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An Acupuncture Meta-Analysis

A recent meta-analysis of acupuncture studies for chronic pain by Vickers et al is getting a great deal of press. The authors’ conclusions are:

Acupuncture is effective for the treatment of chronic pain and is therefore a reasonable referral option. Significant differences between true and sham acupuncture indicate that acupuncture is more than a placebo. However, these differences are relatively modest, suggesting that factors in addition to the specific effects of needling are important contributors to the therapeutic effects of acupuncture.

News reports generally reflect this conclusion – acupuncture works, but mostly (although not entirely) through placebo effect, but that’s OK.

I took a close look at the study and find that the authors display considerable pro-acupuncture bias in their analysis and discussion. They clearly want acupuncture to work. That aside, the data are simply not compelling, and the authors, in my opinion, grossly overcall the results, which are compatible with the conclusion that there are no specific effects to acupuncture beyond placebo.

The meta-analysis looked at 29 randomized clinical trials of acupuncture in back pain, neck pain, headache, and osteoarthritis, involving both sham and no-acupuncture controls. The differences between acupuncture and no-acupuncture were large, reflecting an absolute reduction in pain of about a 30% (50% relative reduction). However, the authors acknowledge:

Because the comparisons between acupuncture and no-acupuncture cannot be blinded, both performance and response bias are possible.

In other words – the unblinded comparison between acupuncture and no acupuncture is entirely overwhelmed by bias and completely useless. The no acupuncture control groups involved patients continuing to receive usual care (whatever they were already receiving that was not effective, or sometimes just being told not to get acupuncture). This was not a comparison to any specific medical intervention. In other words, the subjects were aware they were receiving no treatment.

It is curious that the authors would even bother to include such an analysis, but they reveal their purpose in their discussion:

Even though on average these effects are small, the clinical decision made by physicians and patients is not between true and sham acupuncture but between a referral to an acupuncturist or avoiding such a referral.

This is the agenda of acupuncture proponents – to use the non-specific effect of receiving an intervention to promote the use of acupuncture. If a study shows no significant difference between true and sham acupuncture, then they argue that this placebo effect is enough to justify treatment. If the study (or in this case a meta-analysis) shows a small difference, then they use that small difference to justify the conclusion that acupuncture is real (even though the specific effects are negligible) and then use the large non-specific effects to justify the treatment.

Either way, proponents are inappropriately leveraging placebo effects (which are largely biases) to promote a treatment that has an effect size that is very small and, in my opinion, overlaps with no effect at all.

The authors make much of the small effect difference in their meta-analysis between true and sham acupuncture. They summarize their results by saying, if the no intervention group has a pain of 60%, then true acupuncture reduces it to 30% and sham acupuncture to 35%. While this difference was statistically significant in this meta-analysis, it is highly dubious to claim that the 5% difference is clinically significant, or even perceptible. To me this is no difference at all.

The primary difference between my opinion of this data and the authors’, however, is that the authors are quick to conclude that because their data was statistically significant that means there is a real physiological effect (if modest) to acupuncture. This conclusion, however, reflects probable bias, but certain naivete with regards to the reliability of clinical trials. This level of difference is within the noise of clinical trials, which are simply not precise enough to detect such a small difference.

The authors acknowledge:

Similarly, while we considered the risk of bias of unblinding low in most studies comparing acupuncture and sham acupuncture, health care providers obviously were aware of the treatment provided, and, as such, a certain degree of bias of our effect estimate for specific effects cannot be entirely ruled out.

This is the understatement of the paper – a certain degree of bias cannot be ruled out. What the last century of clinical research has clearly shown is that a significant amount of bias is guaranteed. All it takes is a little bias, innocent exploitation of researcher degrees of freedom, and you have your 5%.

The authors acknowledge that there are a couple of studies that are outliers – those by Vas et.al. had effect sizes 5 times that of the average. When you remove these studies the effects are still significant. There is also researcher bias in that the larger the study the smaller the effect size, but when you remove small studies the effects are still significant. They also argue that unpublished studies (publication bias) would be unlikely to cause their results.

However – when you add the effects from outliers, small studies, and publication bias all together I wonder what the total effect is on the data (not even including the fact that it is a certainty the data is polluted in the false positive direction by researcher degrees of freedom).  The performance of a meta-analysis introduces yet another layer of potential bias or distortion in the methods of the meta-anslysis itself – how are studies chosen for inclusion, for example, and all the researcher degrees of freedom that apply to any study.

Conclusion

The Vickers acupuncture meta-analysis, despite the authors’ claims, does not reveal anything new about the acupuncture literature, and does not provide support for use of acupuncture as a legitimate medical intervention. The data show that there is a large difference in outcome when an unblinded comparison is made between treatment and no treatment – an unsurprising result that is of no clinical relevance and says nothing about acupuncture itself.

The comparison between true acupuncture and sham acupuncture shows only a small difference, which is likely not clinically significant or perceptible. More importantly, this small difference is well within the degree of bias and noise that are inherent to clinical trials. Researcher bias, publication bias, outlying effects, and researcher degrees of freedom are more than enough to explain such a small difference.   In other words – this data is insufficient to reject the null hypothesis, even if we don’t consider the high implausibility of acupuncture.

Further, meta-analysis itself is an imperfect tool that often does not predict the results of large, rigorous, definitive clinical trials.  The best acupuncture trials, those that are well-blinded and include placebo acupuncture, show no specific effects.

Posted in: Acupuncture

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77 thoughts on “An Acupuncture Meta-Analysis

  1. nybgrus says:

    This reminds me of those trials wherein they attempt to test something like Echinacea for cold and flu and determine efficacy of whatever herbal nostrum because it “significantly reduced the number of days of being sick” and when you look at the actual data it demonstrates that those who didn’t take Echinacea were sick for 6.73 days and those who did were sick for 5.88 days. Sure, you crunch statistics and it is significant. But nobody takes into account that is is absolutely ridiculous to quantify length of illness to 6 days 17 hours 31 minutes and 12 seconds.

    I had an amazing chemistry professor in my high school days. In my junior year we took gen chem and then in my senior year we had “science seminar” which was basically just a lab driven synthetic chemistry course with the second semester being organic chemistry. He used to be Merck’s head of synthetic chemistry back in the day. And one thing he pounded into our heads was the concept of significant figures. Beyond just the rules for them, he made us (well at least most of us) understand that the reason you can’t report the results of multiplying 20 numbers together down to the 8th decimal is because there is no possible way we could have been that accurate in our measurements. That level of precision is possible, but not in a high school chemistry lab.

    Seems like researchers these days did not learn their lesson about significant figures.

    *I still smile every time I think of Prof Pfitzner – he had a silly little rhyme, mnemonic, or jingle for just about every important fundamental of chemistry. So when I recall them I still do it in his voice with the tune of his jingle in my head. Mine was the last class he taught, retiring at the age of 74. A bunch of us students got together and threw him a surprise retirement party at the town hall and had giant blown up photos of him everywhere and at the end we scrambled to have him autograph them. I kept my two up on my wall during undergrad and would write out key organic chem reactions on them. We need more teachers like him.

  2. wertys says:

    I can certainly say that, as a pain specialist, even if their results were not methodologically rickety, the effect size alone would not be clinically significant. The logistics and psychological impact of using a passive treatment like acupuncture over the long haul for chronic pain patients makes it clinically inappropriate, even if this is the absolute best case scenario. I note that none of the authors has a background in chronic pain btw…

  3. Janet Camp says:

    The problem is that this study (and its dubious interpretation) gets wide coverage in the popular press, which only makes it harder for skeptics to do their job. Acupuncture clinics continue to sprout up in my city–as do chiropractors. The “patients” are being told that the efficacy of the “treatment” has been tested and validated–oddly enough (supposedly) by the same science that they normally hold in contempt!

  4. geack says:

    Predictably bad article on this study at The Atlantic today, headlined “Biological Implausibility Aside, Acupuncture Works.” In order to brush off the meaninglessness of the tiny “5%” difference in reported pain levels, the author quotes – ready for it? – Ted Kaptchuk. Just sad.

  5. CarolM says:

    I just came through a 5-month bout of sciatica, with X-rays showing spondylolesthesis at L5 S1. The PA, internist and physical therapist all pointed out that there is no way to really know if the spinal condition was causing the pain. As recently as a month ago I figured I’d have to shell out a $500 copay for an MRI, meaning I might have to consider surgery…and then the pain went away. Before that the MD had suggested acupuncture, and friends were quick to recommend chiropractic. No friggin way, as I am an SBM devotee.

    There must be studies out there showing the benefits Nothing.

  6. Jann Bellamy says:

    Under “Interpretation,” the authors conclude: “The total effects of acupuncture, as experienced by the patient in routine practice, include both the specific effects associated with correct needle insertion according to acupuncture theory, nonspecific physiological effects of needling, and nonspecific psychological (placebo) effects related to the patient’s belief that the treatment will be effective.”

    Even if they had shown a significant effect beyond placebo, how does this meta-analysis possibly support the conclusion that there are “specific effects associated with correct needle insertion according to acupunture theory” and “nonspecific physiological effects of needling”?

  7. ConspicuousCarl says:

    CNN’s flunktacious headline was “Acupuncture works, one way or another”.

    Of course CNN notes the name of the journal in which it was published (“Archives of Internal Medicine”–or should that be Archives of Just-Barely-Internal Medicine?), but they did not bother to note the name of the group which wrote the paper (“Acupuncture Trialists’ Collaboration”).

    I also noticed that CNN used the phrase “treatment as usual”, without explaining what that sometimes means (and what it sometimes means is telling the control group to bugger off and let us know how everything works out):

    http://www.mskcc.org/cancer-care/integrative-medicine/acupuncture-trialists-collaboration
    “‘Usual care’ is defined as care, such as medication ‘as needed’, that is also received by the acupuncture group. Usual care controls as defined here are sometimes described as ‘waiting list’ controls, ‘standard care’ controls or controls receiving ‘no additional treatment’.”

  8. SomePapa says:

    Not only are the results poor, but the authors fail to consider the time and resources needed to be expended to get those “results.” Repeated appointments with an acupuncturist takes up a good deal of time. When that expenditure is added to the lack of benefit, acupuncture becomes a clear negative.

  9. DevoutCatalyst says:

    . . .
    .acupuncture.circling.the.drain.again.
    . . . .

  10. A year ago I would have been thrilled with this meta-analysis. But now I think “I’ll bet their placebos lacked credibility” or “such a slim benefit over sham treatment indicates failure of blinding.” Darn you, science!
    Those who read the headlines and call for an acupuncture appointment will probably have a stronger placebo effect than they would have before. Many of my patients are very happy with the results they attribute to my acupuncture. Calculating value for the treatments isn’t so easy. Some calculate it based on taking less pain medications, some on avoided shoulder/back surgeries. Sometimes it is the spouse who notices positive mood changes following treatment and insists treatments continue. Could I elicit the same apparent benefits by just talking with people or giving them permission to take a nap on my treatment table?
    I understand that pain is the most amenable symptom to change by placebo intervention. I also understand that self-reported perceptions of pain are way different than objective changes in actual diseases. Self-reported Visual Analog Scale pain improvement to 3.5 for placebo and 3.0 for ‘verum’ isn’t much different. In my clinic I often get stronger reports: long term back pain “70% better” in one treatment. Regular headaches “totally gone” after a few treatments. Severe tennis elbow instantly improved after treatment. And some don’t get results or the calculation of time and money doesn’t compute to value.
    I see that it is conceptually unethical to promote placebo treatments, in an ideal world. Personally, I find offering acupuncture to those looking for it is more ethically agreeable than selling cigarettes. Heck, I think it’s quite a bit safer and more effective (for uncomplicated musculoskeletal pain) than chiropractic or homeopathy (especially if combined with pragmatic lifestyle advice).
    Well, I thought you should have an acupuncturist comment on this post. SkepticalHealth can call me a quack and say I don’t have “patients.” I’ll keep warning acupuncture fans about Applied Kinesiology, herbs for STDs & Cancer, and other harmful sCAMs beyond my limits, so a good chunk of the Altie world will think I’m far too critical while many in the SBM world will feel otherwise.
    Fortunately, I’m spending a good chunk of time building up the non-TCM part of my income stream. That feels good to me. Unfortunately, this darn meta-analysis will increase calls and referrals for awhile…

  11. nybgrus says:

    I thought Drs. Novella and Gorski might be interested to know that Smithsonian News Blog has picked up the story on the analysis and aptly called it “Acupuncture Might Actually Work (Surprise! It Probably Doesn’t)” and reference both esteemed authors quite extensively. Colin Shulz seems like a science reporter more astute than your average ursine.

  12. Although I may be committing a genetic fallacy, the study was funded by NCCAM and Funded by NCCAM and the Samuel Institute. We are all familiar here with NCCAM.

    Google the Samuel Institute. Do you think that these institutes have some pre-existing interest in a positive spin on old data?

    http://www.samueliinstitute.org/

  13. mousethatroared says:

    Love the photo in the Smithsonian piece too.

  14. evilrobotxoxo says:

    I think Drs. Novella and Gorski should write a letter to the editor of the journal this was published in.

  15. nybgrus says:

    I feel ashamed… the Samueli institute is at my undergrad alma mater. The funny thing is that there is also a Samueli school of engineering there. Yet they don’t seem too interested in “alternative engineering” or looking to see if waving your hands over an air foil can make it fly. Odd.

  16. @skeptical_acupuncturist,

    Pretty much the only correct thing in your post is when you pointed out that yes, I will call you a quack, and yes, I will state that you do not have patients. What you have are suckers, that you (quite literally) bleed dry of money, while doing nothing but administer placebo to them while wooing them with Eastern Mysticism bullsh**. I do think you are interesting: the internal conflict between your reasonable side is at odds with your internal desire to make money and put food on the table. Without ripping people off, you have no other job prospects, so you’re forced to believe that you actually contribute something good, while in fact you do nothing good.

    You know, every day I leave work, and I know that I saved more lives and did more good for humanity in one single day than all of CAM has done since its invention.

  17. Ken Hamer says:

    Articles like this are incredibly easy and cheap to produce — all you need to is cut and paste, and you work is done. The author of the story gets to pretend they are a journalist, the sCAMmers get their word out, and life goes on. In short, there’s no incentive for the author to do anything differently.

    It’s time sceptics in general found the nerve to start laying on lazy pseudo-journalists a Simon Singh/Christopher Hitchens-like savaging, so that the parrots start thinking twice about abandoning their journalistic obligations and simply repeating verbatim what every Tom, Dick, and Kevin Trudeau says.

  18. BillyJoe says:

    SH: “every day I leave work, and I know that I saved more lives and did more good for humanity in one single day than all of CAM has done since its invention”

    And that’s not saying much :|

  19. lilady says:

    I’ve got a suggestion. Why not go and post on the NCCAM blog?

    http://nccam.nih.gov/research/blog

    Some of our “SBM Regulars” have been posting there…including nybgrus and Linda Rosa, RN. *Another nurse* who posts frequently here, has posted about this latest NCCAM-funded acupuncture study, on Dr. Josephine Briggs’ aptly named blog “Ideas From Outside The Mainstream”.

  20. Jan Willem Nienhuys says:

    If the difference between acupuncture an ‘no acupuncture’ is so large, and if the difference between sham acupuncture and ‘real’ acupuncture, it is quite reasonable that some kind of placebo effect plays a role. I write ‘some kind of placebo effect’ because in an unblinded situation you never know whether the effect you see is real or just the effect of patients saying they feel better because they feel they have to say such a thing. I recall that in asthma research (with homeopathy I believe) is has been found that patients said they felt better (e.g. indicating this on a VAS-scale), but that objective measures (e.g. FEV-1 or peak flow) showed no difference.

    But if the placebo effect is so large then it stands to reason that in sham versus ‘real’ these same effects also play a role. The therapist is often not blinded, I guess. In other experiments (I hope someone else can provide sources without spending too much time on it) it has been shown that if the therapists are just given the suggestion that they might be administering the ‘real thing’ (e.g. in an experiment where placebo is compared to a naloxone, half of the therapists are told it is placebo versus painkiller) this already has an effect on the outcome.

    It is not really very difficult (in my opinion) to blind the therapist. For each patiënt a number of places for acupuncture are marked on the skin, say ten small circles numbered from 1 to 10. Some of these are relevant acupuncture points and some are not. The person doing the marking need not know anything about acupuncture. He or she just needs detailed instructions about how to locate the points. The acupuncturist then determines in the absence of the patient which numbers should be punctured. Then the randomizer instructs a third person which circles to puncture: either the ones indicated by the acupuncturist or an equal number of other ones. The third person need not know anything about acupuncture, only about the technique to insert the needles. Contact between randomizer and puncturer can be minimal, just consisting of handing over an envelope with the points indicated. Of course one should take care that the fake points are just as credible as the real points.

    There may other ways to achieve near perfect double blinding, but acupuncture research without extraordinary care for proper blinding shouldn’t be taken seriously.

  21. Ufo says:

    I agree with evilrobotxoxo:

    “I think Drs. Novella and Gorski should write a letter to the editor of the journal this was published in.”

    To me, this seems to be the way forward.

  22. evilrobotxoxo says:

    @skeptical_acupuncturist,

    Ignore SkepticalHealth. All practitioners, if they want to be clinically effective and intellectually honest, have to challenge their assumptions and see what the data says. SkepticalHealth does it, I do it, and you’re doing it, and you’re to be commended for that.

  23. Josh Berndt says:

    Placebo is such a difficult term to talk about when discussing pain-a subjective experience. We are used to the term placebo in a study looking at effects on objective measurable variables (HR, LDL,WBC). All the variables can be accounted for and treatment effects can be pretty clear. When pain is your variable, unless you can control, previous experiences, beliefs, fears, emotional status, activity levels….even the practitioners beliefs, attitude, empathy…. you can’t reliably say your intervention was any better than the “therapeutic effect” or in other words (placebo) would have been without the intervention.

    Unfortunately our SCAM practitioners know this very well and expliot it under the term evidence.

  24. Vera Montanum says:

    The above discussion is on target philosophically; however, the numbers used — eg, 35% reduction in accupunture group, 30% in sham acupuncture group — are taken from a hypothetical example given by Vickers et al. in their paper (actually, they were describing points on a 100mm pain VAS) and are completely unexplained by Vickers and colleagues. I have yet to be able to duplicate those numbers using effect size results in their meta-analysis, but perhaps I’m missing something that somebody else can explain.

  25. @evilrobotoxo, if “skeptical_acupuncturist” was challenging his beliefs, he’d quit practicing.

  26. mousethatroared says:

    SkepitalHealth – People gripe on this board about how CAM doesn’t accept evidence of effectiveness all the time. When a CAM practitioner is willing to engage in looking at the evidence and thinking about changing the direction of his practice, then he is lambasted for being dishonest, because he hasn’t changed quickly enough.

    Way to use your powers of persuasion, SH. Perhaps you could fix the situation in Syria with your silver tongued diplomacy.

  27. Rabbit says:

    Much as it hurts to play math police… the difference between 30% and 35% is not “5%” — it’s closer to 16.6%.

  28. @MIM, it’s impossible that a CAM practitioner looks at evidence rationally and still practices. They are at opposite ends of the spectrum. If he still practices after having a skeptic view, then he’s knowingly committing fraud. As always, thank you for your valuable contributions to the conversation.

  29. … to further my point, this sCAM practitioner refers to his clients as patients and is under the impression that he is truly administering health care to the people he is systematically ripping off. A quick view of his blog reveals that he is truly a quack, but one that likes to pretend to play scientist. So you’ll have to excuse me for not being impressed or inviting him with open arms. Queue pmoran.

  30. Robb says:

    This discussion of placebo effects and poor research reminds me of the research supporting anti-depressant medications and the quacks that peddle them.
    http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.0050045

  31. mousethatroared says:

    SkepticalHealth ” As always, thank you for your valuable contributions to the conversation”

    Well thank you! It’s good to know that even though we often butt heads, we both can appreciate that a conversations without diverse opinions seldom thoroughly explores the issues. :)

  32. Robb says:

    Harriet,
    That’s not really a critique of Kirsch as much as it just siding with Turner’s interpretation of effect sizes where “partial responses can be meaningful” (his words). One of his conclusions was that: “The findings also show that the effect for these patients seems to be due to decreased responsiveness to placebo, rather than increased responsiveness to medication.”
    Correct me if I’m wrong but, this means that, as you say, “the drug outperformed the placebo”, was not due to a greater effect of the drug, but due to a decreasing response to the placebo. He still felt they were clinically significant for severely depressed people.
    In relation to the acupuncture review, they found that: “Significant differences between true and sham acupuncture indicate that acupuncture is more than a placebo.”
    I just find it ironic how sometimes “partial” and small responses can be considered meaningful in some cases and not in others. In the acupuncture and antidepressant review examples, that’s what it all hinges on.

  33. Cymbe says:

    Just use toothpicks – as effective a placebo, but less risky.

  34. BillyJoe says:

    SH: ” it’s impossible that a CAM practitioner looks at evidence rationally and still practices.”

    A bit like the doc who looks at the evidence regarding PSA testing and robots and still has his PSA tested and his prostate removed by robots. :D

  35. mousethatroared says:

    @BillyJoe – Just to be fair to SH, what one chooses to do for themselves IS different than what one is recommending or selling to patients/the public. Yes? If SH is making the decision as a patient to get elective testing or procedures, that is different than if he is recommending them outside the standard of care.

    On the other hand, We live in a society where someone can buy a piece of “brilliant” art for a million dollars, get a tattoo or piercing to make them more “interesting” or “beautiful”, or pay someone to domininate them for pleasure (as long as it’s not “sexual). In that society, I have a hard time thinking that someone who sticks needles into a willing adult claiming that it may lessen their experience of pain, is a fraud. On the other hand, If that person claims they can heal ANYTHING with those needle sticks, then yup, fraud.

    I’m sure that’s not a popular opinion here, sorry. :(

  36. BillyJoe says:

    Michelle:

    “@BillyJoe – Just to be fair to SH, what one chooses to do for themselves IS different than what one is recommending or selling to patients/the public. Yes? If SH is making the decision as a patient to get elective testing or procedures, that is different than if he is recommending them outside the standard of care.”

    I see it more as a test of your scepticism.
    If you employ scepticism when telling others what they should do based on the evidence, but abandon scepticism when it comes to decisions about your own health, then I think there is something seriously wrong with your scepticism.

  37. mousethatroared says:

    I’m skeptical of skepticism tests. :)

  38. mousethatroared says:

    Also, in many cases, doctors don’t tell you what to do based on the evidence. The tell you what the risks and benefits are, based on the evidence. The guidelines are just that, they are for a hypothetical average person, they do not take into account individual risks and personal tolerance for anxiety, uncertainty, side effects, etc.

    In this case, doctor’s job is to help you decide based on your needs as an individual.

  39. I appreciate the irony of BJ and MIM, both of whom are completely devoid of any medical knowledge, debating medical-related topics and the practices of doctors. Truly the blind …. arguing with ?? …. the blind.

  40. mousethatroared says:

    SkepticalHealth – I’m arguing from the perspective of a patient, not a doctor. I’m relaying my experience, as a patient and the parent of a patient, with doctors in the past. No intention of telling you how to do your job. Sorry if I stepped on your toes.

  41. mousethatroared says:

    also SH – Although, for the life of me, I can’t see what I said that was outside of patient/consumer health considerations. Maybe you could show me which statement I made that was “blind” or factually incorrect and give me the correct information?

  42. lilady says:

    @ mousethatroared: I find your observations and opinions to be of value. :-)

  43. mousethatroared says:

    Thanks, lilady!

  44. lilady says:

    mousethatroared…Sometimes SH gets grumpy…just ignore him. This site is not restricted to doctors, nurses, researchers only…it is open for *civilians* to comment, as well. :-)

  45. BillyJoe says:

    MTR,

    “Just to be fair to SH, what one chooses to do for themselves IS different than what one is recommending or selling to patients/the public. Yes?”

    I can’t see how the answer can be yes.
    If the evidence is that a particluar test does not fit the criteria for preventative health testing and if, as a result of looking at this evidence, the doctor does not offer that test to his patients, but then he does have the test done for himself (when he does not have risk factors or symtoms suggesting that the test be done), then I think his scepticism has taken a nose dive.
    Similarly, if there is no evidence for effectiveness of a particular substance in the treatment of a particular medical condition and the doctor is aware of this lack of evidence, but then, when he is diagnosed with that medical condition, he goes ahead and has himself treated with that substance, then again I think his scepticism has taken a nose dive (however much you might sympathise with his condition).
    I know that I will not ever take any disproven or unproven tests or treatments for any condition that I may suffer. Either your outlook is science-based or it is not. You can’t demand science for others but go to mush when you yourself are faced with dealing with your own health issues.
    The true test of a follower of science and science-based medicine is surely how he manages his own health.

    “If SH is making the decision as a patient to get elective testing or procedures, that is different than if he is recommending them outside the standard of care.”

    I would like you to explain why it is reasonable for a doctor to make use of a proceedure or test for which evidence is lacking and which, as a result, he does not recommend to his patients.

    “I have a hard time thinking that someone who sticks needles into a willing adult claiming that it may lessen their experience of pain, is a fraud. ”

    It is fraudulent if the practitioner knows that the procedure has no beneficial effects above placebo but nevertheless convinces paying patients that it has benficial effects above placebo.

    “I’m skeptical of skepticism tests.”

    Fair enough. But I think this particular test of scepticism is probably the most important. If your scepticism causes you to reject a test or procedure for others, but you don’t reject that test or procedure in your own personal situation, then what is the use of your scepticism?

    “Also, in many cases, doctors don’t tell you what to do based on the evidence. The tell you what the risks and benefits are, based on the evidence. The guidelines are just that, they are for a hypothetical average person, they do not take into account individual risks and personal tolerance for anxiety, uncertainty, side effects, etc. In this case, doctor’s job is to help you decide based on your needs as an individual.”

    I agree, but routine testing does not apply in cases when there are risk factors or suggestive symptoms.

    “SkepticalHealth – I’m arguing from the perspective of a patient, not a doctor. I’m relaying my experience, as a patient and the parent of a patient, with doctors in the past. No intention of telling you how to do your job. Sorry if I stepped on your toes.”

    I don’t worry about stepping on SH’s toes.
    If he practices outside the evidence base, I will call him on it.

    “also SH – Although, for the life of me, I can’t see what I said that was outside of patient/consumer health considerations. Maybe you could show me which statement I made that was “blind” or factually incorrect and give me the correct information?”

    SH is very confident in his abilities as a doctor, and probably quite justifiably so, and he does not believe in false humility. I have no problem with that. Nybgrus is the same. No problem. But SH’s self-confidence and egoism does not allow for him to engage with perceived lesser mortals in argument against his position and therefore his stradegy is to simply dismiss the argument.
    I would suggest you take it as a win. :)

  46. lilady says:

    You’re going to *enjoy* this article from Forbes’ Steven Salzburg about pediatric acupuncture:

    http://www.forbes.com/sites/stevensalzberg/2012/09/12/stabbing-needles-into-children-to-treat-asthma-malpractice-or-just-a-very-bad-idea/

    For cripes sake!!!! Treating babies and children with real medical problems by sticking needles into them!!!!

  47. mousethatroared says:

    BillyJoe “I would suggest you take it as a win.”

    But, I don’t want to win. I want things to make sense. Is that to much to ask? (Yes, Yes it is.)

  48. mousethatroared says:

    Lilady – Yes, SH is grumpy and I am grumpy too. Time to have a glass of wine.

  49. lilady says:

    I’m “one up on you mtr”…lovely vodka/tonic with a generous squeeze of lime.

  50. DevoutCatalyst says:

    Is that organic vodka?

  51. lilady says:

    Devout Catalyst Svedka Vodka…not organic.

  52. BillyJoe says:

    Michele,

    ” I don’t want to win…Time to have a glass of wine.”

    Whatever…but you do have a win. :D

    I don’t mind an earthy red, but scotch is better.
    Someone gave me a Johnnie Walker Green Label for my birthday and it’s sitting there above my computer screen eyeing me off…

  53. mousethatroared says:

    @BillyJoe “I agree, but routine testing does not apply in cases when there are risk factors or suggestive symptoms.”

    Just as an aside. I don’t think this is entirely true. Routine testing is screening that is done on a routine. Science suggest different screening routines for people with different risk factors. So the science based recommendation screening for breast cancer is different depending upon family history. Perhaps this is why the USPSTF consumer information sheet says.

    “How should you decide whether to have a PSA screening test?
    Consider your own health and lifestyle. Talk with your health care professional about your risk for prostate cancer. Think about your personal beliefs and preferences for health care. Learn about scientific recommendations, like this one from the Task Force. Weigh the potential benefits and harms of PSA screening and any treatment that may result. If you choose to get a PSA test, talk with your health care professional about the results of your test and whether further testing or treatment is right for you.”

  54. nybgrus says:

    @mouse:

    Technically you are incorrect, but it is a definitional thing. “Screen” means a test done on an otherwise unsymptomatic and healthy population typically without risk factors. It is intended to be a cheap, fast test with a high sensitivity but lower specificity – meaning it can capture as many people with the disease as possible at the expense of false positives.

    Now, pretty much every screening test has some risk factor analysis built into it – but not individual specific risk factors. Age is the number one criterion used as that is also a population level sort of thing that is easily identified, rather than personal or family history which is unique and often times NOT easily identified.

    So when you talk about a person with a strong family history of prostate cancer with an early onset of age, and you do a PSA it is no longer technically considered a screening test.

    But when you do a colonoscopy on someone over 50, with absolutely no other risk factors, that IS a screening test.

    The lines do get a little blurry at times (if you have a 1st degree relative with colon cancer you being to “screen” the individual at age 50 or 10 years younger than the person who had colon cancer, but techincally that is no longer a “screen” even though that term is used, even by doctors). However, when I have been arguing PSA screens and specifically charging the AUA with a poorly written position statement on the topic, that is what I am referring to. Any test that we have out there must be run in context of pre test probability since that actually changes the positive and negative predictive value of the test.

  55. hugoromeu says:

    MDJunction is owned by private people. We are NOT owned or have any association with pharmaceutical companies and other interest groups
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    hugo romeu

  56. mousethatroared says:

    nybgrus – argh, it’s complicated enough without semantics. But I get your point…screening IS referring to the guideline for the general population, once you take into consideration personal risk factors, that is no longer screening.

    A win for BillyJoe :) on the usage of screening.

    I certainly don’t want to delve too deeply into the subject of SH’s prostate…so I will let the question of using a medical test as a skepticism tests rest.

  57. nybgrus says:

    mouse – indeed. And like you, I don’t think of it in terms of “winning” and “losing.” However, to ensure we aren’t just talking past each other even when we are in fact in agreement and (trying to) saying the same thing, defining the terms and being precise in the semantics is important. Not for pedantry’s sake, merely so everyone is having the same conversation. :-D

  58. mousethatroared says:

    Sorry, I wasn’t clear. I was joking with the BillyJoe “winning” comment, based on his previous remark.

    I appreciate the correction. It does clarify the issue for me. Arguing with the wrong terminology is just frustrating and confusing for all involved.

  59. BillyJoe says:

    To also be clear, my comment about Michele winning one over SH was also meant as a joke.

  60. mousethatroared says:

    BillyJoe – LOL – gotta love internet communication.

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