic’s mind habitually leaps forward into “foreseeable” consequences (“Oh God, we will all have to prescribe placebos !”) and then allows such ill-thought-through anticipated outcomes to feed back into the scientific process. That’s wrong. It’s not how science should work. It corrupts the whole process.

    I have thought this partially through and I do not envisage the mainstream endorsing the use of placebo, or CAM in routine patient care — as I have now said many times.

    1. Harriet Hall says:

      “regardless of how a reclusive order of scientific monks defines “acupuncture”, so as to be able to write down “it doesn’t work” in their gospel and then attempt to convert the rest of the world to what is almost certainly a grossly simplistic point of view. ”

      That is untrue and offensive.

      “I have thought this partially through”

      I wish you would think it through the rest of the way before you chastise us. It’s just possible that some of us have thought it through the rest of the way and reached different conclusions.

      1. PMoran says:

        Harriet — So, it is offensive to suggest that certain statements keep cropping up, dogma-like ,within this echoing cloister, simply because no one dares challenge them — yet Dr Gorski likening Dr Brigg’s whole enterprise to a “turd”, and encouraging readers to let her know that he has said so, is not?

        So far as what may have been “thought through” behind the scenes I can have no knowledge.

        1. WilliamLawrenceUtridge says:

          …and whatever does happen up front, you are perfectly willing and able to spin in a negative direction apparently.

    2. WilliamLawrenceUtridge says:

      WLU, you illustrate how the committed sceptic’s mind habitually leaps forward into “foreseeable” consequences (“Oh God, we will all have to prescribe placebos !”) and then allows such ill-thought-through anticipated outcomes to feed back into the scientific process. That’s wrong. It’s not how science should work. It corrupts the whole process.

      That’s not my concern at all. My concern is not that a doctor will inevitably end up like that cretin Steve Rodrigues (though without a reasonable grasp of science and cognitive biases, that is an obvious concern). My concern is that doctors will, in some patient interactions, prescribe placebos alone in the guise of being an effective treatment. This is corrosive to the ethics of the doctor, a danger to the patient (because it means the doctor is less likely to listen carefully for vague symptoms that could indicate serious disorder – an abdominal aortic aneurysm can mask as just fatigue), and generally reduces the ability of each to be honest with the other. And if the patient finds out the doctor has been prescribing solely placebos, their faith in the medical system itself is shaken – doctors become the paternalistic, uncaring caricatures that CAM proponents pretend they* are, perfectly willing to do or say anything to their patients to shut them up – at minimum in the mind of that patient, and probably their friends and family, if not strangers on the bus.

      So please don’t pretend I said “prescribing acupuncture leads inevitably to prescribing only placebos at all times”. You’ve complained enough times about being misunderstood, well please improve your reading or restatement abilities because you know how irritating it is.

      *Almost said “we” there for a second, how’s that for a grossly inflated sense of self. “I’ve argued with people on the internet, I’m totally the same thing as a doctor! I should go on The View!”

    3. Andrey Pavlov says:

      Andrey, I think the “we define acupuncture thus, therefore — ” approach is an embarrassment, given your scientific pretensions.

      The very foundation of good science is defining what you mean and doing it carefully and accurately. It is not WE that define acupuncture in that manner. It is the acupuncturists themselves. It is how they practice it. Take away the needle and the lay population does not think of acupuncture anymore. Yet the needle is not necessary for the effect.

      Now change it, called it “acupressure” and now we don’t need the needle and it is a whole new “therapy.” But not really, because it pushed on the special points that the needles went into and it still works! But it still gets to borrow from the fallacious legitimacy of its cousin, acupuncture. It still stems from “thousands of years old medical tradition.” It still “unblocks qi.” It still uses “meridians.” Which points? Oh, those don’t actually matter either.

      So now we have… what exactly? Well, let’s still call it “acupuncture” or “acupressure” and then say that anything remotely resembling the practice in at least one facet can fit under that umbrella. Oh and they best part? They all still “work,” of course. Just like how all the religions are still “true.”

      That is, unless you want to take ancient TCM theory far more seriously than I do, and more than many acupuncturists

      And you say we over reach? LOL. You presume to know how seriously “many acupuncturists” take their livelihood? Convenient in that it allows you to simultaneously indict me for taking a topic “too seriously” because “many acupuncturists” surely don’t take it that seriously. It’s only their livelihood that their associations have fought to gain state recognized licensure. All which is – at least ostensibly – based in some permutation of TCM (though as WLU has pointed out there are Japanese and Korean versions as well). But I am the one that is wrong for taking them at face value, accepting their clearly stated (scientifically and legally) premises as true, and you, the mighty Peter Moran, is smarter than that and can read between all those lines and finds that in reality, they don’t take TCM all that seriously. Which means… what exactly? That they are being active frauds? Knowing that the fundamental basis, justifications, and rationalizations for their livelihoods is really not “serious” just something used to get that pesky state licensure and something to tell their “clients.” Or that we, too, are supposed to take the same loosey-goosey stance on it and just sort of look at the lot of it obliquely and squint hard enough that “acupuncture” simultaneously means something that can be described, tested, and shown to work and yet at the same time be acceptable as a nebulous hodge-podge of stuff that isn’t actually taken all that seriously (so stop being such a pedantic asshole about demanding it be described accurately and consistently)… oh, but still “works” somehow.

      And how again does that square with your consistent argument that we should give these practitioners a pass because they really and truly believe they are helping their clients and are not at all intentional frauds and feel the same social onus and satisfaction in helping people that you and I do? Are they taking it “seriously” or not, Peter?

      Interest in this will go on regardless of how a reclusive order of scientific monks defines “acupuncture”, so as to be able to write down “it doesn’t work” in their gospel and then attempt to convert the rest of the world to what is almost certainly a grossly simplistic point of view.

      Interest in creation research and “scientifically” studying and 6,000 year old earth will go on regardless of how a reclusive order of scientific monks defines “creation” and “evolution.

      Oh, and just like… open your mind man… stop being so… “simplistic” in thinking about “acupuncture” as this “thing” that should be, like, “defined consistently” and reflect what actual people call “acupuncture” and you too will see how when you stop thinking about it the wrong way it will totally start to “work.”

      WLU, you illustrate how the committed sceptic’s mind habitually leaps forward into “foreseeable” consequences (“Oh God, we will all have to prescribe placebos !”) and then allows such ill-thought-through anticipated outcomes to feed back into the scientific process. That’s wrong. It’s not how science should work. It corrupts the whole process.

      That is reason added. It is plenty enough to say and do the exact same things just for the sake of being clear that acupuncture is a waste of time, money, and resources (intellectual or otherwise).

      1. WilliamLawrenceUtridge says:

        though as WLU has pointed out there are Japanese and Korean versions as well

        Japanese, Korean, Thai, Tibetan, Russian, French, German, “medical” (which seems to be British).

        Acupuncture buds off into something new every time it encounters a new culture, and changes throughout time. This is one of the arguments against it being a real, effective form of treatment – because only the general ritual stays the same, but the specifics vary and are re-interpreted.

        With real medicne, it doesn’t matter what language you speak, or where your parents came from, or your geographic location – all that matters is the specific medicine or surgical technique.

      2. PMoran says:

        Andrey, you hate me drawing attention to this, but your coming late into medicine and into healthfraud activities does mean you have major gaps in your knowledge. You have demonstrated it on numerous occasions yet you still presume to know it all, perhaps feeling safe so long as you are echoing what you believe to be prevailing opinion on SBM.

        You are apparently unaware that acupuncturists have been looking for other explanations than TCM theory as to why it seems to work for a very long time. The first variant of “gate theory”, for example, was first advanced way back in the 1960s but is now discredited. It also drives the sceptic mind nuts when acupuncturists express satisfaction when sham acupuncture seems to work, yet this is a further manifestation of a limited commitment to their own theories. They just believe “it works somehow”, exactly as I stated. This fellow is representative. http://www.healthy.net/scr/bio.aspx?Id=175

        So your derision at my statement that “many acupuncturists do not take TCM theory seriously” says something about your understanding of the medical world, and not a lot about me. So does your likening me to an arsehole, but I guess you learnt that debating style here, too.

        You yourself have agreed that CAM methods may help people with some conditions via placebo and non-specific influences. So you, too should be arguing for a more qualified statement of the scientific position than “it doesn’t work”.

        Who are you fooling by with your pretension that a general readership will discern an unspoken “according to our definitions” rider to such statements as “it doesn’t work” or “SCAM effect = nothing” ? Yourself only, I submit. And how is such a “near enough is good enough” approximation of “the truth” justified , when at stake are possible small or modest benefits to some patients, perhaps with difficult conditions such as some kinds of chronic pain?

        I believe I am right that it is a fear of certain implications (or perhaps mainly that of having to humbly backtrack from previously stated positions) that is driving medical scepticism to depart from its own standards of logic, rational analysis, consideration of ALL the evidence, and caution in expression when the evidence is unclear.

        I am not asking for much. “It doesn’t “work” other than, and within certain limitations, via placebo and a variety non-specific therapeutic influences” would do, being more accurate, more in accord with what the public already senses and being less instantly and deeply alienating of persons who think they have experienced benefits from such methods. It leaves the way open for some common understanding and for fruitful dialogue with CAM users and practitioners.

        When talking to patients considering acupuncture I would start with “well, it seems to help some people feel better” (implied reservations that the patient can explore if they really want to know) “.

        You say — “Yet the needle is not necessary for the effect. ”

        And you think I have not considered that?

        For MY hypothesis it does not matter too much if the skin is being penetrated or not, only that the patient thinks the skin is being penetrated, which of course was also an objective within those studies.

        That alone may induce useful neurotransmitter activity including endorphin release, as well as being necessary for the credibility of the treatment to some patients.

        I am sure the needling will also be painful sometimes — it is just not possible to penetrate the skin on some parts of the body without ever causing pain, and that will have additional distracting and counterirritant effects. This probably accounts for some of the consistent small benefits of “real” over “sham” in studies which use toothpicks or fake needles as the sham.

        1. Sawyer says:

          Andrey, you hate me drawing attention to this, but your coming late into medicine and into healthfraud activities does mean you have major gaps in your knowledge….

          For someone that constantly complains about tone/style/personalities of people at this site, I cannot fathom why you keep making these rookie communication mistakes. There’s not a single person here that doesn’t know Andrey is young, nor is there a person that doesn’t recognize the value of experience in medicine. You just told us something really obvious, and managed to do it in a way that comes off as an insult to Dr. Pavlov … and that’s in your FIRST sentence. Why? Do you think Andrey or anyone else is going to read the rest of what you wrote with an open mind? You’ve set yourself up for failure.

          I really hope you’ll continue to contribute actual medical knowledge to these discussions, but if you wonder why no on heeds your gripes about effective communication, this is the reason. You can’t demand that other people stop making the very same mistakes that you make on a regular basis.

        2. Andrey Pavlov says:

          Andrey, you hate me drawing attention to this, but your coming late into medicine and into healthfraud activities does mean you have major gaps in your knowledge.

          Predictable, as always.

          They just believe “it works somehow”, exactly as I stated. This fellow is representative.

          Indeed. Let’s shift to an anecdote showing that of course not every single acupuncturist is a robot with the same mind when it is convenient to your narrative. It ignores the basis of the licenses that offer validity to the claims in the first place. Do acupuncturists, acupuncture assistants, and acupuncture detoxification specialists (3 licences available in my state) get a license by saying “it just works somehow?” No, it is there because they claim to be part of a “medical system.” The fact that now they are scrambling to find “any way it may work” is because of the pressure of coming up with nothing being highlighted by the likes of us. It is not representative of what the actual origins and majority of practitioners and relevant “professional” bodies found their “practice” on.

          So does your likening me to an arsehole, but I guess you learnt that debating style here, too.

          Please let me refer to your first sentence I quoted at the start of my comment.

          You yourself have agreed that CAM methods may help people with some conditions via placebo and non-specific influences. So you, too should be arguing for a more qualified statement of the scientific position than “it doesn’t work”.

          No, I shouldn’t. It does not necessarily follow that I must say something “works” when that something is not the actual thing working.

          Who are you fooling by with your pretension that a general readership will discern an unspoken “according to our definitions” rider to such statements as “it doesn’t work” or “SCAM effect = nothing” ? Yourself only, I submit.

          The argument, Peter, is not that they must somehow understand our inscrutable definition. It is that your definition is unscientific and that ours is what the acupuncturists themselves are defining it as. We’ve been through this before where you tried to lambaste Dr. Novella when he did provide a definition of acupuncture in a post he made here. You said it was an inappropriate definition. When it was pointed out to you that it was the definition provided by the authors of the paper themselves you managed to somehow turn that into you still being correct. And pulling back from the specifics of the post to some nebulous and rarified “acupuncture” that only you seem to see and is not what the acupuncturists themselves defined it as. You talk about me and my lack of knowledge and experience and yet always manage to step aside the fact that you are slippery and loose with your words, shifting as seamlessly as chiropractors do when discussing “subluxations” and “subluxations.”

          And how is such a “near enough is good enough” approximation of “the truth” justified , when at stake are possible small or modest benefits to some patients, perhaps with difficult conditions such as some kinds of chronic pain?

          Well, it is justified just a teensy bit more than your convenient assertion that the mystery of the mechanisms of action of “massage” and “acupuncture” are essentially identical. Recall that recently? Your sheer incredulousness that we would give massage any sort of pass but be so harsh on acupuncture because, to you, their mechanisms of action, plausibility, and evidence are miraculously indistinguishable implying quite clearly that we are not scientific but merely ideologically driven against acupuncture. And once again, Slick Peter comes out when I explain the painfully obvious distinction by saying:

          Andrey, plausibility is a semi- subjective judgement, and also one not so easily applied to complex interventions such as acupuncture, that may be invoking a variety of additive non-specific therapeutic influences in those for whom it is culturally acceptable.

          So once again, let’s refer to that first sentence I quoted.

          Things are semi-subjective and oh so complex as to be indistinguishable when Peter Moran says so and obviously scientifically clear and otherwise unjustifiable when Peter Moran says so. And if Peter Moran says that physically pushing on a tensed muscle and sticking a filiform needle in a distant location are to all eyes scientifically indistinguishable from each other, they are. And if Peter Moran says that the effects arising around, rather than from, acupuncture are actually really there and big enough to make a clinical difference despite literally thousands of studies that are all over the map, trust Peter; he can see things I (and others here) can only dream of one day being able to see.

          I am not asking for much. “It doesn’t “work” other than, and within certain limitations, via placebo and a variety non-specific therapeutic influences” would do, being more accurate, more in accord with what the public already senses and being less instantly and deeply alienating of persons who think they have experienced benefits from such methods.

          Well besides the fact that we sort of get what you are asking and have said so many times in the past, in fact saying we find it to be facile and nothing more than tone trollery, you have yet to convincingly demonstrate to anyone here that the consequences of the egregious activities you see us engaging in will come to fruition. Actually, more accurately, you have yet to demonstrate that only your outcome can come of it. You speak for the expected actions of a public both as if you know what those will be and as if SBM is the only voice on “our side” of the conversation. You are also very conveniently getting your knickers in a twist when we use the commonly understand and self-given definitions of acupuncture rather than your own, saying it is some uncommon and idiosyncratic definition but then decide that the common and lay person understanding of “works” is not reasonable for us to use and insist on substituting your own uncommon and idiosyncratic one as the better option. Heads I win, tails you lose.

          You incessantly refuse to understand or even acknowledge that there are many, many more voices than we. That each voice is valuable. And that all the evidence clearly indicates that a multi-faceted approach is always the best. One single strategy is doomed to fail. And we here prefer and are better at this tack. And, as you’ve seen, we’ve even had lurkers of all ilks come out and comment in the positive here recently. So clearly we cannot be doing it 100% wrong. You’ve yet to provide any convincing argument that we are even doing it mostly wrong (besides, of course, your learned opinion on the matter). And, quite frankly, if we are even doing it just mostly right that is good enough for us. We have our niche and will settle in to it. You don’t like it? Go somewhere else. Just like anybody else turned off by our message or how we deliver it. Though, anecdote after anecdote just keeps proving you wrong.

          Though you may have missed the recent interaction with <a href="http://www.sciencebasedmedicine.org/a-tale-of-quackademic-medicine-at-the-university-of-arizona-cancer-center/comment-page-1/#comment-235562Claudia who initially felt “This site strikes me as too dogmatic” and now says “Thank you for taking the time to sharpen my thinking skills and ways of categorizing and analyzing these various issues and treatments”

          Boy our tack is just clearly so wrong we can’t even do anything right.

          When talking to patients considering acupuncture I would start with “well, it seems to help some people feel better” (implied reservations that the patient can explore if they really want to know) “.

          Yes, we know you would intentionally frame the response so as to lead a patient to believe it works in a sense other than what you yourself admit. You chastise us for being so unscientific as to claim a [gasp!] difference between acupuncture and massage and yet are content to exert a little paternalism in knowingly misleading your patients who will view that statement as nothing short of a tacit endorsement. It must be nice to argue positions when you get to make up the rules as you go along in order to favor your preferred outcome.

          And you think I have not considered that?

          My apologies. I should have been more clear. You have considered it. You just haven’t been able to figure out what it means. Or you are content to play the same pseudoscientific shenanigans as the quacks in order to never be wrong.

          “[Medication x] is not necessary for the effect.”

          “You think I haven’t considered that? For my hypothesis is only matters that the patient thinks [medication x] has an effect, which of course was an objective in some studies”

          Congratulations. You have just shown me that we should have new highly effective placebo doctors. We should go chat with Andrew Weil and see about starting a fellowship in it. I’m sure the homeopaths would love to get in on that action.

          That alone may induce useful neurotransmitter activity including endorphin release, as well as being necessary for the credibility of the treatment to some patients.

          Indeed. So you, too should be arguing for more homeopathy as well.

          I am sure the needling will also be painful sometimes — it is just not possible to penetrate the skin on some parts of the body without ever causing pain, and that will have additional distracting and counterirritant effects. This probably accounts for some of the consistent small benefits of “real” over “sham” in studies which use toothpicks or fake needles as the sham.

          The one actually interesting thing you’ve said and something I myself hadn’t fully considered. Thank you for the excellent point.

          Acupuncture is intended to be unfelt. Feeling pain is typically considered an accident. Which is why my statement still stands – it is not a feature of acupuncture to feel the needles enter the skin, thus that cannot be scientifically referred to as the mechanism of action (despite your protestations otherwise). However, it is an excellent point that the occasional accidental twingle of feeling could be a possible explanation for the few studies that seem to show some difference between verum and sham acupuncture. Making it even less likely that there is actually anything there in acupuncture to “work.”

          1. PMoran says:

            “No, I shouldn’t. It does not necessarily follow that I must say something “works” when that something is not the actual thing working.”

            Andrey, I can’t be bothered to respond to everything. Some samples –.

            I did not ask you to “say something works”. In what you quoted from me, and were responding to I was merely asking for a “more qualified statement.” which would convey a more true and complete state of our knowledge

            You have produced no cogent evidence as to how what acupuncturists truly believe, but I have, and I will produce a lot more if you wish.

            It is true that it is difficult to detach acupuncture as a treatment protocol from its roots. It would probably not “work” as well if it were not a little mysterious, a little invasive, hands-on (seeking “de qui” probably helps) , involving repeated contact with practitioners and “time-outs” from daily life in a caring environment. When you say it is “other things” that are working, you are underestimating the difficulty in disentangling all the influences that are potentially involved.

            Your licensing argument doesn’t hold water. Chiropractors are licensed to treat subluxations that a lot of chiropractors don’t believe in.

            1. Andrey Pavlov says:

              I did not ask you to “say something works”. In what you quoted from me, and were responding to I was merely asking for a “more qualified statement.” which would convey a more true and complete state of our knowledge

              No, you are advocating deliberate misleading of a patient. If what the average Joe thinks of as acupuncture (TCM based needles therapy in specific points) does not actually elicit the effect (TCM, needles, and specific points don’t matter) then it is perfectly reasonably to say “acupuncture doesn’t work.”

              If you really want a more qualified an accurate statement it would go something like this:

              “While acupuncture doesn’t work, the placebo effects from the ritual as well as expectancy effects from doing something new and exotic do have some subjective effects on some people.”

              But people wouldn’t like being told that the effects are “all in their head” now would they? Because to them, that would mean it didn’t work. Which is precisely why it is reasonable to say, it doesn’t work.

              It would probably not “work” as well if it were not a little mysterious, a little invasive, hands-on (seeking “de qui” probably helps) , involving repeated contact with practitioners and “time-outs” from daily life in a caring environment.

              Precisely. Because it involves lying (intentionally or not) to the patient. And why you felt the need to put “work” in quotes.

              Your licensing argument doesn’t hold water. Chiropractors are licensed to treat subluxations that a lot of chiropractors don’t believe in.

              Oh please. It is extremely well documented here that it is a significant minority of chiropractors that don’t believe in subluxations. And that the schools, the licensing exams, and the professional bodies all explicitly demand that subluxation theory is the core of the practice. And what the legal status is based on. And why they lobbied to get “subluxations” covered under medicare so they can get away with seamless doublespeak.

              Your rebuttal is bone dry.

          2. As scientist you guys are locked in rock solid concepts and I fear are not doing any outside study.

            1. Acupuncture is not what you all think it is! There is Auricular, TCM French Energetic and my favorite Myofascial. The all have different intents and methodologies. The all use needles that will hurt, 60-70% will be felt by the patient and they know from experience what to expect, so you can not trick them. 15% of the points will make the patient day ouch or crap. 15% will felt only as a simple “touch sensation.”

            2. Acupuncture or needling can be so painful that patients will need laughing gas or a breather to withstand the discomfort. A lot of providers are too timid which will affect outcomes and frustrate patients.

            3. Acupuncture points as per the diagrams are just a starting place or guide and not an edict from the Chinese Gods.

            4. The overall therapeutic concept of yoga, massage, scraping, rolfing, adjustments and acupuntuer have a linking thread and that’s related to myofascial pain and dysfunction and Gunn/Cannon logic.

            5. Subluxation is an incomplete concept, just a name for a messed up spine/muscles/alignment for notation purposes, but the treatment compensates for the false belief.

            6. The business of medicine is in the way.

            7. It is not scientific and truly illogical to mix mathematical with biological science method.

            I’m disappointed that this most “prestigious” of SBM sites have the most closed minded of providers and scientist. You guys would not believe your loved ones if they gave you a testimony of a successful treatment.

            Don’t impose you incomplete conclusions on the public, that is unethical given the title of this site.

            1. Windriven says:

              “As scientist you guys are locked in rock solid concepts and I fear are not doing any outside study.”

              Very many of the people on this site are actively involved in research, Steve. But you don’t mean that kind of study, do you? You mean transmutation of lead into gold, the health impact of being born Leo with Sagittarius rising, and the wonder ours benefits of tincture of bat guano, don’t you?

              1. ” they know from experience what to expect, so you can not trick them. ”

              When acupuncture is tested, study populations aren’t chosen from those who have had acupuncture in the past. Those naive to acupuncture don’t know what to expect. The only trickery is from those who sell acupuncture as effective.

              2. “Acupuncture or needling can be so painful that patients will need laughing gas or a breather to withstand the discomfort.”

              Even if this is true, so what? It will hurt like hell if I smash your hand with a ball peen hammer. Does that make it an effective treatment? Because it hurts?

              3. “Acupuncture points as per the diagrams are just a starting place or guide and not an edict from the Chinese Gods.”

              The Chinese aren’t big on gods. Confuscius was never considered a god. Acupuncture points are supposed to be important to flow of qi. So what you are really saying is that none of that matters and you just poke around. Brilliant. And this differentiates acupuncture from theatrical placebo how???

              4. “that’s related to myofascial pain and dysfunction and Gunn/Cannon logic.”

              Yes, Steve. Unfortunately, the halls of science are littered with wonderful theories whose only shortcoming was that they were wrong.

              5. “but the treatment compensates for the false belief [in subluxations].”

              And if chiros stopped at LBP, no one would give them much grief. It is their claims that ‘adjustments’ can benefit anything else, much less their claims that they are competent to diagnose and treat complex diseases that are frank quackery.

              6. “The business of medicine is in the way.”

              Really? And you don’t charge for your quackish treatments?

              7. “It is not scientific and truly illogical to mix mathematical with biological science method.”

              You saved the best laugh for last! Mathematics is the language of science. We count, we measure, we quantify, we compare distributions, we examine frequencies and likelihoods. Mathematics is the language of those activities.

              I don’t know where you got your ‘education’ in mathematics or in the biological sciences but you should really see if you can get your money back.

            2. WilliamLawrenceUtridge says:

              As scientist you guys are locked in rock solid concepts and I fear are not doing any outside study.

              I will happily review any scientific publications you provide. I already did twice now, and both times the references you provided did give scientific support for your beliefs. Perhaps third time’s a charm.

              1. Acupuncture is not what you all think it is! There is Auricular, TCM French Energetic and my favorite Myofascial. The all have different intents and methodologies. The all use needles that will hurt, 60-70% will be felt by the patient and they know from experience what to expect, so you can not trick them. 15% of the points will make the patient day ouch or crap. 15% will felt only as a simple “touch sensation.”

              There’s a whole hell of a lot more than just those four, not that it matters. Let’s take your favourite – myofascial. What evidence supports its efficacy? Can you provide any references?

              2. Acupuncture or needling can be so painful that patients will need laughing gas or a breather to withstand the discomfort. A lot of providers are too timid which will affect outcomes and frustrate patients.

              So what you are doing here is moving the goalposts (and blaming the victim) – if the customer doesn’t get better, it’s their fault for not being able to tolerate the pain. It gives you a convenient “out” of they don’t improve. I’m sure you’ve got a lot more too.

              3. Acupuncture points as per the diagrams are just a starting place or guide and not an edict from the Chinese Gods.

              Indeed, the scientific literature shows that needling location doesn’t matter – nor does needling depth, skin penetration or diagnostic method. All that matters is the practitioner is enthusiastic, and the patient thinks they are getting the real thing. Which is why it’s considered a placebo.

              Also, here’s your second out – “you didn’t needle in the right place”.

              4. The overall therapeutic concept of yoga, massage, scraping, rolfing, adjustments and acupuntuer have a linking thread and that’s related to myofascial pain and dysfunction and Gunn/Cannon logic.

              And what sources support all of these?

              5. Subluxation is an incomplete concept, just a name for a messed up spine/muscles/alignment for notation purposes, but the treatment compensates for the false belief.

              Subluxations don’t exist, chiropractors can’t agree where they are. There’s no research support for it, and it’s hilarious to me that you claim they exist but chiropractors don’t understand them. “Out” #3, “subluxations aren’t completely understood/I’m the only one who understands them”.

              6. The business of medicine is in the way.

              Do you provide your services for free?

              How does medicine being a business prevent you from locating scientific research to support the services you charge for?

              7. It is not scientific and truly illogical to mix mathematical with biological science method.

              Do you even know why they use statistics in science?

              The only real reason you use statistics is to distinguish, in a structured way, between groups. If there is no difference between the groups in the first place, the statistics won’t help. A consistent finding of acupuncture research is that “real” and “fake’ acupuncture give the same results, including non-penetrating needles. How do you explain this, scientifically?

              Pretending biology and “math” can’t be combined scientifically is another “out”, a distraction from the fact that you can’t justify what you charge for scientifically.

              I’m disappointed that this most “prestigious” of SBM sites have the most closed minded of providers and scientist. You guys would not believe your loved ones if they gave you a testimony of a successful treatment.

              I certainly wouldn’t, I have a relative that believes in homepathy and high dose vitamins, and I think it’s nonsense and placebo. Anecdotes, no matter who they come from, are not useful for anything but hypothesis generation. Do you know what a hypothesis is?

              And you seem to have the impression that SBM is somehow the ruler or overlord of scientific medicine. It’s just a blog run by doctors and other health care practitioners (and a lawyer). Nobody here has control over anything but the contents of the blog. And none of them prevent you from conducting research, either on pubmed, or on your own. All science-based medicine asks for is evidence, and a coherent worldview that doesn’t give special treatment to sets of claims. You can’t provide evidence, and you are claiming above that acupuncture can’t be/isn’t researched like other modalities. Why not?

              Don’t impose you incomplete conclusions on the public, that is unethical given the title of this site.

              3,000 scientific studies of acupuncture, and after all that there is still no solid answer. I think we’re done, there’s no need for further research – acupuncture is an elaborate placebo.

              Also, unethical is subjecting patients to risks and charging customers money for an inert treatment. You should be ashamed.

        3. Harriet Hall says:

          @Peter Moran,
          “Andrey, you hate me drawing attention to this, but your coming late into medicine and into healthfraud activities does mean you have major gaps in your knowledge.”

          If that is so, how do you explain that I agree completely with Andrey? I will be 69 next month; I graduated from medical school in 1970. Do I have major gaps in my knowledge? How long does one have to be in medicine and healthfraud activities before one’s knowledge is as perfect as yours?

          It is despicable to attack Andrey for his age and inexperience rather than providing a reasoned, evidence-based refutation of whatever you think he is wrong about. It is an ad hominem attempt to persuade us that we should believe you over him simply because you are the voice of wisdom and he’s just a young whipper-snapper.

          You can take your “holier than thou” attitude and…. (I’d better censor the rest of that sentence.)

          1. brewandferment says:

            well, I think Andrey was too kind by calling him “Slick Peter” and at this point I think would be justified in replacing sl with pr…

            “holier than thou and do something anatomically impossible with it” is a politer way to say it than my old USN habits would be!

        4. WilliamLawrenceUtridge says:

          Andrey, you hate me drawing attention to this, but your coming late into medicine and into healthfraud activities does mean you have major gaps in your knowledge. You have demonstrated it on numerous occasions yet you still presume to know it all, perhaps feeling safe so long as you are echoing what you believe to be prevailing opinion on SBM.

          That sounds an awful lot like “since I can’t refute your argument, I’m going to claim you’re too stupid to see my point.” Now, I may lack your fancy learnin’, but I will point out that nobody seems to grasp your point, which suggests it’s either unconvincing, or you’re explaining yourself badly.

          That jab at “oh, you’re just here because you’re an anus-licking suck-up” is nice and subtle too by the way, ignoring the fact that Andrey does indeed disagree with others here – including me just above. And of course, also dodging why Andrey (and myself, and most of the contributors) agree on these topics – the data supports it and a common disgust at the lies and misdirection perpetuated by SCAM practitioners.

          Oh, and we love being super-mean.

          You are apparently unaware that acupuncturists have been looking for other explanations than TCM theory as to why it seems to work for a very long time.

          Isn’t it funny how they keep failing though? You know what consistently shows promise as a response and has never been refuted? Placebo effects, which are enhanced by nearly every aspect of the acupuncture ritual.

          Maybe it just. Doesn’t. Work.

  33. MadisonMD says:

    IMO it’s fine to give a placebo to the patient. However, this should be given with the honest information that is what it is. I find that when I honestly provide this information* patients are ok with it but have no tolerance for risk– hence a pharmaceutical is less acceptable than a B vitamin tablet with essentially no side effects. Yet most seem to choose of their free will not to have any placebo. Have I poisoned the well or have I done my duty to provide expert honest and complete medical information?

    *Unless perhaps it conflicts with strongly held beliefs.

    1. WilliamLawrenceUtridge says:

      But if you give a patient honest information that it’s a placebo, that undercuts the very effect you are trying to have. I suppose it depends on how you deliver it:

      - “This is a vitamin B6 pill. You do not have a vitamin B6 deficiency, so it won’t help with that, but it won’t do you any harm.”

      - “This is a sugar pill. There is nothing in it but sugar, it is a placebo.”

      While the first is accurate, the second is more honest to the intent. How much honesty would, should, could you give?

      Not that you can give one answer for all patients.

      1. Windriven says:

        Or … This is a vitamin B6 pill. There are no studies supporting its efficacy for the treatment of toenail fungus and no plausible action by which it might work has been proposed. But there have been anecdotal reports claiming benefits for some people. It is safe at the dosage that I am prescribing.

        1. Harriet Hall says:

          I think most patients would consider this a recommendation supported by “evidence” – the evidence of anecdotal reports. It would be better to include something about why anecdotal reports are not acceptable as evidence. If time is a factor, one could simply hand out a copy of Barry Beyerstein’s classic article about why bogus therapies seem to work.

        2. Andrey Pavlov says:

          Also bear in mind that these sorts of thoughts on phrasing placebo-ish medicine is something one can only even consider, let alone do, on an individual basis. With the patient in front of you, rules can be bent in order to make sure you are both communicating effectively for the patient and keeping lines of communication open and strong.

          It is a different story when speaking at large in a non-professional (or at least non-clinical) setting.

          1. PMoran says:

            “It is a different story when speaking at large in a non-professional (or at least non-clinical) setting.”

            Why should there be such a vast difference in approach, when most audiences will include the very same people with the very same questions?

            Look, I would not mind so much if it was admitted that an “end justifies the means” approach is guiding some sceptical rhetoric rather than “this is what the science says” . That might, depending upon personal taste, go some way towards justifying the pretence that certain statements (e.g. “it doesn’t work”) along with the interpretation clearly intended for them are entirely consistent with the evidence and with a strong scientific consensus, when they are not other than in the limited sense of having any unique physiological activity.

            I would also not mind so much if I thought the “ends” those means are justifying had been well thought- through, so as to be sure that the presumed adverse consequences of making more accurate statements were inevitable, and that the ends envisaged from misleading the public concerning the potential of placebo and non-specific influences are more realistic, rational, entirely desirable, even helped by using such a deception/oversimplification when the public is already mostly very aware of such possibilities.

            I would not mind so much if we were not trying to dominate what people do when the limitations of mainstream medical attentions have been reached or where there is no entirely satisfactory medical treatment in terms of efficacy or safety. We still have a duty to advise, but in my view we should be sure that such advice conveys accurate information and is consistent with individual patient welfare at all levels.

            As always, such discussions come back to the assumption that doctors would have to use placebos or CAM. They would not, and I regard my next task as explaining why that would be so. Andrey touched upon one reason with his remark that responsiveness to expectancy and non-specific influences will be a very individual matter.

            1. Andrey Pavlov says:

              Why should there be such a vast difference in approach, when most audiences will include the very same people with the very same questions?

              Seriously? Because it is a different audience in a different setting with a different construct. I’m baffled you would even ask this question. The old idiom “know your audience” doesn’t mean anything to you? That speaking to a patient in a consultation room is entirely different to speaking to a group of patients in a group session, to speaking to medical students in a lecture, to speaking on public TV and so on. By your logic we must always speak to everyone in the exact same manner and with the exact same tone and language. Which is utterly ridiculous.

              I would also not mind so much if I thought the “ends” those means are justifying had been well thought- through

              And years later your thoughts are no more clear on the matter and every one of us is left scratching our heads time and time again. Clearly, it must be that we are so dim in comparison to you that we just can’t fathom the depths of your insight into the matter. My paltry education and inexperience make the reason for my obtuseness obvious. But to continually stump every editor and contributor here… well you must be on a whole new plane of insight inscrutable to us mere mortals.

              I would not mind so much if we were not trying to dominate what people do when the limitations of mainstream medical attentions have been reached or where there is no entirely satisfactory medical treatment in terms of efficacy or safety.

              Though even strawmen can fall from that rarefied air, it would seem.

              How many times has it been repeated that we care not what people do in their private time and with their own resources? We care that such quackery should not be taught in schools, or given government sanction, or be endorsed by our profession. We do not think we should have the right to tell the Cleveland Clinic that it cannot offer a TCM herbal center. But we damned well reserve the right to point out how silly and stupid that is.

              As always, such discussions come back to the assumption that doctors would have to use placebos or CAM.

              No, that is an assumption you are making for us. We have never ever said that. In fact, the explicit argument I have made (and Drs. Hall and Gorski) is that we can recruit all the same non-specific therapeutic effects of quackery and bundle it with actual medicine. That there is no need or role for placebo medicine or CAM.

              I’d be convinced it was strawmen raining from the sky, if it weren’t for the fact that the all-wise Peter Moran could never do such a thing.

            2. Harriet Hall says:

              @Peter Moran,
              ” if we were not trying to dominate what people do when the limitations of mainstream medical attentions have been reached or where there is no entirely satisfactory medical treatment in terms of efficacy or safety”

              I can’t believe you’re still repeating that misrepresentation of our position after we have debunked it so many times! We are not trying to tell people what to do. Patient autonomy is a basic principle of medical ethics and we fully support it. We are arguing against misinformation and against overtly or subtly influencing patients to believe that we are recommending CAM or that CAM is supported by good science and acceptable to rigorously science-based doctors.

  34. Yall are mixing science, evidence and personal beliefs, which in the SBM world or even medicine should be done with clarifications.

    Acupuncture is a vast world of disciplines, concepts and ideologies, some are rooted in ancient traditional beliefs and some in pure science. The most effective are in a class of myofascial release therapy with needles so called Myofascial Needling.

    Pure science and the truth can not be negated, sorry! The trues of both SBM and CAMs will compensate for their deficiencies which will improve clinical outcomes. So that means CAMs are a part of this pure science and is forever. CAMs must be converged back into traditional medicine for modern medicine to survive into the future.

    What you have thought through are your personal concepts. Without all the data your thoughts are flawed, incomplete and dangerous to unsuspecting people. Please let people know these are only your opinions.

    1. WilliamLawrenceUtridge says:

      Yall are mixing science, evidence and personal beliefs, which in the SBM world or even medicine should be done with clarifications.

      As usual, the irony is hilarious, hypocritical and in your case a little sad. What of your practices are science and evidence based? Which ones are personal beliefs?

      Acupuncture is a vast world of disciplines, concepts and ideologies, some are rooted in ancient traditional beliefs and some in pure science.

      Which do you employ? If it’s pure science, why do you keep invoking “ancient wisdom”? Are you willing to state that traditional acupuncture is worthless? What science justifies acupuncture? And before you claim you “provided a list of references”, I’ll point out that I looked at your list and they were almost all irrelevant. I’ve called this fact to your attention multiple times now, with no response from you beyond “shucks, gollee Mr. Griffiths, durn won’t nobody looks ats mes references”.

      The most effective are in a class of myofascial release therapy with needles so called Myofascial Needling.

      Where are the references to support this point? Do you have any? Or are you like the orthopedic surgeons you so like to criticize – willing to act based on strong opinion rather than evidence?

      Pure science and the truth can not be negated, sorry!

      Can science ever find the truth?

      The trues of both SBM and CAMs will compensate for their deficiencies which will improve clinical outcomes.

      Science-based medicine asks for proof before delivering a therapy, CAM avoids proof, and if there is proof that something doesn’t work, CAM practitioners ignore it and keep charging customers for it – just like you do.

      So that means CAMs are a part of this pure science and is forever.

      Merely because you say something doesn’t make it true – CAM has not been tested (or it would be used by real doctors) or it has been tested and has failed (like acupuncture). CAM practitioners just want to ignore the need for testing and ignore the results and keep charging patients anyway for worthless and unproven treatments. If Pfizer demanded the right to sell drugs that were ineffective or untested, you would be furious. Why are CAM practitioners so willing to ignore science when it is inconvenient? Aside from greed, of course.

      CAMs must be converged back into traditional medicine for modern medicine to survive into the future.

      That’s a great idea, and just requires two things:

      1) Testing CAM modalities to see if they are effective before they are used
      2) Abandoning CAM modalities that, upon testing, turn out to be useless.

      These are reasonable requests, and for real medicine are totally uncontroversial. Yet CAM practitioners consistently ignore them and persist in their intellectually, morally and medically bankrupt practices. And you are willing to defend them.

      What you have thought through are your personal concepts. Without all the data your thoughts are flawed, incomplete and dangerous to unsuspecting people. Please let people know these are only your opinions.

      Yes, absolutely. That is why I ask for scientific data before I adopt or defend a concept. That is why I keep asking you to provide scientific data to justify charging patients money for treatments.

      Why can’t you provide me with any scientific data, published, empirical evidence, that supports how you treat your patients? Why do you drop in massive lists of irrelevant sources if you think that beliefs are less important than data?

      Or are you a hypocrite who just wants to avoid recognizing that you can’t support your opinions with anything scientific?

  35. PMoran says:

    “If that is so, how do you explain that I agree completely with Andrey? I will be 69 next month; ”

    You agree completely on what, specifically? I stated that many acupuncturists are practicing without any commitment to TCM medical theory and Andrey derided that in the insulting fashion he commonly resorts to in debate. I provided some of the evidence showing that this is indeed so, also offering the web site of a representative example.

    Do you wish to now also challenge what I said? I am ready with more evidence that what I said is true if you wish to. Or perhaps you too have missed, or misinterpreted, an important trend concerning acupuncture and other CAM activities, — as I have outlined to some extent in the SBM post I have sent to Dr Gorski.

    So far as your regarding it as “despicable” to draw attention to Andrey’s inexperience and lack of knowledge on many matters. I would say, firstly, that you can have no knowledge of what I am reacting to unless you have read and dispassionately analysed much of the thousands of words in our interchanges, and I am confident you have done neither.

    Secondly, it is not those attributes that I criticise but his pretentiousness, lack of self-awareness (e.g. the utter inconsistency of his own views as expressed in the same comment on some matters) while at the same time trying to lord it over others, also his tendency to too readily resort to a patronising, self-reassuring style of debate when others don’t quickly accede to his point of view.

    He has recently allowed that he is in a learning phase, and I compliment him for that, while suggesting that he has yet to do some homework to do on many matters.

    1. Andrey Pavlov says:

      and Andrey derided that in the insulting fashion he commonly resorts to in debate.

      Tit for tat Peter. Sawyer quite well pointed out that you hold little moral high ground for chastising us for exactly the same behaviour you engage in yourself. Ultimately it is a game of “who started it” which matters not except that I dish it out, but also take it.

      I would say, firstly, that you can have no knowledge of what I am reacting to unless you have read and dispassionately analysed much of the thousands of words in our interchanges, and I am confident you have done neither.

      Careful. You have a poor track record of trying to divine Dr. Hall’s position on topics. I’ve lost count of how many times she has had to comment directly contradicting your statement about her.

      (e.g. the utter inconsistency of his own views as expressed in the same comment on some matters)

      An inconsistency only you seem to be able to see. Others here, Dr. Hall included, have however commented that you have an inconsistent position. I’m obviously in no position to judge as I am indeed biased and cannot deny that. But others here are and they have – much more often siding with my thoughts than yours.

      The rest of the paragraph is, yet again, nothing but tone trollery. If you can’t take it, you shouldn’t dish it out.

      He has recently allowed that he is in a learning phase, and I compliment him for that, while suggesting that he has yet to do some homework to do on many matters.

      Yes I have. And I will continue to say that and feel that way until I draw my last breath.

      As for “suggesting” that I have homework to do… please Peter. You’ve done nothing more than lord over sanctimoniously as the attending chastising the student. At best nothing more polite than the worst of anything I have ever sent your way.

      I am, as always, happy to hear thoughts and criticisms from others, particularly Dr. Hall.

    2. Harriet Hall says:

      @Peter Moran,

      I make an effort to read every comment. As for acupuncturists not practicing with commitment to TCM medical theory, I don’t doubt that a lot of those who use acupuncture do it “because it works” regardless of theory; but those who practice acupuncture as their sole raison d’etre have necessarily been indoctrinated in the theory during their training and have been tested on it to obtain their licenses. I have a book about the biology of acupuncture by a researcher whose studies show it doesn’t matter where you put the needle, or even whether you penetrate the skin, but he still recommends inserting needles in the traditional acupoints.

      You continue to ascribe to Andrey the very characteristics that the rest of us can see in your own posts. I think it is you who lack self-awareness, and you are the one who comes across as lording it over others. I enjoy Andrey’s posts and learn a lot from them, and he does not come across as claiming omniscience as you sometimes do. I find your continued carping and your “holier than thou” attitude exceedingly annoying.

      1. PMoran says:

        ” I don’t doubt that a lot of those who use acupuncture do it “because it works” regardless of theory”

        That is so. Manifestly so. It has been for many years. Yet for stating this simple truth I was held out by Andrey to be presenting myself as “smarter” than anyone else. being able to discern things that weren’t there and able to read minds. Are you helping his self-awareness and debating skills by calling me “despicable”?

        “You continue to ascribe to Andrey the very characteristics that the rest of us can see in your own posts.”

        Of course you do. No one likes criticism or even the mildest of contradiction. We will always look for ways of self-justification and of saying “the real problem lies with you”. The truth is out there for us to find, nevertheless.

        I suppose the guts of our disagreement is that I am saying that therapeutic interactions are extremely complex and not yet well-understood, while SBM is adopting a more simplistic and dogmatic stance on key matters.

        SBM wants there to be one kind of medicine that “works”, and thinks that it has a clear way of deciding that.

        Leaving aside some recently found limitations to the scientific methodology involved, I am suggesting this: th at in practice the effects of a medical interaction can range from seriously negative outcomes when there is no useful treatment to provide, through simple satisfaction of the urge to “do something” when sick, on to weak placebo influences such as being easily distracted once having “dealt with” the illness , then stronger placebo responses from stronger needs and the arousal of strong expectancy, then these influences but combined with simple, common therapeutic ones such as counter-irritation, relaxation, meditation, and various kinds of psychosocial support, usually from more complex ongoing, hand-on kinds of intervention.

        Then you get onto treatments that can also elicit useful physiological responses with widely varying degrees of effectiveness upon symptoms, then another rung above that where there are also beneficial effects upon disease processes, and a top rung where methods that permanently cure illness, such as antibiotics reside.

        On the available evidence that is a more accurate a depiction of reality as the black and white that SBM dogma wishes to impose upon medicine. Again, let’s first decide where the truth lies, before leaping to practical consequences.

        1. Windriven says:

          “SBM wants there to be one kind of medicine that “works”, and thinks that it has a clear way of deciding that.”

          Peter, I don’t think that is wholly accurate, at least not as I understand science based medicine. In my appreciation there is a hierarchy with well-supported science-based medicine at the top followed by evidence-based modalities, followed by historically effective modalities, and ranging down to the speculative-but-nothing-to-lose treatments.

          In a separate hierarchy is ‘stuff that has been looked at with due care and found wanting.’ with therapies with some placebo value at the top and ranging down to the just howlingly idiotic like homeopathy and reiki. I don’t imagine that any self-identified science-based physician would find it ethical to prescribe anything in this second range without careful explanation of the character of the therapy.

          Is that different from your appreciation of SBM?

        2. Andrey Pavlov says:

          I suppose the guts of our disagreement is that I am saying that therapeutic interactions are extremely complex and not yet well-understood, while SBM is adopting a more simplistic and dogmatic stance on key matters.

          It seems the guts are that you focus on what is yet to be understood while ignoring that we understand what it cannot be. And what it cannot be demonstrates that no matter what it may be that we yet don’t understand is only conceivably worthwhile in the context of actual medical intervention, not as a pure placebo (which acupuncture is, despite your ridiculous continued dropping of ‘counter-irritation’ as an accepted possible MOA).

          SBM wants there to be one kind of medicine that “works”, and thinks that it has a clear way of deciding that.

          Windriven seems to understand what we are on about. And he isn’t a physician. You should read his response a few times.

          I am suggesting this…

          “This” being painfully obvious things which we have discussed, generally agree upon, and find trivially true.

          The difference is where to draw the line. You and Dr. Katz feel that there is no lower limit to draw (well, you are sometimes forced to agree, grudgingly, that medical science forces us to kind-of, sort-of have a line somewhere but that we should endeavor to find sneaky ways past that line somehow). We feel there is.

        3. Andrey Pavlov says:

          <blockquote.Leaving aside some recently found limitations to the scientific methodology involved

          Those limitations make it less likely that acupuncture has any beneficial effects, non-specific or otherwise.

  36. PMoran says:

    Harriet: “I can’t believe you’re still repeating that misrepresentation of our position after we have debunked it so many times! We are not trying to tell people what to do.”

    You may genuinely think that. Nevertheless, the general thrust of the posts on SBM ( with your personal posts and a lot of others admittedly being at a much more temperate and advisory end of a spectrum), and even more so within what goes unchallenged in the comments section is that CAM use is utterly useless, dangerous, fraudulent, a threat to science, a slippery slope into the abyss and mainstream medicine should be enough for anyone, anyway. Does this send no message at all?

    Yes, there is exaggeration in that characterisation of medical scepticism, but not much is needed because CAM users and potential users are already hypersensitive on many of these issues and they will read between the lines (“the mainstream didn’t help me” — “look at deaths in hospitals” — “homeopathy is more dangerous than drugs?”) .

    And medical scepticism’s true intentions will not be judged on that alone –.

    SBM undeniably attacks anything which looks to be facilitating or dignifying CAM.

    Those who really don’t much care about what people do at their own expense and risk are likely to be demeaned as “shruggies” or “accommodationists”.

    Institutions that provide forms of CAM for those who may want it are regarded as “selling out to pseudoscience”.

    Given all this, it defies all logic that medical scepticism would not be interpreted as having the ultimate goal of stamping out CAM as an option for patients , just as every CAM user and sympathiser and human rights activist already believes. Deny it as much as you want — the very logic we have created demands that of us.

    So we may think we are not telling people “what to do”, but it will not pass notice that with our other hand we are prepared to beaver away so as to make it as difficult as possible for them to do what they want. The reaction will be exactly the same —butt out of my affairs!

    I am asking whether there are better ways to walk this tightrope. We could concentrate upon specifics and context rather than treating CAM as an undifferentiated evil blob that by definition warrants any level of opposition. I know it doesn’t apply to you, but it cannot be denied that this simplistic viewpoint is commonly held among sceptics. Should something called “Science-based-medicine” be reinforcing that or should it be trying to clarify more realistic and rational purposes in relation to CAM, if such exist?

    It would improve our credibility if we merely confined ourselves to explaining why we think some claims are exaggerated or dangerous, and where other obvious dangers lie. If we have evidence of intentional fraud, present it. We also have the right to complain about likely cost-ineffective or unfair uses of communal funds.

    Beyond that we have an ethical problem if we are potentially poisoning the well for persons that we claim to be treating as free agents.

    I am not saying that these things are not already done, it is just that the most important and most effective messages can sometimes take second place when sceptics get into “sock it to CAM” mode.

    1. Andrey Pavlov says:

      I am asking whether there are better ways to walk this tightrope

      And we’ve been waiting 4 years for the answer.

      Beyond that we have an ethical problem if we are potentially poisoning the well for persons that we claim to be treating as free agents.

      Sort of like when Randi “poisoned the well” for Peter Popoff and forced him off the air? Tens of thousands of people were “cured” by him. Felt better for having been at his sessions. Willingly sought him out and gave him their money. As free agents, on both sides. Seems that we should have just let Popoff be and just advise a patient who asks, “well… some people feel better for it…” giving them the out to ask more if they want to, otherwise letting them believe that forking their money over for theatrical faith healing can help with their chronic pain ailments that we can’t manage particularly effectively. And if they press us further, “well… the data show that magical faith healing is probably not effective but that there are certainly aspects of Popoff’s practice that do genuinely help some people feel better….”

      Seems to me the ethical problem is not with us trying to prevent people wasting their money and getting defrauded (intentionally or not).

    2. Harriet Hall says:

      “You may genuinely think that.”

      Are you suggesting that I may NOT genuinely think that, and that my understanding is inferior to yours? That’s offensive.

      “if we merely confined ourselves to explaining why we think some claims are exaggerated or dangerous”

      …we wouldn’t be as effective in getting our message across. That approach has been tried, and I don’t think you can come up with any evidence to support it.

      I should have learned my lesson by now; every time I try to discuss an issue with you, you resort to the same misrepresentations of our position and with such vague superior “wisdom” that other commenters have been puzzled as to exactly what you are trying to say. You can’t see the mote in your own eye, and your holier than thou attitude is tiresome. I am thoroughly fed up with you and will try to restrain myself from responding to your comments in future.

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