Articles

Andrew Weil/AAFP Article Rejected by Slate

I was asked to write an article for Slate, the on-line magazine, about Andrew Weil’s selection as the keynote speaker for the 2012 AAFP annual scientific assembly. The science and health editor, Laura Helmuth, was initially enthusiastic about what I wrote, but eventually decided not to publish it. Here is the initial draft of my article. My comments follow.

Original Draft of Article for Slate

The American Academy of Family Physicians picked Andrew Weil to be the keynote speaker at its annual scientific assembly October 16-20 in Philadelphia. What were they thinking? That’s like having an astrologer give the keynote speech at an astronomy meeting.

The AAFP stands for the best in conventional medicine, for the standard of care as determined by physicians and scientists. Weil doesn’t. The AAFP stands for evidence-based medicine. Weil doesn’t.

Perhaps those who invited him didn’t know he had made pronouncements like this:

I would look elsewhere than conventional medicine for help if I contracted a severe viral disease like hepatitis or polio, or a metabolic disease like diabetes. I would not seek allopathic treatment for cancer, except for a few varieties, or for such chronic ailments as arthritis, asthma, hypertension (high blood pressure), multiple sclerosis, or for many other chronic diseases….

In his article “A Trip to Stonesville: Some Notes on Andrew Weil” Arnold Relman, former editor of The New England Journal of Medicine, shed some light on Weil’s background and his thought processes. Weil earned an MD from Harvard, but instead of choosing a specialty and following the usual path into residency training he dropped out, experimented enthusiastically with a variety of psychedelic drugs, and lived on an Indian reservation to learn from a shaman.  Then he re-invented himself as America’s guru of integrative medicine, established a commercial and educational empire, wrote books, and appeared on the cover of Time.

According to Relman, Weil accepts science, but only to a degree. He has openly promoted “stoned thinking,” alleging that thoughts experienced while under the influence of psychedelic drugs or in altered states of consciousness are as valid as, or more valid than, scientific evidence. He has been known to reject clear evidence from clinical trials when it conflicted with his beliefs. He considers reality to be ambivalent; he tolerates mutually antagonistic ideas. He frequently dismisses common sense and medical fact. He believes in miracles and in the ability of mind to cause and to cure disease.

Weil has snowed a lot of people because he offers so much excellent science-based information and advice that is consistent with what other doctors say. But he promiscuously mixes that good advice with questionable advice in a way that makes it impossible for the average consumer to tell which is which. The textbook Consumer Health: A Guide to Intelligent Decisions characterizes Weil’s advice as “a mixture of sense and nonsense.” The Quackwatch website lists Weil under “nonrecommended sources of health advice.”

Some of Weil’s advice is frankly dangerous. He encourages self-care and irresponsible trial-and-error experimentation. For example, he recommends that patients with rheumatoid arthritis avoid pharmaceuticals and experiment with a series of lifestyle changes, dietary manipulations, alternative treatments, and diet supplement products.  Patients who follow this advice risk joint deformities and disabilities that might have been prevented by taking disease-modifying anti-rheumatic drugs (DMARDs) early in the course of their disease. It is irresponsible for a doctor to recommend that rheumatoid arthritis patients try unproven treatments like bee-sting therapy, feverfew, and homeopathy while avoiding any mention of the proven benefits of DMARDs.

Weil is the public face of “integrative medicine,” an unfortunate movement that tries to infiltrate medical practice with treatments that have not been adequately tested for safety and effectiveness and in some cases have even been tested and shown not to work. Dr. Marcia Angell, former editor of The New England Journal of Medicine, has called integrative medicine “the new snake oil.” Dr. Steven Novella, Yale neurologist and founder of the Science-Based Medicine blog, has said it is “used to lend an appearance of legitimacy to treatments that are not legitimate.” Dr. Arnold Relman has said:

There are not two kinds of medicine, one conventional and the other unconventional, that can be practiced jointly in a new kind of “integrative medicine.” Nor… are there two kinds of thinking, or two ways to find out which treatments work and which do not. In the best kind of medical practice, all proposed treatments must be tested objectively. In the end, there will only be treatments that pass that test and those that do not, those that are proven worthwhile and those that are not.

Dr. Mark Crislip put it more bluntly:

If you integrate fantasy with reality, you do not instantiate reality. If you mix cow pie with apple pie, it does not make the cow pie taste better; it makes the apple pie worse.

“Integrative medicine” is a marketing term rather than a meaningful scientific discipline. Weil is a better marketer than doctor. He appeals to consumers who are suspicious of “the medical establishment” and “Big Pharma,” or who have succumbed to the naturalistic fallacy (the idea that artificial drugs are bad and anything natural is good, a myth easily refuted by examples like strychnine).

Weil has developed a thriving business selling vitamins and supplements. And he has run afoul of the FDA for making unsubstantiated claims for his products.     What he does is inconsistent with the position of the AAFP that:

The decision to provide special dietary intervention or nutrient supplementation must be on an individual basis using the family physician’s best judgment based on evidence of benefit as well as lack of harmful effects.

The Medical Letter also discourages routine vitamin supplementation for the general population. After their unbiased panel of experts reviewed all the available evidence, they said:

Supplements are necessary to assure adequate intake of folic acid in young women and possibly of vitamins D and B12 in the elderly. There is no convincing evidence that taking supplements of vitamin C prevents any disease except scurvy. Women should not take vitamin A supplements during pregnancy or after menopause. No one should take high dose beta carotene supplements. A balanced diet rich in fruits and vegetables may be safer than taking vitamin supplements. No biologically active substance taken for a long term can be assumed to be free of risk.

Weil acknowledges that the best nutrition is obtained through diet but says it is essential to take supplements as insurance against gaps in the diet.  His website features a “Vitamin Advisor” questionnaire that formulates individual recommendations; its deficiencies have been exposed on Quackwatch.  The word “vitamin” is used loosely, since most of the recommendations are for non-vitamin diet supplements. Rather than just an advisor, it’s a marketing tool that puts the Weil brand of recommended supplements in a shopping cart. It recommended that my healthy 27-year-old daughter take a daily multivitamin, a daily antioxidant, a calcium/magnesium pill, evening primrose oil, milk thistle, omega 3, and 1000mg vitamin C, at a total monthly cost of $99.90.  No reputable medical authority would agree. I have reason to think she will remain just as physically healthy without those products, and she will definitely be financially healthier.

As if that weren’t enough, Weil has now embarked on a new endeavor: a collaboration with Innate Response Formulas to develop a system of “Seasonal Therapeutics” with seminars and a new line of products tailored to  the seasons:

  • Autumn: Season of Harvest: focuses on liver and GI
  • Winter: Season of Reflection: focuses on immune and mood
  • Spring: Season of Renewal: focuses on purification and allergy
  • Summer: Season of Vitality: focuses on cardio and joint health.

The seminars promise to teach attendees how to:

  • Use evidence-based, targeted nutritional supplementation to restore integrity to the gastrointestinal mucosa, enhance digestive function, repopulate the microbiome, and optimize immune function
  •  Utilize seasonal changes in the diet to assist the body’s detoxification mechanisms
  • Integrate stress management strategies that encourage the exploration of gratitude and meditation

This program claims to be evidence-based, but there is no scientific evidence that winter is the season of reflection, that the average person’s gastrointestinal mucosa has lost integrity and needs to be restored, that digestion needs to be enhanced, that the body needs help with its detoxification mechanisms or that diet changes would assist it, that any regimen of supplements is capable of optimizing immune function, that training in exploring gratitude improves health, or that a seasonal approach to diet and supplements offers any health benefits. This is speculation, pseudoscience, imagination, and marketing genius, not science.

The annual AAFP Scientific Assembly used to stand for the best in scientific medicine. It used to be a great opportunity for family physicians to learn about new developments, to review current standards of practice, and to brush up on their skills. By inviting Weil, the AAFP has descended to a new low and has sadly tarnished its reputation. I’m a life member of the AAFP, but I won’t be attending this meeting, and I have written a strong letter of protest to its organizers. We need good medicine based on good evidence; we don’t need medicine based on speculation or “stoned thinking.”


 Other Protests

I was not the only one to object. Back in August, Orac also criticized the AAFP for selecting Weil.  The Institute for Science in Medicine wrote a letter to the AAFP and received an answer with flimsy excuses  that Orac promptly demolished. Both letters are published on the ISM website. Others, including the Dutch Society Against Quackery, wrote letters of protest. In online forums, many commenters from the US and other countries have expressed their astonishment that the AAFP was allowing him to speak.

Editing Changes

During the editing process, there were several deletions, additions, and questions raised. The editor deleted the quote from Relman about “there are not two kinds of medicine” because she felt it was redundant. She changed my characterization of integrative medicine from “trying to infiltrate medical practice with treatments that have not been adequately tested” to “treatments that in many cases have not been adequately tested.” She suggested trimming Weil’s statement about not seeking help from conventional medicine “since he’s saying that he would not use allopathy for the latter things, just the first few.”(I really don’t understand this. If anything, I suppose the comma placement in the quote might lead to confusion and to the misinterpretation that he would accept conventional treatment for chronic diseases along with “a few varieties” of cancer; but it is clear from his other writings that he wouldn’t. He consistently recommends alternative treatments for all of those chronic diseases. My example of rheumatoid arthritis is a case in point). She asked for a stronger quote. She thought the point wasn’t as strong as it could be  “since there aren’t great treatments for some viral diseases.” (Viruses were only one item on his long list, and there are effective evidence-based conventional treatments for many viral diseases, and alternative medicine has nothing better to offer.)

She had 3 main areas of concern:

  • She said the lawyers would want me to contact Weil for comment. I didn’t see why this was necessary; but I complied, sending an e-mail to a publicity link on his website. I didn’t get an answer, so we could legitimately say “Weil could not be reached for comment.”
  • She said the lawyers would object to some of my statements so she made me tone down my language. For instance, I could not say some of Weil’s advice was “dangerous.” (Even though I think I demonstrated that it was.) And she objected to my saying “Weil doesn’t” in the second paragraph; I revised that and added 2 links to demonstrate that he doesn’t. I was not allowed to say Weil was a better marketer than doctor.
  • Her biggest concern:  I had not provided original sources for everything I said.

Primary Sources

I had relied on both primary and secondary sources. Mainly one secondary source; and that one, Arnold Relman, was a trustworthy one. I had also relied on having long ago read library copies of couple of Weil’s books, on what I read on his website, and on my observation of his activities over many years. I was unable to provide links to primary sources for a few of my statements.

  • I had taken Marcia Angell’s “snake oil” quote from a secondary source but I was unable to verify it from the primary source, so I offered to substitute this:

Marcia Angell, former editor of The New England Journal of Medicine, said “One of the things that’s so amazing to me is the way a lot of proponents of alternative medicine will follow anything… Andy Weil says without any evidence whatsoever, faithfully on his word alone.”

  • She asked me to provide a link or an example for my statement that Weil has rejected evidence from clinical trials. I couldn’t find a link but I provided an example where he rejected credible evidence against osteopathic manipulation for ear infections because he had “seen it work.” He describes that in one of his books, but I read it a long time ago and can’t even remember which book.
  • She wanted a link to Weil’s own words showing that he believes in miracles and the ability of the mind to cure disease. I couldn’t locate any specific links. Relman reported that after reading Weil’s books, and the texts of his books are not available on the Internet.
  • She made me delete the quotation from The Medical Letter simply because it is not available online without a subscription. (Since when are print sources not acceptable references? Most articles from journals like JAMA, NEJM, and Lancet aren’t available online without a subscription either, except for abstracts on PubMed). She asked for a link to another source questioning daily multivitamins, and I provided two of them. She did not want to use my quotation of the AAFP’s position on multivitamins because she thought it was not strong enough to support my point.

After considerable editorial back-and-forth, she announced that she couldn’t run the story on Slate after all. It would need “a lot more primary reporting of Weil’s misdeeds” and there was not enough time left before the AAFP meeting to seek those out (partly because she took so long to get around to editing my draft after I submitted it!). I thought I had enough primary sources to establish that he was guilty of misdeeds (his run-in with the FDA, his flawed Vitamin Advisor, his seasonal supplements, his recommendations for rheumatoid arthritis, etc.). And I considered Relman to be eminently reliable as a secondary source.  She said:

I agree that the Relman article was a good one to reference, and it was a good idea to link to it and other articles. But we do want to provide readers with primary sources, at least for a story’s strongest claims. I agree with your interpretation of the data, but in part for the sake of readers who don’t agree or aren’t convinced, it’s best to provide the raw data (in this case, Weil’s own words) so readers can judge for themselves.

One problem with that is that readers are not good at judging for themselves. If they were, Weil could never have risen to such prominence.

I’m Not Cut Out for This

I am not an investigative reporter but a doctor who comments on the news from a science-based medical perspective. The editor knew that when she originally approached me to write for Slate after reading my work on SBM and elsewhere. Before she rejected my Weil article she had accepted and published my article on acupuncture in the military. The editing process for that article was relatively painless. She tightened and improved my text, and she even made it more forceful and controversial by giving it an inflammatory title and calling acupuncture “quackery” (I had deliberately avoided using that word but I let her persuade me to use it, which I now regret).

This was my second foray into popular media after my painful experience with O, The Oprah Magazine.  I thought this time it was going to be better. I was disappointed. She did say she would be happy to run other stories by me in the future, but I don’t know…I don’t need the money (a token $100 per article) and I  don’t need the hassle. My writing on SBM is unpaid, and it doesn’t reach as many readers; but it maintains my independence and integrity. Like Frank Sinatra,  I can be proud that “I did it my way.”

 

 

 

Posted in: Herbs & Supplements, Science and Medicine

Leave a Comment (94) ↓

94 thoughts on “Andrew Weil/AAFP Article Rejected by Slate

  1. TonyMach says:

    In defense of a quack.

    You write:
    “He encourages self-care and irresponsible trial-and-error experimentation. For example, he recommends that patients with rheumatoid arthritis avoid pharmaceuticals and experiment with a series of lifestyle changes, dietary manipulations, alternative treatments, and diet supplement products.”

    And what is this “irresponsible trial-and-error experimentation” that we find at the webpage you linked to?
    “Try changing your diet in the following way. One at a time, eliminate the following categories of food for two months:
    # All sugar except natural fruits
    # All citrus fruits
    # Wheat, corn and soy
    At the end of each trial period, restore the eliminated items to your diet. You may find that one or more has an influence on your arthritis symptoms.”

    So let’s dissect this:
    # Citrus fruits are *not* essential for our nutrition as far as I know.
    # Same with sugar, which is *not* an essential nutrient – especially considering that he recommends a high-carb diet.
    # With regards to wheat I was under the impression that it was commonly considered a dietary villain. Both corn and soy are non-essential, as far as I know. For soy one can argue about soy isoflavones and their negative impact on the endocrine system (if not more).

    The only controversial thing about this experiment I can see is maybe the elimination of wheat – you would probably say replace it with other non-wheat whole grains, I would say replace it with other (non-grain, non-sugar) carbs.

    The only possible downside will be a few months casing down ghosts with a different diet – the upside is to possibly find out something that helps. Good gracious, what a terrible prospect, a patient experimenting with his nutrition!

    Personally, having traced down some of my health problems clearly and definitly to nutrition (and finding several supposedly “healthy” foods to be definitely unhealthy for me), I can only say that his advise with regards to nutrition is much more sensible that what one hears from the medical mainstream. And having medical professionals being hostile towards such positive personal findings is neither helping the patient nor advancing the medical sciences.

    A properly conducted elimination/challenge diet is much better in showing a path to a healthy life than years of medical studies, it seems to me. The medical profession would do good to encourage and accompany patients to do proper and safe experiments in personal health, and show them how to do so (you know, the scientific method). When exactly did experiments fell out of favor in the medical sciences?

    (On what I agree, his “supplements and medications” recommendations are bunk. And his “For symptomatic treatment use aspirin and other over-the-counter anti–inflammatory drugs” advise is something most patients with significant pain and inflammation would follow anyway no matter what you told them…).

    1. Harriet Hall says:

      @TonyMach,
      I did not say there is anything wrong with trial-and-error. I specified “irresponsible” trial-and-error, and I provided an example. Did you understand my point about DMARDs?

  2. TonyMach says:

    Oh, one more thing, he writes in the article you linked:

    “Nutrition and Supplements
    # Follow a low protein, high carbohydrate diet; minimize consumption of foods of animal origin.
    # Eliminate milk and milk products, including commercial foods made with milk.
    # Avoid all polyunsaturated vegetable oils, margarine, vegetable shortening and products made with partially hydrogenated oils of any kind.
    # Increase intake of omega-3 fatty acids by eating more cold-water fish, walnuts or freshly ground flaxseeds. You may also want to consider taking a fish oil supplement to help keep your protein intake low.”

    Let’s see:
    # I’m not up to date, but I was under the impression that for the medical profession a low-(meat-)protein, low-fat and high-carb diet is *the* dietary solution du jour for everything?
    # People with lactose intolerance live just fine without milk and dairy.
    # Look up Bill Lands with regards to overconsumption of seed oil and n-6 fatty acids.
    # n-3 fatty acids seem to be mildly positive because of overconsumption of n-6 fatty acids (again, see Bill Lands for details)

  3. windriven says:

    “One problem with that is that readers are not good at judging for themselves. ”

    Another problem is that readers are better led than driven to a conclusion.

  4. rork says:

    Maybe the paragraph starting “According to Relman, Weil accepts science, but only to a degree” did need more backing beyond Relman says so. To do everything right would get pretty long though, and take lots of time.

    Thanks for trying, and thanks for this article.

  5. anoopbal says:

    ‘What were they thinking? That’s like having an astrologer give the keynote speech at an astronomy meeting.”

    ha ha that was funny, Harriet

  6. WilliamLawrenceUtridge says:

    What would be nice would be the AAFP giving time for a skeptical speaker after Dr. Weil. Failing that, skeptical family physicians in the audience who could ask pointed questions illustrating Dr. Weil’s double-think. A pre-prepared list of such questions would be a useful tool.

  7. MTDoc says:

    I’m still stuck on the first paragraph. What, indeed, was the AAFP thinking! I’m also a life member of the AAFP and have always been proud of my certification and three recertifications. Perhaps I won’t brag quite so much about that in the future. Oh, well.

  8. Fascinating. You were invited to provide an informed opinion from a skeptical perspective, not investigative journalism! But then Slate got a whiff of the legal hazards, raised the bar, and decided to push for journalistic rigour like you were preparing for a court case. In a sense, you were!

    Mainstream writing gigs are a really different world than skeptical blogging. The skeptical blogosphere exists to serve an audience and needs that mainstream publishing generally can’t (because of legal fears) and won’t (because of temperament and values). If mainstream publishing was in general capable of hosting robust critical thinking, it couldn’t be mainstream! Instead they largely stick to token skeptics and false balance.

    We celebrate the handful of skeptics who have made the jump to mainstream media precisely because it is so difficult to cross over. It almost always involves painful compromises, and it’s surely no coincidence that most of the notable examples have an oblique approach (Adam Savage) and/or a super civil style (Sagan).

  9. estockly says:

    I just don’t get it. Weil is a public figure. Opinion or not, the standard for him to bring a suit for libel or slander is incredibly high.

    The burden of proof is on him to show that what you wrote is false, and that you knew or should have known it was false, and you proceeded with malice.

    Your defense is: Truth, and/or an absence of malice.

    This whole thing sounds fishy. If Weil is quick to sue maybe they just didn’t want to be bothered. I hope we don’t start seeing his products advertised on Slate!

    Glad you posted it here.

    ES

    ps I don’t see the problem with the AAFP inviting him to speak, it might be helpful for real doctors to know what their patients are hearing from the Alt-Med camp. Maybe that’s what they were thinking?

  10. WilliamLawrenceUtridge says:

    @TonyMach

    Dr. Hall also discussed the bait-and-switch, and promiscuous mixing of reasonable, science-based advice with irrational, harmful, useless, expensive and/or unproven advice. You have listed the former, while Dr. Hall identified the latter. So I’m not sure what you’re complaining about, she did acknowledge that some of Weil’s advice is science-based.

    Packaging reasonable recommendations for a healthy diet with largely unnecessary, expensive and lucrative (for Andrew Weil) supplements has been a long-standing criticism of CAM in general. I mean talk about conflict of interest – he has a section entitled “Related Weil Products”. Not generic products or simple names. Not vitamin C or burdock root. Andrew Weil‘s proprietary, trademarked, link. And recommends an apiarist to supervise bee-sting therapy. Not a doctor, an apiarist. If I had an allergy to peanuts, I don’t think recommending a peanut farmer, not even Jimmy Carter, would be a good idea. Though Mr. Carter seems like a reasonable person, so he might know how to administer an epipen or mouth-to-mouth if I went into anaphylactic shock.

    Weil certainly seems to be a believer in the naturalistic fallacy – if it’s natural it’s better. Never mind dying from allergic reactions is perfectly natural.

    Also, tracing your symptoms to specific foods is kinda questionable, I’d be interested in seeing what happened in a double-blinded challenge-dechallenge-rechallenge test. Certainly possible your symptoms were caused by food, but you can’t be sure without a careful testing protocol. At least you didn’t take his advice regarding homeopathy.

  11. elburto says:

    @Tony –

    Personally, having traced down some of my health problems clearly and definitly to nutrition

    If you’re the same TonyMach that posts over at SB, then your anecdata primarily revolves around functional disorders, yes?

    Cutting out wheat and getting relief from chronic fatigue has zero bearing on people with destructive autoimmune illnesses.

    DMARDS change lives. Aspirin is pointless for RA, same goes for shunning oranges and. taking Weil,brand zinc, or whatever.

  12. windriven says:

    @TonyMach

    Cherry pick away with Weil’s inanities. The point isn’t so much experimenting with tincture of newt spleen or withdrawing milk from one’s diet that brands Weil a dangerous quack, it is his failure to direct people to competent medical guidance first.

    We aren’t talking about experimenting with an omelet made with ingredients dreamed up during a psilocybin induced hallucination. We are talking about the joints of living human beings; joints that are not for the most part replaceable and damage which is not for the most part reversible.

    Encouraging people to eschew best medical evidence in favor of hokum is loathsome.

  13. David Gorski says:

    She tightened and improved my text, and she even made it more forceful and controversial by giving it an inflammatory title and calling acupuncture “quackery” (I had deliberately avoided using that word but I let her persuade me to use it, which I now regret).

    I don’t have a problem calling acupuncture quackery, actually. I used to be more cautious about it, but, if anything, the more studies I read on acupuncture the more convinced I become that it is quackery.

  14. Harriet Hall says:

    @David Gorski,

    “I don’t have a problem calling acupuncture quackery”

    The word quackery, rightly or wrongly, is often associated in the popular mind with deliberate intention to deceive. I try to avoid using it to avoid misunderstandings. I think most acupuncturists really believe they are providing effective treatment.

  15. Harriet Hall says:

    @Estockly,

    “it might be helpful for real doctors to know what their patients are hearing from the Alt-Med camp. Maybe that’s what they were thinking?”

    That hypothesis is disproved by the AAFP’s letter responding to the ISM complaint. Follow the link.

  16. estockly says:

    >>That hypothesis is disproved by the AAFP’s letter responding to the ISM complaint. Follow the link.

    Thanks, Dr. Hall. Looks like they had a focus group pick their speaker from a short list. What were they thinking, indeed! At least there’s this:

    >>Finally, having Dr. Weil speak in no way indicates our endorsement of any of his work or products.

    ES

  17. The Dave says:

    “At least there’s this:
    >>Finally, having Dr. Weil speak in no way indicates our endorsement of any of his work or products.”

    About as effective as the Quack Miranda Warning…

  18. Narad says:

    The only possible downside will be a few months casing down ghosts with a different diet

    A year, actually, if the seemingly arbitrary two-month measurement unit is to be taken seriously.

  19. mho says:

    Is there a SLATE competitor who might take the article?

  20. BobbyG says:

    Who cares about Slate?

  21. BKsea says:

    I think the change to:

    “trying to infiltrate medical practice with treatments that in many cases have not been adequately tested”

    is absolutely correct. Most of the methods doing the infiltrating HAVE been adequately tested. They don’t work.

  22. windriven says:

    @mho and BobbyG

    “Who cares about Slate?”

    If you want to do more than preach to the choir we all should. But we need to frame our arguments appropriate to the audience we are touching.

  23. pmoran says:

    Until we have credible scientific evidence showing what antineoplastons are, how they act in the body, and what realistic expectations of treatment with them might be, I see no reason for any cancer patient to take this route.”

    Says Andrew Weil about the Burzinski treatment. Seems fair.

    Do you have a cite for Andrew Weil stating he would not use allopathic medicine for cancer? This is not in accord with any of the advice he currently gives on his web site. I forwarded here recently a quote of his advising cancer patients to find out what the mainstream offers before considering alternative care.

    Just as Ted Kaptchuk has lurched towards proper science from his TCM origins, and Edzard Ernst has from his homeopathic roots, and Ralph Moss has become more temperate about mainstream medical treatment vs “alternative” with maturity, I think Weil should be judged by what he says now, rather than in the enthusiasms of his hippy youth. There is much to look down upon in his commerce in fringy medical practices, but he is not the threat to orthodox/scientific medicine that your piece suggests and by no means as seriously as many others.

    He has now delivered his address and seems to have said nothing too outlandish. What about his comments about the sugary drinks that now sem to fill up so many supermarket trolleys? Are we not (probably) as a population over-medicated? Do you think the characterization of him as an “astrologer speaking astronomers” was justified?

    My concern is this: when like minds, possibly even in this august group, get together they tend to collectively end up with more extreme tendencies than those possessed at the beginning. One of those might be to wind up treating largely allied minds with same Inquisitional ferocity as we apply to mortal enemies of science and good medicine.

    Your piece may not have been accepted because it looked over-the-top — or an attempt to silence someone with potentially valid criticisms of the mainstream and its style of practice.

  24. ConspicuousCarl says:

    Here’s a source for Weil’s spiritual nonsense if anyone so demands:

    Health and Healing: The Philosophy of Integrative Medicine and Optimum Health
    By Andrew T. Weil (Houghton Mifflin Harcourt, Dec 9, 2004)

    Page 115:
    “Belief, thought, emotion, and spiritual forces are phantoms to allopaths, sometimes mentioned in casual conversation but never accorded scientific relevance. This professional blindness to vital components of human beings keeps many doctors from understanding or making serious use of such phenomena as placebo responses, hypnosis, faith healing, and suggestion. It keeps them from seeing the significance of folk cures for warts, spontaneous remissions of cancer, yogic control of supposedly involuntary functions, and so forth, and from appreciating the body’s own capacity for healing.”

    Page 83 of this same book contains Weil’s dangerous preference against modern medicine in the cases of diabetes and most cancers as already quoted by Harriet Hall in the above article.

    Page 26 (Chapter 3, “Why Does Homeopathy Work?”) states, “That homeopathy does work is abundantly clear from many testimonials by both patients and doctors.”

    That’s not the end of his anti-science, pro-nonsense rant by a long shot (with the paragraph following the faith-healing quote offering a derision of the “materialistic bias of scientific medicine”), but I can’t include all of it without typing out virtually the entire book.

    So that’s it. Andrew Weil doesn’t want scientific medicine for cancer and diabetes because all of you “allopaths” are too blind to know how to use faith healing. His belief that homeopathy works is established by testimonials, which makes him an unscientific stump, but there’s no reason why he should care about that because he hates the materialistic nature of scientific medicine anyway. What more is needed before hurling every synonym at this guy and telling him not to bother attending medical conferences?

    All of the nonsense quoted above is available here:
    http://books.google.com/books?id=M7nop–9qwQC&pg=PA83&dq=would+look+elsewhere+than+conventional+medicine+for+help+if+I+contracted+a+severe+viral+disease+like+hepatitis+or+polio,+or+a+metabolic+disease+like+diabetes&hl=en&sa=X&ei=gFeQUMenEaOS2QXf_4HwCA&ved=0CDUQ6AEwAg

  25. Narad says:

    Says Andrew Weil about the Burzinski treatment. Seems fair.

    Aside from the part where there is no question of what “antineoplastons are.”

  26. pmoran says:

    CC, Weil has presented similar sentiments in less flowery terms. In a radio interview in Australia about ten years ago he stated “placebos are the ‘meat’ of medicine”.

    Expand the concept of “placebo” to include all psychological influences on patient well-being (including exploring the patient’s existential/spiritual concerns). Accept that such influences don’t only influence symptom perception; they can affect the patient’s ability to cope with illness, as well as probably sometimes providing a key to resolving psychosomatic complaints and some varieties of abnormal illness behaviour.

    You are then very close to finding Weil’s claims supportable.

    For there is no way for pure science to help with human existential concerns. It also has no interest in symbolic healing rituals, even if some patients may merely need a treatment “hook” on which to hang their expectations, or their burning desire to get better.

    So where is the problem? It’s actually in the language used e.g. — ‘the body’s own capacity for healing”. That turns me off too.

    Where I would disagree with Weil is his implication that warts going away and cancers going into spontaneous remission are within the scope of placebo “effects”. But that may merely reflect my biases against psychological influences having such dramatic effects on (presumably) the immune system, and, of course, limited evidence of such effects.

  27. Quill says:

    If you want to know why something gets squelched by a company after someone there has already invited it, do as the late Molly Ivins often suggested: follow the money. In this case it is complicated, but suffice to say that interests who promote Weil also have an interest in The Washington Post Company, which owns Slate. It’s not too hard to understand that brand Weil is of some value and there are those that don’t want to see it challenged, especially not by pesky things like facts and science.

    Real medicine is messy, complicated and often difficult to understand, hence expensive. Selling Weil-branded nonsense is practically overhead-free and immensely profitable. Easy to see why any challenge to something like that would be met with some resistance.

  28. Quill says:

    For there is no way for pure science to help with human existential concerns. It also has no interest in symbolic healing rituals, even if some patients may merely need a treatment “hook” on which to hang their expectations, or their burning desire to get better.

    Only if you consider psychiatry, psychology, anthropology, linguistics, sociology and many other -ologies not pure science. And then you enter the physicist’s argument that physics is the only pure science while all others derive from it or at least end up with only biology and chemistry making the triad. Medicine is still out.

    Be all that as it may, I agree that a central problem with Weil is his use of language. “Placebos are the ‘meat’ of medicine.” What does that even mean? It’s so squishy and connotes so many things, from sci-fi horrors to things lurking in Ferran Adrià’s kitchen. Weil’s use of language in his published works is incredibly suggestive and often passionate, but in the end he ends up saying very little.

  29. Quill says:

    And speaking of language, does anyone else see the problem here with Weil and the woo-crowd et al:

    Weil acknowledges that the best nutrition is obtained through diet but says it is essential to take supplements as insurance against gaps in the diet.

    If something is essential than by definition it can’t be supplemental! The whole supplement industry, if their claims are true, is mislabeled. It should be the essentials industry and dietary supplements should be dietary essentials. A close look at the language used by Weil and the like is as profitable for a person as understanding the science behind it all. If someone tells me that they are selling something that is optional but is in fact necessary then I already know something is very wrong & should consider what it is before buying anything.

  30. windriven says:

    @Quill

    “In this case it is complicated, but suffice to say that interests who promote Weil also have an interest in The Washington Post Company, which owns Slate. ”

    Sorry, that doesn’t suffice. You have made a serious allegation and have offered absolutely no proof. The notion that the editorial content of The Washington Post or, for that matter, Slate hinges on the economic success of some quack requires serious proof.

  31. nybgrus says:

    Accept that such influences don’t only influence symptom perception; they can affect the patient’s ability to cope with illness, as well as probably sometimes providing a key to resolving psychosomatic complaints and some varieties of abnormal illness behaviour.

    You are then very close to finding Weil’s claims supportable.

    In other words, re-interpret Weil’s words in such a way as to become more palatable to yourself, asign your own meaning to them, and then apply it to the real world.

    Funny, I though only religious people did such things of their holy texts.

    For there is no way for pure science to help with human existential concerns. It also has no interest in symbolic healing rituals, even if some patients may merely need a treatment “hook” on which to hang their expectations, or their burning desire to get better.

    Quill said it well, but I will echo it – pish posh.

    Unless you wish to ascribe to some sort of ethereal soul or other such dualism of the universe, of course it can. It certainly cannot do so at this point – at least not fully – but it does indeed inform it to an amazing degree and will only do so more and more as time goes on.

  32. WilliamLawrenceUtridge says:

    @pmoran

    In a radio interview in Australia about ten years ago he stated “placebos are the ‘meat’ of medicine”.

    Medicines are the meat of medicine. Placebos are, at best, the garnish, and a garnish that can and should be applied to real treatments.

    Expand the concept of “placebo” to include all psychological influences on patient well-being (including exploring the patient’s existential/spiritual concerns). Accept that such influences don’t only influence symptom perception; they can affect the patient’s ability to cope with illness, as well as probably sometimes providing a key to resolving psychosomatic complaints and some varieties of abnormal illness behaviour.

    Providing reassurance to patients is valuable. But that’s not placebo by my definition. And again, none of which supports pure placebo medicine; the best placebo is one that accompanies true medical treatment not lies irrespective how well-intentioned they are.

    For there is no way for pure science to help with human existential concerns.

    So…you don’t see the treatment of life-threatening infections with effective antibiotics, or the prevention of deadly diseases with vaccination, or the surgical curing of solid tumors as helping with human existential concerns? All science-based interventions. Medicine without actual treatments is horribly, horribly patronizing, a giant step backwards to the 18th century.

    It also has no interest in symbolic healing rituals, even if some patients may merely need a treatment “hook” on which to hang their expectations, or their burning desire to get better.

    Bullshit, what scientific medicine would benefit from, and in fact researches, are how to enhance the rituals that surround diagnosis and treatment. Doctors are interested in improving bedside manner, time spent with patients and enhancing the placebo effect – accompanied by real treatments. Such a stance has been defended many times on SBM – doctors are not uninterested in patient satisfaction, comfort and happiness, they just want to offer more than that.

    So where is the problem? It’s actually in the language used e.g. — ‘the body’s own capacity for healing”. That turns me off too.

    What turns me off is the lies, misrepresentations, unfounded and hypocritical criticisms of real medicine, naked greed and the fact that CAM actively discourages conventional treatments like vaccination, chemotherapy and antibiotics. That you are offended by the language, but not by the effects, is disconcerting.

    Where I would disagree with Weil is his implication that warts going away and cancers going into spontaneous remission are within the scope of placebo “effects”. But that may merely reflect my biases against psychological influences having such dramatic effects on (presumably) the immune system, and, of course, limited evidence of such effects.

    Pete, I’m continually astonished that you would be so critical in the area of your own specialty (cancer treatment) but appear to give essentially a free pass on the rest of CAM despite considerable evidence that non-cancer “treatments” are just as scientifically bankrupt. You have the oddest double-standard, and I find your comments here deeply disappointing compared to your website. I don’t understand how your skepticism can be so focused and one-dimensional. I genuinely don’t understand it.

  33. Quill says:

    Windriven says:

    “Sorry, that doesn’t suffice.”

    To you perhaps. This is a comment section of a blog. The burdens are low.

    “You have made a serious allegation and have offered absolutely no proof.”

    Serious to whom? Those who don’t grok how things work in the world of editorial matters at for-profit publications? Perhaps so.

    “The notion that the editorial content of The Washington Post or, for that matter, Slate hinges on the economic success of some quack requires serious proof.”

    No one said anything of the kind — that is your reading into things.

  34. windriven says:

    @Quill

    “No one said anything of the kind — that is your reading into things.”

    Bullcrap.

    This is what you said: “suffice to say that interests who promote Weil also have an interest in The Washington Post Company, which owns Slate.”

    Don’t be a coward. Stand behind the things you say. If you have proof, let’s have it. If you’re just shooting you mouth, fess up.

  35. Quill says:

    Oh windriven. Do you have a drawing pin caught in your sock?

    “Bullcrap.”

    A faux-genteel ejaculation of no meaning whatsoever.

    “This is what you said….”

    Yes, you can cut and paste, good. However, what I said is clear: financial interests often drive editorial decisions. This is a well-known fact.

    However, you took that and ran with it on your own trip, writing of things “hinging” on the financial well being of “quacks.” That isn’t even an extreme reading of what I wrote, it’s totally off the rails.

    “Don’t be a coward.”

    That is just irrelevant, gratuitous rudeness.

    “Stand behind the things you say.”

    No one has said anything. This is called writing and reading.

    “If you have proof, let’s have it.”

    Google is your friend, as you already well know. Don’t throw him off so soon.

    “If you’re just shooting you mouth, fess up.”

    You’re the one doing the shooting, which must be hard with that foot in there too.

    Parenthetically, one might wonder why my inoffensive post should stir you up to such foolishness.

  36. windriven says:

    @Quill-

    Quit trolling and man up.

    ” what I said is clear: financial interests often drive editorial decisions.”

    That is not what you said. What you said is, “interests who promote Weil also have an interest in The Washington Post Company, which owns Slate.”

    Who are these interests?

    “Parenthetically, one might wonder why my inoffensive post should stir you up to such foolishness.”

    This part of your post is offensive. You imply that shadowy interests (oooh, is it the Rothschilds?, the Bilderberg Conference? or is it the hated Trilateral Commission?) who promote Weil are able to manipulate the editorial content of Slate (a generally useless waste of bandwidth) through the Washington Post. One suspects that you are a conspiracy nut or just a common garden troll. And if you’ve been around SBM you shouldn’t be surprised to be challenged to support your allegations.

    So, despite many lines of huffy nattering you still haven’t identified your alleged spooky manipulator of Slate. What a bag of wind.

  37. Quill says:

    @windriven: Your imagination is interesting, your projected implications paranoid and your assertions risible.

    “What a bag of wind.”

    That is the definition of being windriven. QED.

  38. mho says:

    @windriven

    I didn’t say “who cares about Slate.” I would like to see Dr. Hall’s article get published and suggested there might be a competitor of Slate who might be interested.

  39. Is this the AAFP that accepted the Coca Cola sponsorship?
    http://www.cbsnews.com/8301-505123_162-43840775/aafp-makes-deal-with-coke-for-educational-content/

    I guess so.

    I believe you docs need to deeply examine the concept of the professional organization. These are heavily conflicted with commercial enterprises. These professional groups could simply decide to be dues-sponsored.

    Many of not most SBM readership belongs to a group that survives without such funding.

    Slate is chicken. Anyone paying attn to Weill for ten seconds can hear him coming with that money jingling in his pocket.

    The assessment that he mixes in a bunch of soft statements with hints, allusions, and suggestions of some nutter stuff is exactly what he does. Sure, you can argue on his behalf, and be right, in a sense. Sure, taking a multi-vitamin might be a good idea for some, and sure a rotation diet may identify food sensitivities (I did this to identify a devilish wheat allergy – in my dog). But this is all the set-up for the hard sell.

    Chopra has got to be jealous.

  40. constantine says:

    It doesn’t make sense: quacks can claim whatever they like, and it is the skeptics who have to jump through all the legal hoops?

  41. NYUDDS says:

    I hope Jann Bellamy will agree with my contrived scenario below. It’s a point that is worth making again and again. Simply put:

    Laura Helmuth,The Great Decider, represents the State Boards of Registration in Medicine.
    Harriet Hall, The Persistent Objector, represents the medical profession.
    The AAFP represents Quackery, Andrew Weil’s positions, by association.

    It does not matter what The Persistent Objector says, proves, writes or does; if the AAFP and Quackery can convince The Great Decider that their position is correct, and she agrees, then it is correct. Period. The horse is already out of the barn and many more will follow using the same flawed logic and science we all deplore. Chiropractors and acupuncturists are presently licensed in MA and naturopaths, homeopaths and others are slowly following their successful formula for acceptance. Optometrists have legislatively expanded their scope of practice and chiropractors, as we all know, seek to become PCP’s.

    But they can be stopped.It’s elections season. Make sure you are personally involved with your local officials, state reps and senators and congressmen. Make sure to let the state societies in you area of expertise know you exist. Help the points of view that you hold dear and the people associated with supporting those points of view and above all, once you are “established,” use the title “Doctor” to teach, teach, teach. Put bluntly, IMHE, legislators at the state level are not well-informed re: math or science. They are hungry for information that is useful, as they seek to form their own opinions and influence others. And make that lobbyist earn their money!

  42. Skeptic says:

    @ Harriet Hall, who wrote:

    “The word quackery, rightly or wrongly, is often associated in the popular mind with deliberate intention to deceive. I try to avoid using it to avoid misunderstandings. I think most acupuncturists really believe they are providing effective treatment.”

    [emphasis added (if my formatting works :-o )]

    But that is the crux of the problem, isn’t it. That their belief isn’t justified.

    I think the right thing to do is to use the term to help re-enforce the terms broader definition, not to avoid it. Too many people think that if if an alternative practitioner is sincere then there is no problem. It doesn’t really matter what their intent is if they are prescribing non-scientific medicine to people. People who are antithetical to science based medicine and who willfully ignore the evidence are quacks and should be called on it. IMO.

  43. ConspicuousCarl says:

    I can’t make up my mind on the fraud/believer issue. It is not logical to assume that they are all intentional frauds, but my legal opinion is that the old “I’m not a fraud, I’m actually just extremely stupid” should be an affirmative defense.

  44. kathy says:

    WLU wrote, “… the best placebo is one that accompanies true medical treatment not lies irrespective how well-intentioned they are.”

    I imagine that when placebo fades away and leaves you “as you were”, it must be horribly disappointing, but maybe people just justify it? Is there any study of patients’ reactions post-placebo, when reality strikes back? Anyone have a reference I can look at?

    Skeptic wrote, “Too many people think that if if an alternative practitioner is sincere then there is no problem.”

    I am wondering what it really means to say someone “believes” something, and what the meaning of the word “sincere” is (and please, no quotes from Huckleberry Finn!). There seem to be so many shades and grades of meaning.

  45. WilliamLawrenceUtridge says:

    Since most people spend more time justifying past actions than they do questioning them (see Mistakes Were Made (But Not By Me) as a good, quick read on this) most people would probably see the placebo as “working”. Snake Oil Science also talks about why even after the placebo effect fades, the patient might still see improvements (not directly, but it’s worth reading anyway). I’m guessing the exceptions would be the initially skeptical; committed CAM boosters will almost certainly never change their minds, since it would entail changing their world-view away from the comfort of magical thinking.

  46. David Dressler BA RMT says:

    Reads like true mud-slinging. So, Dr. Weil is vile because he didn’t talk about anti-rheumatic drugs and only talked about alternatives? Do conventional MDs talk about alternatives when they talk about their drugs? Weil’s approach is dangerous because he encourages trial-and-error experimentation? Let me see. He is encouraging people to try various natural remedies that don’t have a history of harm the way countless drugs do. And drug trials aren’t about trials and catastrophic errors? And “proven benefits” of disease-modifying anti-rheumatic drugs? Are these the drugs that might lessen the symptoms of rheumatic inflammation without getting at the cause, the same cause that is causing heart disease and dementia, and a basis for some cancers, for which the gnawing joints are a possible warning sign? Gosh. And $99.90 for all those vitamins seems pretty reasonable to me in today’s economy. What do anti-rheumatic drugs cost?

  47. pmoran says:

    Pete, I’m continually astonished that you would be so critical in the area of your own specialty (cancer treatment) but appear to give essentially a free pass on the rest of CAM despite considerable evidence that non-cancer “treatments” are just as scientifically bankrupt. You have the oddest double-standard, and I find your comments here deeply disappointing compared to your website. I don’t understand how your skepticism can be so focused and one-dimensional. I genuinely don’t understand it.

    Thanks for the thoughts.

    I dispute the “– essentially a free pass”. It is evidently not coming across that any tolerance of CAM on my part would be tentative, selective, conditional and tacit, just as it has to be for most practicing doctors. most tolerance would apply mainly upon those areas where CAM, despite its obvious limitations, may provide a safety valve of sorts for patients whose medical needs are not being adequately served by the mainstream (and which won’t be for the forseeable future, through various constraints upon mainstream medical practice and limitations to its armamentarium). One thing you cannot provide doctors with is more time.

    I myself see difficulties in in the systematic application of such an approach, but am still wary of the extremely oppressive attitudes towards CAM that are commonly expressed here. Our porridge has to be at just the right temperature to be palatable for many.

    So my comments often have more to do with the quality of our dialogue with CAM and with fellow physicians, if that is what we are partly trying to engage in here. I don’t think that our words are always entirely coherent with observable reality or with what is permitted by the evolving science of therapeutic interactions. And I feel obliged to say so, since otherwise we are at risk of becoming an incestuous little clique with our own collection of fantasies about ourselves, about mainstream medicine and its science, and about CAM, just as the latter has about us. Also, as the late, lamented, Robert Hughes once wrote “there is no evil so great that it cannot be exaggerated”.

    Cancer is not placebo-responsive and death and/or survival from it are such overwhelmingly important outcomes that we scarcely ever think about much else in relation to it. Also it is usually not that difficult to find out if a treatment is “working” to the patient’s benefit or not in those respects.

    Contrast this with acupuncture. We know that it lacks specific, unique, mystical healing power, but are the remarkable effect sizes shown in some studies for sham acupuncture representative of real patients benefits or not? At present we have no way of telling — literally no way of telling. It is shameful for us not to be interested in finding out, and, in my opinion, fantasy to believe that we could mimic the same effects as readily and cost-effectively in the mainstream.

    Notwithstanding that, the symptoms of cancer, too, are likely to be helped by placebo and non-specific influences under the right conditions. Let’s wait and see what studies of acupuncture for cancer pain show and we’ll talk about this again, with me swallowing my words if necessary.

    I won’t get into spirituality here except to point out that it looks rather unwise to be completely dismissive of any role in medicine for what is an almost universal aspect of humankind. We scientists may take solace in being part of the grandeur and mystery of the universe, but that also implies that there is something that we need solace for.

  48. Harriet Hall says:

    @David Dressler,

    I only criticized “irresponsible” trial and error. It is irresponsible to tell RA patients to reject drugs and try things like homeopathy. The alternative methods that Weil advocates are not true alternatives because they have not been tested and shown to work (and some have been tested and shown not to work). The one thing we do know to work is DMARDs and they work precisely because they are directly affecting the inflammatory process rather than just covering up symptoms.

    It is irresponsible for Weil to continue to recommend craniosacral manpulation for children’s ear infections, since it has been tested and shown not to work.

    I don’t think my description of Weil’s position constitutes “mud-slinging.” I did point out that much of what he says is excellent science-based medicine. My criticism is that he mixes good science with nonsense.

    $99 might not be unreasonable for pills if they were actually effective. But the vitamins and supplements Weil sells can be bought for much less elsewhere, and there is no credible evidence that they do anything. And since you asked, methotrexate costs $16 for a 3 month supply. A real bargain for something that actually prevents joint deformities and disabilities.

  49. David Gorski says:

    I dispute the “– essentially a free pass”.

    I don’t. William nailed it for the most part. The only difference in the way I’d characterize it is that you give certain forms of CAM a free pass, while going after cancer quackery in almost as harsh a way as I do. Acupuncture, of course, is a prime example of a form of CAM that you essentially give a free pass, as you demonstrate later in your very comment!

    Contrast this with acupuncture. We know that it lacks specific, unique, mystical healing power, but are the remarkable effect sizes shown in some studies for sham acupuncture representative of real patients benefits or not? At present we have no way of telling — literally no way of telling.

    Nonsense! Of course we do. Harriet, Steve, Kimball, Mark, Ben, and I (among others) have discussed how we do on multiple occasions right here on this very blog. You just weren’t listening. Are you sure you really mean that we literally have no way of telling. Seriously?

  50. Quill says:

    What -is- it with acupuncture and some skeptics? It really is like the needle that sticks into some and won’t come out. Isn’t it just like chiropractic and the rest of CAM in that since its base premises are either invalid or fantastical that the results can’t be counted on and the practice of it introduces unnecessary dangers?

    This acupuncture free pass really is persistent in ways that just don’t make good sense. Perhaps it is as this blog has posted before, a combination of exotic mystique, cultural titillation and a general fascination with things that appear to do -something- but no one really knows why.

  51. pmoran says:

    We know that it lacks specific, unique, mystical healing power, but are the remarkable effect sizes shown in some studies for sham acupuncture representative of real patients benefits or not? At present we have no way of telling — literally no way of telling.

    DG:Nonsense!

    Of course we do. Harriet, Steve, Kimball, Mark, Ben, and I (among others) have discussed how we do on multiple occasions right here on this very blog. You just weren’t listening. Are you sure you really mean that we literally have no way of telling. Seriously?

    I refer to studies that include a sham group and a waiting list or “no treatment” group, whichcommonly show worthwhile, apparent, subjective benefits from acupuncture. In such comparisons spontaneous fluctuations in symptoms, reversion to the mean and most incidental influences should be adequately controlled for, leaving either spurious positive results from reporting biases or genuine symptom relief ( from all the non-specific elements of the medical interactions including whichever ones you want to include under the heading of “placebo” .

    The question is how we measure the proportion of those. How much is “real” benefit? I stick with what I have said, but you are welcome to show me any error.

    I think Steve at least sees this, and Harriet has little problem accepting the reality of some of the benefits from placebo influences. Mark indeed wants to class them all as sheer illusion, but without either direct evidence of that or any implausibility to the concept.

  52. pmoran says:

    Quill:What -is- it with acupuncture and some skeptics? It really is like the needle that sticks into some and won’t come out. Isn’t it just like chiropractic and the rest of CAM in that since its base premises are either invalid or fantastical that the results can’t be counted on and the practice of it introduces unnecessary dangers?

    This acupuncture free pass really is persistent in ways that just don’t make good sense. Perhaps it is as this blog has posted before, a combination of exotic mystique, cultural titillation and a general fascination with things that appear to do -something- but no one really knows why.

    There is nothing so special about acupuncture in my mind. I would expect similar results with any moderately invasive measure having comparable credibility with the study population, involving a similar number and duration of episodes of calm during “treatment” applications, and comparable enthusiam in the “healer”. There is no reason why some chiropractors may be able to produce nearly comparable results treating headache or other subjective complaints, (but I would not support the use of neck manipulation).

    We simply don’t understand our own craft enough to be pronouncing finally on some issues if we do not have a sure answer to certain questions. Using “working better than placebo” as a more or less exclusive therapeutic model has inhibited serious thought about the placebo and allied influences within skeptical circles.

  53. ConspicuousCarl says:

    David Dressler BA RMT on 01 Nov 2012 at 3:50 pm

    And $99.90 for all those vitamins seems pretty reasonable to me in today’s economy.

    I guess you’re right about that part, and I don’t mind admitting it when that is the case. But I do wonder what you think about the fish thing.

  54. nybgrus says:

    I refer to studies that include a sham group and a waiting list or “no treatment” group, whichcommonly show worthwhile, apparent, subjective benefits from acupuncture. In such comparisons spontaneous fluctuations in symptoms, reversion to the mean and most incidental influences should be adequately controlled for

    You don’t think being waitlisted and/or offered no treatment doesn’t have a nocebo effect?

  55. David Gorski says:

    Using “working better than placebo” as a more or less exclusive therapeutic model has inhibited serious thought about the placebo and allied influences within skeptical circles.

    Again, nonsense. “Working better than placebo” is so useful as a construct because it helps to prevent us from confusing a real therapeutic effect with nonspecific effects and biases common in clinical trials. There’s a real reason why CAM advocates want to co-opt the placebo effect as somehow representing “powerful mind-body healing” (which Steve rightly ridiculed in his recent CSICon talk by pointing out that the mind is the body and the body is the mind), The vast majority of their treatments are placebo, with no real therapeutic effect.

  56. Harriet Hall says:

    @pmoran,
    “Harriet has little problem accepting the reality of some of the benefits from placebo influences”

    Don’t put words in my mouth. Harriet acknowledges that patients report feeling better after getting placebos. She does not have a problem with accepting the reality of that phenomenon. She does, however, have a real problem with the assertion that patients are actually better off by objective measures, and she does not accept that deliberately prescribing a placebo is ethical. She thinks research on the neurophysiology and psychology of the placebo effect is useful for what it can teach us about the value of suggestion and expectation in the doctor-patient relationship when the doctor is providing effective treatments, because a placebo effect is an integral part of any encounter.

    I have little problem accepting the reality of some of the benefits from illegal drugs. People feel better when they inject heroin (of course they do, or there would be no reason to try it). But that benefit does not justify the harm. Placebos are not as dangerous as heroin, but they do represent a danger: they undermine the trust in the doctor/patient relationship, they can lead patients to reject effective treatments, and their effects are usually small and transient.

    There are rare situations where I would consider giving a placebo out of simple humanity. An example I gave before is an elderly woman with a short life expectancy who has been getting B12 shots for decades, is convinced she needs them, and lacks the capacity to understand an explanation of why she doesn’t. I would give her the B12 but I would feel guilty about it. I think we must have rules based on rigorous science, and that we should feel guilty when we make exceptions to the rules in special situations where we must choose the lesser of two evils.

  57. WilliamLawrenceUtridge says:

    @pmoran

    One thing you cannot provide doctors with is more time.

    Actually, you can. You can encourage the training of more doctors, and expand the reimbursable time they get. Doctors control the amount of time they give patients, and can have longer appointments – nobody will kick down the door and force them out. If this is truly your concern, the solution is not giving quacks more press or failing to call them on their failings – it is to advocate changes to the incentives and disincentives within your particular medical system. When an imperfect system is essentially competing with an outright fallacious one – improving the imperfect system seems a better and more laudable goal than trying to make the fatally flawed system less bad. Which would you rather do – rearrange the deck chairs on the sinking Titanic, or give it better radar so it avoids the ice berg?

    After reading what I have on acupuncture (very far from comprehensive, most of it skeptical), I can’t understand “skeptics” who support it, particularly as it is practiced now. No specific effects, short-term symptom reduction, accompanied by penetration of the skin – often in vulnerable patients (can anyone defend it being a good idea to break the skin of someone with cancer or AIDS?). It has been a valuable exercise in learning about the placebo effect, but shouldn’t the next efforts be ways to enhance real treatments via what we have learned? The goal of all placebo research should be finding ways to boost the effects of real treatments, such is my opinion. And the standard for acupuncture treatments should be non-penetrative interventions after a conventional diagnosis, without any bashing of real medicine.

    End rant.

    @Dr. Gorski:

    “For the most part”? Aw…I prefer unstinting praise ’cause I’m a shameless whore for attention :)

    And let’s see if the filters pick up on “whore”…

  58. pmoran says:

    WLU:PM:One thing you cannot provide doctors with is more time.

    Actually, you can. You can encourage the training of more doctors, and expand the reimbursable time they get.
    Doctors control the amount of time they give patients, and can have longer appointments – nobody will kick down the door and force them out. If this is truly your concern, the solution is not giving quacks more press or failing to call them on their failings – it is to advocate changes to the incentives and disincentives within your particular medical system. When an imperfect system is essentially competing with an outright fallacious one – improving the imperfect system seems a better and more laudable goal than trying to make the fatally flawed system less bad. Which would you rather do – rearrange the deck chairs on the sinking Titanic, or give it better radar so it avoids the ice berg?

    I’d rather we didn’t have some of the conundrums that I see in present medicine at all, but I do think (as does Harriet) that patient needs at the individual level will occasionally counterbalance, if not actually outweigh, doctrinal purity of the “working better than placebo” type while ever there is evidence for the activity of another model of medicine operating in parallel and according to its own erratic psychogenic rules.

    I assure you I have no illusions about the rattiness of most CAM, the mendacity of some of it, and its uselessness in the treatment of actual pathology, but it can be regarded as a joke at the expense of some of the mainstream’s own pretensions that it seems to work — it seems to be able to serve as medicine in helpful respects — wherein the ‘it’ refers to the overall medical package rather than any single component.

    The practical implications ? — while doctors will try to do better in relevant respects and should be commended for that, there is also no way that any health care system can afford to fully fund this “soft” end of medicine and they shouldn’t even consider it as policy without reasonable evidence of cost-effectiveness in QALY terms for the specific context (which are actually not that far off for CAM in some settings on the evidence of pragmatic studies that we would accept without much hesitation if they related to a drug or surgical intervention) .

    So I am not thinking about changing mainstream medicine in any systematic way. Many doctors already use placebos in the form of unproven methods when they feel that it is appropriate, so it hardly matters what we think about that anyway.

    My wish is to better understand the extent to which we should try to suppress CAM, either legislatively or intellectually, when it is pursued at the patient’s own expense and risk, when it is reasonably safe, and there exists reasonable grounds for believing that they are of help to some. Where there are obvious dangers they can always be addressed directly and far more efficiently than by trying to overturn an entire grassroots social phenomenon.

    The slippery slopes that medical skepticism sees as inevitable with any relaxation of attitudes towards CAM are in my view one of the self-serving skeptical fantasies that I have recently referred to, as well as displaying a degree of paternalism and authoritarianism and lack of respect for the general good sense of most of the public that we might object to in other contexts. Never forget that we are the victim of our own confirmation biases.

    After reading what I have on acupuncture (very far from comprehensive, most of it skeptical), I can’t understand “skeptics” who support it, particularly as it is practiced now. No specific effects, short-term symptom reduction, accompanied by penetration of the skin – often in vulnerable patients (can anyone defend it being a good idea to break the skin of someone with cancer or AIDS?). It has been a valuable exercise in learning about the placebo effect, but shouldn’t the next efforts be ways to enhance real treatments via what we have learned? The goal of all placebo research should be finding ways to boost the effects of real treatments, such is my opinion. And the standard for acupuncture treatments should be non-penetrative interventions after a conventional diagnosis, without any bashing of real medicine.

    I can agree with most of this, but not the added skeptical fantasy that we have enough safe and effective treatments on which to base comparable (to CAM) exploitation of non-specific influences including the placebo. We have solid evidence that CAM is mainly resorted to where mainstream care is lacking (sometimes only perceived to be lacking, but there is usually some basis for the dissatisfaction).

  59. nybgrus says:

    I’d rather we didn’t have some of the conundrums that I see in present medicine at all, but I do think (as does Harriet) that patient needs at the individual level will occasionally counterbalance, if not actually outweigh, doctrinal purity of the “working better than placebo” type while ever there is evidence for the activity of another model of medicine operating in parallel and according to its own erratic psychogenic rules.

    I’ve read this numerous times, slept on it, read it again and still honestly can’t understand what you mean by this.

    Patient needs? Such as what? A need to have their disease process ameliorated? Placebo has extremely limited role in this and there is no reason actual treatment can’t be part of the process. In other words, this still is not a justification for placebo only medicine.

    Doctrinal purity? As Dr. Gorski said, there is a reason why “better than placebo” has been the mainstay of scientific research. Most here also recognize the utility of using placebo alongside actual treatment – we call that “bedside manner.”

    Evidence for the activity of another model of medicine? What evidence? You mean the garbage coming out of CAM journals? That line of reasoning would allow for astrology and alchemy to “outweigh the doctrinal purity” of astronomy and chemistry.

    According to its own erratic psychogenic rules? I don’t even know where to begin.

    Additionally, I would have thought you’d learn not to put words in Dr. Hall’s mouth. It smacks of weakness and poor form if you need to continually reference Dr. Hall in order to lend credibility to your own conclusions; especially with how many times she has smacked you down and said your references to her are either wholly or partially incorrect. You know, like just two comments up.

    And how do you reconcile:

    I assure you I have no illusions about the rattiness of most CAM, the mendacity of some of it, and its uselessness in the treatment of actual pathology

    with:

    it seems to be able to serve as medicine in helpful respects

    Which is it? Ratty and useless or able to serve as medicine?

    while doctors will try to do better in relevant respects and should be commended for that, there is also no way that any health care system can afford to fully fund this “soft” end of medicine

    What “soft” end? This is bedside manner. This is empowering patients, patient centered medicine, patient education, compassion, caring, and yes, some extra time on occasion. How can we not afford to “fully fund” this? As WLU pointed out, time is what it really boils down to and while you seem to think that no matter what there simply can never be more than 15 minutes per patient encounter I see no theoretical barrier to increasing doctor/patient ratios and compensation to allow for more. It is what I am being trained to do and what I do every day that I see patients.

    which are actually not that far off for CAM in some settings on the evidence of pragmatic studies that we would accept without much hesitation if they related to a drug or surgical intervention

    Right. We wouldn’t have an issue accepting it because it comes along with actual treatment. This shouldn’t be that difficult to grasp. Evidence that counseling a patient extensively and caring about their social circumstances whilst prescribing anti-hyperglycemics is uncontroversial. Doing the same whilst claiming that cinnamon extract will be effective because it is “all natural” and has some shoddy bench science to try and make that claim is quite different.

    So I am not thinking about changing mainstream medicine in any systematic way.

    Clearly, but as WLU pointed out, why not?

    Many doctors already use placebos in the form of unproven methods when they feel that it is appropriate, so it hardly matters what we think about that anyway.

    What kind of rationale is that? People commit crimes like burglaries, so it hardly matters what we think about it? We should find a way to let them burglarize whilst we sit by idly? Using actions we condemn to try and assert that we shouldn’t condemn them is ridiculous.

    The slippery slopes that medical skepticism sees as inevitable with any relaxation of attitudes towards CAM are in my view one of the self-serving skeptical fantasies that I have recently referred to, as well as displaying a degree of paternalism and authoritarianism and lack of respect for the general good sense of most of the public that we might object to in other contexts.

    Once again, the slippery slope of relaxing attitudes towards burglary means that increasing incidence of burglarly is a fantasy? Why on earth does it make sense to allow medical students to go unchallenged in thinking that CAM studies are not the garbage that they are?

    And if there is any paternalism here it is on your part thinking you can be the arbiter of dispensing placebo medicine.

    The public has good sense? To an extent. But if the “good sense” was good enough, why would we need to train physicians at all? I am a pretty well educated and smart guy, but I can easily be hoodwinked by a slick enough person in a field outside my expertise. Medicine, biology, and science in general is well outside of the expertise of the public. There is a reason why we have consumer protection laws and regulation to ensure the safety of basically everything we come into contact with. Why you are advocating for removal of this protection of the medical consumer is beyond me.

    We have solid evidence that CAM is mainly resorted to where mainstream care is lacking (sometimes only perceived to be lacking, but there is usually some basis for the dissatisfaction)

    Actually the evidence is that CAM is resorted to mainly because of cultural/social bias and undue influence from perceived authority figures. People like Dr. Oz, Weil, Mercola, and the general lack of scientific understanding leading to the naturalistic fallacy (amongst others) are much more reasonably implicated in the usage of CAM than people sitting frustrated having been told by their physician “I am sorry there is nothing we can do for you” and deciding on an arbitrary nostrum.

    And lastly, you never bothered to respond to my question the answer of which should be self evident by your own posts. You claim quite forthrightly that frustration in medical care leads to CAM use, so don’t you think that being denied medical care (being waitlisted) would lead to frustration and thus a nocebo effect? As a corollary, don’t you think that people who would be interested in participating in the experimental arm of a CAM study might well be predisposed to thinking (and probably hoping) it would work? And wouldn’t that at least almost entirely explain the discrepancy between acupuncture and waitlist that you would rather ascribe to legitimate objective improvements in outcome?

  60. cloudskimmer says:

    Dr. Hall,
    I wish you would go to the AAFP conference armed with a sheaf of pamphlets containing your article, hand them out to attendees and ask hard questions of Dr.(?) Weil. The thought of him speaking to a group of Doctors without response is almost unbearable. Too bad that their survey reveals his popularity is high among this group. It makes it harder for the public to find a good general practitioner, when so many embrace woo.

  61. pmoran says:

    David, You may have missed my challenge for you (or anyone) to show how we distinguish between the contributions of reporting biases and true patient benefits in apparently placebo responsive complaints. You accused me of talking nonsense when I said we couldn’t, but sadly, I do seem to have missed the explanations that you stated have been given on these pages many times.

  62. pmoran says:

    Nybgrus, of course you cannot understand my contention that we may have two different therapeutic models working in parallel because it is an idee fixee of just about every skeptical mind that placebo “effects” do not have to be taken seriously in just about any context. They are dismissed as either having too small an effect to be worth bothering with, or as being entirely due to various illusions. This is despite considerable suggestive evidence to the contrary and no direct information as to their impact “in the wild” other than anecdotal experiences which themselves suggest the possibility of powerful responses to interventions at the psychological level.

    Actually the above is not quite true, as we still, rather loosely, recruit the possibility of placebo effects when it suits us — perhaps when it is difficult to completely explain a medical or experimental outcome in any other way. I admit I have at times spoken with my tongue forked in this way, which is why I am now so intent upon applying scientific-level critical examination to common skeptical precepts (and sometimes finding them weakly supported).

    The extra medical model roughly corresponds to “mind-body medicine”, but without the pretensions and over-the-top expectations of some of the proponents of that. It does not require mind-body dualism (DG and SN , please also note) . It is perfectly legitimate to divide therapeutic influences into those having direct physico-chemical effects on the body and those which only act via certain deeply entrenched quirks of human psychology.

    Actually the evidence is that CAM is resorted to mainly because of cultural/social bias and undue influence from perceived authority figures.,

    Just how do these factors foster CAM use in asymptomatic patients? Think this through. Did you observe how “alternative” treatments of peptic ulceration almost disappeared when the mainstream seemed to have found “the answer”.

  63. Harriet Hall says:

    @pmoran,

    The albuterol/acupuncture/placebo study of asthma showed that patients’ subjective benefits from placebo did not correspond to any objective improvement in lung function. You may want to argue that the subjective benefit was important, but how can you measure that? And how can you ethically justify prescribing placebos?

    You seem to have some fuzzy idea that we should make nice and give patients what they think they want, rather than what is demonstrably in their best interest. And you haven’t provided any supporting evidence. You can only assert that we need more research on placebo effects, which I think is something we can all agree on. Don’t argue for throwing out the standard of “no better than placebo” unless you can replace it with something better.

    I think I get a glimpse of what you mean, but your explanations are not clear, and I suspect it is because your thinking is not clear, and you keep coming across as an apologist for CAM, as a severe critic of the state of science-based medical practice, and as an opponent of rigorous science, which I don’t think you really are.

  64. pmoran says:

    Nybgrus:Once again, the slippery slope of relaxing attitudes towards burglary means that increasing incidence of burglarly is a fantasy?

    In context, the “relaxed attitude” referred to “the extent to which we should try to suppress CAM, either legislatively or intellectually”. It is likely similarly extreme attitudes towards burglary would also have diminishing returns.

    Also, the evidence is on MY side. Acupuncture has attracted a small fee under the Australian Medicare system for about twenty years without there being any major problems. Homeopathy is still widely used as a routine in Europe without evidence of corruption of science or major adverse public health cosnequences.

    Why on earth does it make sense to allow medical students to go unchallenged in thinking that CAM studies are not the garbage that they are?

    Who is advising that?

    Even the man in the street knows that psychology is a potent influence on how people feel. He will have no difficulty in understanding how people can think themselves into feeling less sick through placebo influences. Being as permissive of this kind of medical activity as we can, consistent with reasonable patient safety, is all that I am considering, not wholesale embracement of CAM and not any systematic use of it by the mainstream.

  65. weing says:

    “It is perfectly legitimate to divide therapeutic influences into those having direct physico-chemical effects on the body and those which only act via certain deeply entrenched quirks of human psychology.”

    You mean like telling a patient who is feeling pain to suck it up, but doing it in a nice way?

    “Did you observe how “alternative” treatments of peptic ulceration almost disappeared when the mainstream seemed to have found “the answer”.”

    What do you mean by that? Surgery? H2 blockers? PPIs? antacids? They are still used. What about the rare cases of Zollinger -Ellison syndrome? The antibiotics don’t work here.

  66. nybgrus says:

    Nybgrus, of course you cannot understand my contention that we may have two different therapeutic models working in parallel because it is an idee fixee of just about every skeptical mind that placebo “effects” do not have to be taken seriously in just about any context.

    Bollocks. I believe they should be taken very seriously. And utilized to our advantage. But not as monotherapy.

    Think this through. Did you observe how “alternative” treatments of peptic ulceration almost disappeared when the mainstream seemed to have found “the answer”.

    Really? Because there sure are a lot of ‘em out there….

    http://www.ehow.com/how_2099314_treat-stomach-ulcers-natural-remedies.html

    http://www.livestrong.com/article/27595-cure-ulcers-naturally/

    http://www.homemademedicine.com/home-remedies-peptic-ulcer.html

    http://www.soulhealer.com/ulcer.htm

    http://www.earthclinic.com/CURES/ulcer.html

    http://www.naturalnews.com/028644_stomach_ulcers_remedies.html

    https://www.startaloecure.com/reflux/index.php?sid=www.livestrong.com&gclid=COf6h-L-s7MCFRR7nAodskkAuA

    http://balancedbites.com/2012/01/why-you-want-more-stomach-acid-not-less.html

    http://impractitioners.hubpages.com/hub/Heartburn-caused-by-too-little-stomach-acid

    And on and on and on.

  67. pmoran says:

    The albuterol/acupuncture/placebo study of asthma showed that patients’ subjective benefits from placebo did not correspond to any objective improvement in lung function.

    That provides grounds for caution, but why no interest in the substantial benefits reported in such studies despite the absence of objective improvement? This surely raises the possibility of considerable placebo potential in the innumerable clinical contexts where symptom relief is mainly required. Perhaps 80% of medical activity overall is of this type, because of the lack of immediate cures for many common complaints so this is not a trivial matter.

    You may want to argue that the subjective benefit was important, but how can you measure that?

    Exactly. In these comparisons with “waiting list” or with “usual care” it boils down to whether patients are really feeling better, as they often staunchly claim, or whether they are lying about that for a number of possible reasons. This is the point that David seems to be missing. I am sure that some respondents are involved in well-meaning distortions of the reality, but what evidence do we have for regarding that as the overwhelmingly dominant influence?

    And how can you ethically justify prescribing placebos?

    I am not asking you to. If left to their own devices the public will, in effect, seek them out on their own, sparing mainstream systems considerable expense. If kept reasonably safe via legislative controls doing so will also reduce adverse drug reactions and the risks of substandard mainstream medical care.

    Many doctors already use dubious or unproven methods when they think individual patient needs outweigh other considerations and there is no better option in their medicine cabinets. We have no way of stopping that within most medical systems but we can at least ensure that there are no financial incentives for doctors to use such methods excessively. In most countries it is illegal for doctors to sell medical products to their patients and I strongly support that.

  68. pmoran says:

    Weing: “It is perfectly legitimate to divide therapeutic influences into those having direct physico-chemical effects on the body and those which only act via certain deeply entrenched quirks of human psychology.”

    You mean like telling a patient who is feeling pain to suck it up, but doing it in a nice way?

    I am not sure how what I said led to this. The use of medical treatments is subject to intense compulsions, and people seem to have also evolved the ability to feel better from any kind of therapeutic interaction, especially those including a “treatment” (whether it actually “does” anything or not). That is what I mean.

    “Did you observe how “alternative” treatments of peptic ulceration almost disappeared when the mainstream seemed to have found “the answer”.”

    What do you mean by that? Surgery? H2 blockers? PPIs? antacids? They are still used. What about the rare cases of Zollinger -Ellison syndrome? The antibiotics don’t work here.

    Again, not sure of your point. PPIs and the Helicobacter story came in quick succession and were unquestionably promoted as a more convenient and effective treatments than anything that went before, as they indeed were. In consequence it became rare to find patients seeking alternative treatments for ulcer on the internet and little attempt to promote “alternative”methods on web sites — not much call for it.

    Since the vast majority of CAM use is complementary to mainstream care we would expect patterns of use should be moulded by the degree to which mainstream care fully resolves various complaints.

  69. pmoran says:

    Nybgrus: And lastly, you never bothered to respond to my question the answer of which should be self evident by your own posts. You claim quite forthrightly that frustration in medical care leads to CAM use, so don’t you think that being denied medical care (being waitlisted) would lead to frustration and thus a nocebo effect?

    Sorry, I did forget to respond to this very valid point. I agree it is difficult or impossible to find a completely uninfluenced control group so as to be able to determine the true effects of adding a medical intervention or placebo. But the unwanted influences will work both ways. Antagonizing the possible nocebo effects you mention, the controls will have received reassuring medical assessment and if on a waiting list the expectation of further care, possibly within a mere few weeks, depending on study design.

    A more serious impediment to trustworthy results would be the pedestrian atmosphere of typical clinical trial environment, aggravated by the knowledge of patients in the placebo arm that they may be receiving a spurious “treatment”.. These must seriously dampen responses to placebo.

    In that study that was supposed to show that people would respond even to a “known placebo” the patients were still primed to be responsive (or to report favorably) by being told that placebos can have powerful healing properties (as DG rightly pointed out).

  70. Harriet Hall says:

    @pmoran,
    “Since the vast majority of CAM use is complementary to mainstream care we would expect patterns of use should be moulded by the degree to which mainstream care fully resolves various complaints.”

    And yet that doesn’t fully explain all the patterns of use. All too often CAM rejects effective treatments in favor of “natural” ones.

  71. nybgrus says:

    but why no interest in the substantial benefits reported in such studies despite the absence of objective improvement?

    We do have interest. We discuss it regularly. The conclusion though is that it doesn’t appear to be useful, especially as monotherapy.

    Perhaps 80% of medical activity overall is of this type, because of the lack of immediate cures for many common complaints so this is not a trivial matter.

    Citation needed.

    but what evidence do we have for regarding that as the overwhelmingly dominant influence?

    We have numerous phenomena (such as the Hawthorne effect) to explain why people would be likely to mis-report. But where is your data that it is anything more than that or that it is significant portion of it? Yes, the data warrants research… not clinical application (ahem, as monotherapy).

    Many doctors already use dubious or unproven methods when they think individual patient needs outweigh other considerations and there is no better option in their medicine cabinets. We have no way of stopping that within most medical systems but we can at least ensure that there are no financial incentives for doctors to use such methods excessively. In most countries it is illegal for doctors to sell medical products to their patients and I strongly support that.

    And now I think I finally understand you.

    My interpration of this is that you are arguing that we simply can’t possibly hope to do away with CAM, crankery, and pseudoscience and even though it is all bollocks we should only legislate away those that are truly and directly harmful (chelation therapy for example) but then just turn a blind eye to all the other “harmless” stuff and let it be. A battle not worth fighting. Kind of like saying that “the poor you will have with you always” and therefore deciding not to do too much about poverty.

    I agree that in the interim we should focus mostly on those CAMs that do have direct and significant harm. But that should not be our end goal. You think too poorly of your fellow human and his/her desire to learn and be empowered. Yes, to some extent we will always have some pseudoscientific belief and utilization, but that is not justification for being slack and letting it slide unless we (who, you? me? Dr. Gorski? Dr. Weill? Dr. Oz?) decides that it is “too harmful.”

    Of course, your rebut would be that “suppression” of CAM would have a backlash effect and increase usage rather than decrease it and likely increase usage of the more harmful modalities. I think that, depending on tactic, on a small scale you would be right. But on the large scale you are not. The world is getting smarter on the whole, people more educated than ever before. My 9 year old nephew knows more about science and the world than most adults did 100 years ago. The reason for the “boon” of CAM is not so much because people are seeking it out and therefore somebody just had to step up and fill the demand. It is a marketing campaign, used to misinform people and encourage them to buy.

    Do you really think that Average Joe is sitting there and thinking “Boy, I wish I could find some Royal Jelly and Panax Ginseng to help my headaches and improve my memory! Why won’t somebody please sell that stuff!” No! They read online, see commercials, get flyers, emails, etc telling them that these things help with that and they should go out and buy it. Or the see Dr. Oz on Oprah saying that green coffee bean extract is useful for whatever and get asked “Do you feel tired? Run down? Have a funny twitch in your left pinky toe? That could be a sign of [XXX] so you should have our all natural, totally safe, completely effective herb [YYY]” That is what we tend to be focused on – not the true believers like Mercola and Null. We won’t change their minds, but Average Joe watching the commercial or looking at the banner ad doesn’t know any better and furthermore thinks that since there are “studies” to back it up and it is legal to sell there must be some legitimacy to it.

    Since the vast majority of CAM use is complementary to mainstream care we would expect patterns of use should be moulded by the degree to which mainstream care fully resolves various complaints.

    Yet you completely ignore the factors above. You are making the unreasonable and unfounded assumption that CAM use is reflective of medical practice, without realizing the massive influence that marketing and false legitimacy play.

    I agree it is difficult or impossible to find a completely uninfluenced control group so as to be able to determine the true effects of adding a medical intervention or placebo. But the unwanted influences will work both ways. Antagonizing the possible nocebo effects you mention, the controls will have received reassuring medical assessment and if on a waiting list the expectation of further care, possibly within a mere few weeks, depending on study design.

    You admit the point, but then go right ahead and minimize the nocebo effect claim that it is somehow balanced by changes in the placebo effect, and just go on and focus on what you want to, making assumptions (about what reassurances they have received and what the impact of that would be*) to just write off the nocebo effect in order to cling to the effect size of your placebo effect.

    *Really? You think that telling a patient to wait and reassuring them that they will eventually be seenand treated is going to mitigate a nocebo effect? Have you never seen a waiting room with patients? Or heard them whinging about how the doctor’s appointment is going to be a whole 1 or 2 weeks away? I’m wondering what sort of practice you are used to where being told to wait elicits anything but a negative effect, especially in patients with chronic pain.

  72. weing says:

    “The use of medical treatments is subject to intense compulsions, and people seem to have also evolved the ability to feel better from any kind of therapeutic interaction, especially those including a “treatment” (whether it actually “does” anything or not). That is what I mean.”

    Not sure what you mean by compulsions. I would rather call them needs. Anyway, what else are they supposed to do? Die? They do that or they just linger and either get better on their own or with real medical intervention. People survived pneumonias in the past without antibiotics but not without sequelae.

    There is still CAM for peptic ulcer disease. Check out the crap mixed in with real medicine here. Interestingly they don’t talk about the drinking of semen by Chinese emperors for their PUD.

    http://www.sw.org/health-education?productId=107&pid=33&gid=000125

    http://www.planetayurveda.com/peptic-ulcer.htm

  73. pmoran says:

    Hallon 04 Nov 2012 at 12:46 am
    @pmoran,
    “Since the vast majority of CAM use is complementary to mainstream care we would expect patterns of use should be moulded by the degree to which mainstream care fully resolves various complaints.”
    And yet that doesn’t fully explain all the patterns of use. All too often CAM rejects effective treatments in favor of “natural” ones.,

    Yes, that’s the soft underbelly of compromise about CAM and I am not about to try and justify something that I also find very distressing and frustrating.

    Yet even this may be one of those evils that can be exaggerated, at least to the extent that it can be prevented, since extreme beliefs and behaviour well may prove be the most intransigent. Fortunately the majority of CAM use in cancer remains complementary to at least some mainstream treatment. Being more accepting of this could improve compliance with mainstream advice. Some oncologists certainly operate on that premise.

    Seeing this as a battle between science and nonsense probably doesn’t help as much as we think because where life or death matters are concerned many people will be inclined to hedge their bets.

    We might spend more time focusing upon where the real dangers lie. Breast cancer is a particularly troublesome area, and it is not hard to see why when you consider what we ask of these women. An almost imperceptible and painless breast lump, or even a tiny radiological abnormality, can demand painful biopsies, multiple surgical procedures, weeks of radiotherapy and months of chemotherapy along with their both short-term and long-term side effects, all with little assurance in those with poor prognostic indices that the cancer will not come back within a few years.

    Here is an area justifying a considerable expenditure of practitioner time, in making sure that we understand the patient’s perspectives, and patiently explain the rationale behind advising such aggressive initial management of cancer. A mere few decades ago doctors often tended to adopt a brusque “you will die if we don’t so this” approach, thereby contributing to the quackery problem. Far too often patients would be inconsiderate enough to go on to die anyway, despite all the treatment, with their friends looking on and drawing tehir own conclusions.

    I think we are doing much better nowadays. I suspect the tide is already turning slowly, partly also through the fact that CAM clearly has not been able to live up to its more extravagant claims.

  74. pmoran says:

    Nybgrus, you need to think more about this when you have time. I have not dismissed the possibility of the nocebo effects you describe — I have acknowledged that.

    Yet if you truly believe that they must outweigh the several opposing factors that I have mentioned, even that those in the other arms of the relevant studies won’t know whether they are supposed to get better or not — almost a prerequisite for the elicitation of placebo responses — I say that you are the one letting your biases take over.

    An additional problem for the relevance of these measurements for the role of placebo influences within CAM is that they may not go close to reflecting what might be possible in susceptible patients when in the hands of a charismatic “healer”.

    The weakness in just about all placebo research is not this. The difficulty lies in distinguishing true symptomatic benefit from patient reporting bias, otherwise often referred to as “answers of politeness” or “experimental subordination”.

    All I am saying is that we need to know more certainly what is going on — certainly before we carry on dismissing CAM as an entirely useless, even pathological, psychosocial phenomenon..

  75. nybgrus says:

    We actually don’t differ too much here pmoran.

    I am not trying to claim that the nocebo nullifies the whole thing. I was simply pointing out your bias in assuming it doesn’t. We don’t have good hard evidence to suss out the differences you speak of – specifically because nearly all trials that exhibit this weren’t designed to do so.

    In the meantime we do have a fair bit of evidence to demonstrate the “answers of politeness” along with numerous other factors that would decrease the effect size of placebo and the burden of proof still lays on those making the claim. No matter how you slice it, the nocebo effect must come into play, “answers of politness” and Hawthorne effect as well as regression to the mean and just regular old variance must come into play. And thus the effect size of the placebo must be smaller than it appears to be in these studies. Precisely how much smaller I will freely admit we cannot answer. We additionally have evidence that in every objective measure placebo has no clinical utility and no reason to expect it would.

    My only bias here is that until proven to have clinical benefit and an effect size worth exploiting, that it would be irresponsible to use as (mono)therapy. And no matter what the clinical benefit or effect size it is unethical to use it through deception (which is the primary way CAM operates, by vastly overstating or making up wholesale putative MOA’s)

    So your conclusion is inherently un-scientific. We do not need to prove the negative to dismiss CAM. CAM needs to prove the positive for us to accept it. And that is why you continually get flack from myself and others here at science based medicine.

  76. ConspicuousCarl says:

    I guess David Dressler isn’t going to answer my fish question.

    On another topic, it occurs to me that with the coming health insurance guarantee, the last thing we need is a bunch of idiots refusing to get health insurance because they think that a closet full of herbs and an acupuncturist is a good plan for if they ever get cancer (heck, Andrew Weil says we shouldn’t use western medicine for cancer anyway, right?). Then when they get sick and that fails to work, they are going to want to “buy” insurance and suck money out of a system they haven’t been paying into.

  77. pmoran says:

    Nybgrus::We actually don’t differ too much here pmoran.

    I am not trying to claim that the nocebo nullifies the whole thing. I was simply pointing out your bias in assuming it doesn’t.

    Oh, come on! Typically “untreated” or “waiting list” groups also improve subjectively over the time period of the relevant studies, due to, among other things, your “regression to the mean and regular old variance”. At most nocebo effects could dampen that, thus mildly exaggerating the apparent placebo responses.

    In the meantime we do have a fair bit of evidence to demonstrate the “answers of politeness” along with numerous other factors that would decrease the effect size of placebo and the burden of proof still lays on those making the claim. No matter how you slice it, the nocebo effect must come into play, “answers of politness” and Hawthorne effect as well as regression to the mean and just regular old variance must come into play.

    Here you are demonstrating your lack of familiarity with the subject. The purpose of the waiting list or untreated or “usual care” groups in comparisons with placebo is to control for such influences as these last two, as well as other incidental influences — it was once thought that what was left was “placebo” but we now recognise the likelihood of a contribution from reporting biases.

    And thus the effect size of the placebo must be smaller than it appears to be in these studies. Precisely how much smaller I will freely admit we cannot answer. We additionally have evidence that in every objective measure placebo has no clinical utility and no reason to expect it would.

    Agreed. Would you also agree that that such studies are only a small part of the evidence pointing to the possibility/likelihood of helpful placebo influences in at least some individuals? And that smallish pooled responses may obscure much larger responses in some? We are in part trying to be sure we understand the testimonial.

    My only bias here is that until proven to have clinical benefit and an effect size worth exploiting, that it would be irresponsible to use as (mono)therapy. And no matter what the clinical benefit or effect size it is unethical to use it through deception (which is the primary way CAM operates, by vastly overstating or making up wholesale putative MOA’s)

    So your conclusion is inherently un-scientific. We do not need to prove the negative to dismiss CAM. CAM needs to prove the positive for us to accept it. And that is why you continually get flack from myself and others here at science based medicine.

    What conclusion, other than that we need to be surer about certain matters before we finalize policy on CAM?

    And shame on you for your bombast, your glib dodging of the necessity to support your own stance, and your appeal to the authority of the like-minded, who may also be subordinate to prevailing skeptical dogma because it fits what we want to believe.

  78. nybgrus says:

    Oh, come on! Typically “untreated” or “waiting list” groups also improve subjectively over the time period of the relevant studies, due to, among other things, your “regression to the mean and regular old variance”.

    Have you not noticed that the only studies which seem to consistently generate some positive results from acupuncture are the ones for chronic back pain? Did you not learn the factors that influence the chronicity of back pain and the effects of that? If there was a real “placebo” response beyond expectation bias, why wouldn’t the same evidence exist for acute back pain? After all, we are all in agreement here that pain is the most likely to be affected by placebo. So why only chronic and not acute? I’ll leave you to think about that one, since I’ve written it out in great detail before.

    Here you are demonstrating your lack of familiarity with the subject. The purpose of the waiting list or untreated or “usual care” groups in comparisons with placebo is to control for such influences as these last two, as well as other incidental influences — it was once thought that what was left was “placebo” but we now recognise the likelihood of a contribution from reporting biases.

    And, to support my thesis, trials that employ usual care have a smaller effect size than those that employ a wait list.

    Agreed. Would you also agree that that such studies are only a small part of the evidence pointing to the possibility/likelihood of helpful placebo influences in at least some individuals? And that smallish pooled responses may obscure much larger responses in some? We are in part trying to be sure we understand the testimonial.

    Yes, I do agree. Would you agree this is not enough evidence to support the use or acceptance of placebo as monotherapy?

    What conclusion, other than that we need to be surer about certain matters before we finalize policy on CAM?

    None other. That’s the one. The “policy on CAM” is finalized by the principles of science. Do the experiments first, get the data first, and only then accept positive data to alter practice and attidudes. You do not accept CAM as having a valid role absent of good evidence. The onus is not ours to prove that acupuncture doesn’t work, the onus is on acupuncture proponents to prove they work. This is a simple and fundamental tenet of the scientific process.

    It is not only perfectly reasonable, but absolutely required, to say that the data shows it is nothing but a placebo, that seems to work in certain people under certain circumstances and we cannot ethically administer a pure placebo, therefore we cannot endorse the use of acupuncture.

    And shame on you for your bombast, your glib dodging of the necessity to support your own stance, and your appeal to the authority of the like-minded, who may also be subordinate to prevailing skeptical dogma because it fits what we want to believe.

    ????

  79. Harriet Hall says:

    @pmoran,

    “And shame on you for your bombast, your glib dodging of the necessity to support your own stance, and your appeal to the authority of the like-minded, who may also be subordinate to prevailing skeptical dogma because it fits what we want to believe.”

    Shame on you for lowering the tone of the discussion and insulting one of our most respected commenters!

  80. pmoran says:

    Harriet, yes its not usual for me, but I can only take so much of Nybrus’s ill-founded and pretentious triumpalism every time he tries to withdraw from debate when the going gets tough. Few would be following closely enough to notice. My name also pops up when he is in self-promotion mode in third party discussions.

    And be fair. Do you not regard being called “unscientific” as the absolute depth of personal insult within these walls? I am prepared to debate that point with anyone who cares to.

  81. pmoran says:

    Nybgrus, I think you are still confusing different kinds of clinical study and their meaning. I am talking about studies where placebo (or CAM methods that we assume only work via this and other non-specific effects) are compared with no treatment, usual treatment, or waiting list controls. If the patients think they are getting an effective treatment it is almost invariable for there to be subjective reported benefits. Does not science now more or less predict that?

    You seem to be wanting to include studies where sham is compared to “real” versions, studies that are asking quite different questions, mainly looking for evidence of intrinsic physiological activity. These tell us absolutely nothing about what is going on in the sham population, and I entirely agree that the small differences commonly found between sham and “real” are within the bounds of experimental error. Forget about all that.

    We are talking about whether patients can derive useful benefits from placebo interventions, possibly even when there are no suitable pharmacological remedies available. Elsewhere I have myself given good reasons why the mainstream should not get involved in the use of placebo medicines in any systematic way, so forget about that, too. I have pointed out that they can easily seek them out themselves, as CAM itself demonstrates.

    You are using a chiropractic stratagem to avoid having to consider this matter in your overall policies regarding CAM. Chiropractors refuse to consider the possibility of neck manipulation causing stroke unless we can produce cosmic standards of scientific proof. You want the same standard to apply to whether you are prepared to tolerate the public deriving benefits from what you regard as non-kosher methods. If there are no benefits at all from them and potential dangers then we are justfied in doing everything in our power to take this option away, both legislatively and intellectually.

    So the question matters even if you think the evidence is not conclusive. There is a case for a provisional or somewhat in between stance, if we are not to be shown to be overly oppressive and ignoring some of our own science at some point in the future. It i s highly inconvenient for us, but a lof of science is.

    This is written in haste as I am off to have left THR. I may be out of it for a few days.

  82. David Gorski says:

    And shame on you for your bombast, your glib dodging of the necessity to support your own stance, and your appeal to the authority of the like-minded, who may also be subordinate to prevailing skeptical dogma because it fits what we want to believe

    Nybgrus, you appear to be entering David Gorski territory in Peter’s mind. I don’t know whether to congratulate you or to express sympathy. :-)

  83. mousethatroared says:

    pmoran – best of luck with your procedure. Hope you make a quick recovery!

  84. nybgrus says:

    My word.

    First off, thank you Dr. Hall for the kind words. It certainly means a lot coming from you. And Dr. Gorski…. I too am ambivalent.

    But in all seriousness, I really don’t harbor any ill will or “skeptical dogma” towards you pmoran. I am absolutely certain that at times my rhetoric is lacking, my conclusions and assumptions wrong, and my responses inadaquate. I was a bit surprised by the most recent response, though I certainly take no personal offense to it since in context I can readily accept venting frustration and don’t doubt I deserved perhaps a little bit of that.

    I’ll also clarify that the times I mention you in other posts is both to cite an example as I see it and to perhaps engage in discussion. I do learn a fair bit engaging you and certanly don’t mind a tete-a-tete (vs certain others here).

    I do agree that calling you unscientific was a serious…. allegation. But I think it was warranted in this case. Once again, as has been pointed out by numerous commenters here, including the authorship, your exact stance is simply extremely hard to pin down and it really does change without due reason. In this case, you’ve begged the question and applied a standard that would be simply untenable by any reasonable medical practitioner.

    I agree that the comparisons you speak of in your first two paragraphs are, to some degree, not reasonable to make and are not very revealing. That in fact has been my thesis this whole time. All I am saying is that the only way we can contend to support acupuncture is based on these data and the data is simply not able to support it. By stating that we should – in whatever nebulous way you are trying to say but I still can’t figure out – somehow or another support the use of acupuncture, you are acting on bad evidence. By claiming the evidence supports your stance by invoking placebo effects as an MOA you are advocating unscientific thinking and extremely dubious ethics.

    But lets try and boil this down:

    You agree that the data essentially tells us nothing useful about the actual clinical applications of acupuncture (placebo) beyond that some people will derive some useful subjective improvement in their chronic pain condition.

    You also agree that we as physicians should not systematically utilize placebo medicine.

    So what is left is whether patients can derive some useful benefits from placebo medicine.

    I agree that some patients will derive, in some cases, useful benefits from placebo medicine.

    However, we do not have a way of accurately predicting who will, what the long term ramifications are, nor an ethical way of dispensing it.

    Lets put it in terms of a drug. Lets say Merck makes a drug which we know will help some fraction, almost certainly less than 1/3 of people, and has a low but real side effect profile. We cannot predict who the drug will help and we don’t even have a particularly great metric to measure whether it helped or not. What should we do with this drug? Put it out on the market for anyone to buy and then what? Turn a blind eye? Hope that the right people buy and use the drug enough to make up for the side effects and economic loss to those not helped? And all of that before we even consider the practical ramifications that said drug tends very commonly to be dispensed by people who give unsound medical advice in general and the marketing and putative MOA is completely obfuscated and mostly fabricated.

    I am not using the chiropractic strategem as you state. I could reasonably argue you are. I am adopting the position of the null hypothesis and demanding not extra, but a bare minimum standard, of evidence to endorse a therapeutic modality. You are the one looking at this noisy messy data and seeing a signal somewhere in there (one I won’t argue exists) with absolutely no way to measure the effect size or the safest way to apply it, and saying we should just be content to… once again, not clear; throw our hands up and turn a blind eye? Tacitly endorse it? Actively refer our patients? Once again, all without even beginning to consider the ethical and practical ramifications of placebo medicine and tacit legitimization of CAM and pseudoscientific therapies.

    I agree that there is a case here for that provisional in between stance. And Dr. Hall has clearly espoused exactly what I think that stance is. As a profession state there is no evidence it works beyond placebo, that the putative MOA’s are garbage, and that there are real risks with unknown but limited and usually very small effect sizes. As a physician, not to prescribe or refer. And if a patient asks you to state in a kind, understanding, and compassionate way that you cannot actively recommend it for the reasons above, but that a minority of patients do percieve a benefit and if they insist on trying it to heed reasonable precautions and keep the doctor in the loop. To me, that is the middle ground. Lambasting truly bad studies like ones that try and use shoddy fMRI data to prove an accupoint on your foot activates the occipital lobe does not violate that middle ground.

    (as an aside, to further reinforce why I think such a strong stance is not only warranted but needed, in my lecture notes from recent modules discussing analgesia in pediatric patients non-pharmacologic adjuvants are discussed… including acupuncture. Without the uncompromising professional stance we can only expect more of such infiltration with doctors thinking this is a reasonable and non-placebo adjuvant for pain management.)

    In any event, I wish you speedy recovery from your surgery and I absolutely will not hold it against you if you don’t find the time or energy to respond here further. I do not take this as me having “the last word” and “winning” the argument, so please don’t feel unnecessary compunction for those reasons. In any event, I am interested in the discussion not “winning.”

    Best,

    NyBgRus

  85. Harriet Hall says:

    @Nybgrus,

    I think perhaps one of the problems is that pmoran is positing the possibility or probability of a benefit to patients from placebos that he has not been able to objectively pin down or measure. Both the concept and the language are fuzzy. He sees patients as having needs that scientific medicine doesn’t or can’t meet, and CAM as meeting those needs. It’s hard to even talk about it without precise definitions and quantifiable effects.

    I can certainly agree that CAM will always be with us, and that some CAM beliefs are more harmless than others. I think we should not be on a quixotic quest to ban CAM, but we should direct our efforts to educating the public and trying to limit false claims (truth in advertising!) and misrepresentation of the evidence. Prohibition didn’t eliminate alcoholic beverages, but education about fetal alcohol syndrome has reduced the consumption of alcohol by pregnant women. And the tide has turned against the anti-vaccine movement.

    If CAM has a legitimate place, it may be as a “comfort measure” akin to fluffing pillows. If a patient is told the truth about Bach flower remedies and still chooses to take Rescue Remedy, I really can’t object.

  86. nybgrus says:

    I don’t disagree. I just have higher (perhaps pie in the sky) hopes that sometime, long after I am dead, people will demand the education on Bach flower remedies and then say no thank you. I believe that the only way to achieve that is to hold firm on what we do know and not hedge our bets with what we only suspect.

    Perhaps surprisingly, despite my “stridency” here, my absolute distaste for the term “natural,” and my overall distaste for everything CAM I am always the first on my team to suggest non-pharmacological therapies, more conservative approaches, and spend the most time talking with my patients, learning about their lives, and educating them about their conditions.

    I think that less is more and we need solid justification for any treatment we provide. And I also think that placebo is not equivalent to doing nothing, even if it is as harmless as homeopathy (though of course I agree that certain CAMs are more harmful than others and should be higher priority). I am interested in showing people why they should care if the data is good or not – even for the lay person. I really truly enjoy all the opportunities I get to talk with non-scientific people and watch as their eyes light up with understanding. And I respect those that continue to pursue dubious (but harmless) treatments.

    But I also see in my own institution, working alongside medical students who are literally shocked that I think CAM is bunkum and have been called “closed minded” for not being willing to consider the potential positives of [X]. I don’t always have the time to have a sufficient enough discussion, so I must simply be un-nuanced at times and have flat out said “All of CAM is crap” when asked by a fellow student. But the times I do have the chance, I have never failed to open some eyes and convert someone away from shruggie-ism.

    And of course, fluffing pillows is fine. In fact, one of my common statements is that I actually endorse the idea of making chemo infusion lounges into beauty parlors where patients can get mani/pedis, massages, haircut/style, etc. But the difference, as you well know, is in the message. Give a cancer patient a foot massage – they deserve one and would certainly benefit from it. But don’t call it reflexology. And of course, if the cancer patient really wants reflexology, even after my explanation of why it is a waste, I agree – who am I to object?

  87. Quill says:

    Dr. Hall wrote in part: “I think perhaps one of the problems is that pmoran is positing the possibility or probability of a benefit to patients from placebos that he has not been able to objectively pin down or measure. Both the concept and the language are fuzzy.”

    As a non-medical person but someone who has credentials in the liberal arts and also taught English and writing to a wide variety of people, I agree. The fuzziness is obvious. Fortunately all he needs to do is keep thinking and writing on the subject and clarity is likely to come unless it gives way to unvanquishable frustration.

    I’d also like to wish him the best with his femur resurfacing (if I got the acronym right) and hope for his speedy recovery.

  88. BillyJoe says:

    Quill,

    “I’d also like to wish him the best with his femur resurfacing (if I got the acronym right) and hope for his speedy recovery.”

    THR stands for a total hip replacement.
    Most commonly, it involves removal of the head and neck of the femur and its replacement with a prosthesis that is hammered down into the shaft of the femur. As well, the socket in the pelvic bone is covered with a prothesis. Here in Melbourne they use a ceramic cup but, elsewhere, a metal cup has been used that has caused severe complications necessitating its replacement.
    My mother had one a few years ago and made a rapid uncomplicated recovery – except that she developed a heel ulcer that penetrated right down to the calcaneal bone and that took over twelve months to heal. About two weeks later I saw an invention on “The New Inventors” to prevent that from happening.
    I hope they use that device and the ceramic cup on our friend Peter.

  89. nybgrus says:

    Indeed, THR is quite an amazing surgery. I’ve assisted in 3 of them. My fiance’s grandmother had one, grudgingly. Both her hips were shot, and she could barely walk, but one was much worse than the other, so she got that one done under some protestation. She recovered so quickly and so fully that she insisted on getting the other one done. She now putters around in her late 80′s quite well.

    Better living through science. The ethos that is the one part of the early-to-mid 20th century worth keeping alive.

  90. Quill says:

    BillyJoe & nybgrus: Thanks for the information on what THR stands for. I know more than a few who have had it and I also think it’s amazing, and example of not not only better living through science but also how science is able to take care of so many “natural” problems that seem to come along. ;-)

  91. RE: Science-based Medicine vs Evolutionary (neo-Darwinist) Medicine!? — Part II (for me too)!?

    I would like to extend my sympathy to Harriet Hall; as recently, I also happened to run against the biased editorial firewall at the EvolutionMedicineReview.com, where I submitted a response/review to one of their latest biomedical articles on Targeting the tumor ecosystem, by Kenneth Pienta; but it has since not been released, and still remained on my webpage; which I would like to copy en masse, and post below for yours and your readers convenience and scrutiny:

    ——————–
    [2 -- Mong H Tan, PhD on 12 Nov 2012 at 4:27 pm -- Your comment is awaiting moderation.]

    RE: A critical Review on “Targeting the tumor ecosystem”: Why couldn’t We (oncologists, clinicians, scientists, biomedical reviewers, critics, etc) be more specific and forthright about Targeting the tumor ecosystems of today and beyond!? — Or, Targeting which tumor-specific ecosystems: The primary or the metastatic tumor ecosystems!?

    Preamble: First, let me compliment on Kenneth Pienta and his colleagues, for their (apparently) novel (but inherently-misconstrued, and misattributed, their otherwise specific) anti-tumor stromal elements as “ecological therapy” (or ET; instead of the more appropriate “ecological pathogenesis” terminology of “tumor ecosystems”) — and — their otherwise very specifically-targeted “anti-CCL2 (chemokine ligand 2/monocyte recruiter) therapeutic” effects and concepts: whereby the “targeted therapy” (not the misattributed ET concept) which is currently being tested in clinical trials (such as, the SWOG study S0916, in phase II trials) in critical attempting to eradicate the last (possibly) metastatic tumor cells — particularly those specific monocyte-transformed TAMs (tumor associated macrophages) and tumor cells, that have had metastasized to, and seeded in, bones — of their prostate cancer (PC) patients!? Thus, I thought the above Pienta’s very abbreviated (especially in modern oncology and biotherapeutic concepts) but intriguing (so-called) ET article, could have had been more appropriately and forthrightly entitled “Metastatic Prostate Cancer-to-Bone: Targeting the Tumor Ecosystem”!?

    1] From our modern biomedical research and development (R&D) perspective: Especially in the evermore specialized, disease-targeted, focused, and personalized medicine (PM) era of today and beyond; and in the evermore specific pathogenetically-defined, elaborated, and individualized cancer therapy (ICT) nowadays, the evermore etiologically-targeted PM-translated and specialized biomedical R&D pursuits and therapeutic concepts, in clinical and preclinical trials (in and for any targeted ICT and in and for any given tumor systems since the 1980s) must First be clearly and elaborately analyzed, specified, identified, classified, and diagnosed or spelled out, in totality and in advance, and categorically-based on the following: a) characterizing and qualifying their each tumor-associated therapeutic targets (including any other stromal effects, etc) in and for any specific tumor types, tumor-stromal systems, growth and development conditions (primary and/or metastatic in etiology or pathogenesis) in totality and in advance; b) following and focusing on their each specifically-targeted, screened, identified, and tested anti-tumor (and/or anti-tumor-associated stromal factors, including angiogenesis, TAMs, etc) concepts and protocols, in and for their each respective tumor model-systems; and c) all these biomedical R&D standards and practices are to be fully pursued in accordance with their each specified and/or prescribed preclinical and clinical screening and testing rules, concepts, and guidelines in the labs — be it in the academic or industrial R&D settings, worldwide, since the 1980s!?

    2] Whereas in the ET concepts and protocols as outlined above (specifically-designed or elaborated in and for a PC metastatic-to-bone ecosystem): It seems the specifically-targeted anti-CCL2/anti-TAMs therapeutic model-system, has had been exclusively directed to eliminate the autologous* — not heterologous* — bone metastases (or micro tumor-stroma ecosystems) of the PC patients, alone!? As it seems a) Not to be targeting any specific treatments to the autologous “primary” (or spontaneously-arising) PC micro ecosystems, at all; b) Nor to be indicating any specific treatments to the metastatic PC-stroma ecosystems, that might have had seeded elsewhere, in or at any other autologous organ sites or tissue systems, at all; and above all, it seems c) Not to be critically concerning or including the generally-required cross-screening and/or testing of the anti-tumor ecosystem-specificity (especially the anti-CCL2/TAMs specificity or cross-tumor ecosystems reactivity tests) in and for any other similarly-tested biotherapeutics, in and on any other tumor cell types* (including any other peritoneal cancer metastases to bones, etc) and/or in/on any other tumor ecosystems (primary or metastatic in origin) within an autologous cancer patient, as well!?

    [*Histologically, cytologically, pathologically, immunologically, and biomedically speaking: The term “cell types” is more biogenetically-defined than the “ecological” or elusive term of “cell species” -- as ones that have had been otherwise mischaracterized in ET theory above (!?) -- so as to accurately infer to the fact, that in any PM-specified ICT -- not the misattributed ET concept -- in and for any tumor systems (primary or metastatic in pathogenesis) as ones that have had been etiologically or oncologically identified, classified or diagnosed; and as ones that have had been referring to the spontaneously-occurring, and/or later metastasizing, tumors -- all arising within the same “genetically-autologous” cancer patient-body system, of course -- whereas the generally ecologists or naturalists (or especially the neo-Darwinists or biogenetic-reductionists) misuse of the ecological term of “cell species” could easily -- and would -- otherwise “biogenetically” confuse, unduly complicate, and indeed, it has had misattributed the otherwise inherently-autologous “cell types” (including normal and/or autologous tumor cells) to an otherwise “genetically-heterologous” or “ecologically-mixed” population of “cell species” in and within an otherwise-intact (or autologous) cancer patient-body system!?]

    3] As such, within our concurrent biomedical, specific immunological, and oncological histocompatibility and biotherapeutic context; and from the perspective of the novel PM-translated ICT concepts and practices (especially since the 1960s-80s), such a grossly-generalized or broadly-misattributed ET or “ecological therapy” above as one that has had been attempting to devise a very specific anti-micro-tumor-ecosystem therapy (while without any cross-testing in and for any other tumor cell types and/or metastases in any other organ sites, etc) may Not be universally translated nor applicable to any other cancer ecosystems, at all (!?) — lest the above ET (specifically-devised in and for a metastatic PC-to-bone) concepts and protocols, could be further categorically analyzed, tested, identified, specified, characterized, elaborated, differentiated, and established (especially in and for any other possible tumor cell types, disease biogenetic ecosystems, therapeutic classifications, etc) by and within our concurrent biogenetic R&D and biomedical oncology terms, as follows: a) the primary or the metastatic tumor ecosystems; b) the autologous or the heterologous biogenetic therapeutics (such as anti-CCL2/TAMs antibodies: which are mostly heterologously-derived or raised xenogenically in animals other than the PC patients themselves); and last, but not least, c) the primary or the metastatic-collaborators or tumor-associated enablers (such as TAMs, monocytes, osteoclasts, etc: which are certainly and inherently-autologous in and within the PC patients themselves); etc (see Comment 1 above)!?

    Thus, critically I would certainly wonder if the above Pienta’s apparently-novel ET concepts and protocols (specifically-focused and developed in and for the metastatic PC-to-bone alone) could be (at once) generalized and/or applied to any other tumor-specific PM-translated ICT, as well; whereby such a specific “anti-CCL2/TAMs-translated or targeted therapy” may soon be further inquired and considered, in and for any other potentially-metastatic tumor cell types-to-bones to emulate, test, identify, strategize, or model on: all elaborative and specific anti-tumor and/or anti-tumor-associated stromal characterization and identification of the biotherapeutic ET concepts, protocols, effects, and criteria, are to be modified and/or incorporated in full accordance with their each respective tumor types, tumor ecosystems, disease growth and development conditions, of course — as I duly outlined in my recent review of the specific genomic-based ICT above (see Comment 1 above)!?

    Best wishes, Mong 11/12/12usct3:27p; practical science-philosophy critic; author “Decoding Scientism” and “Consciousness & the Subconscious” (works in progress since July 2007), Gods, Genes, Conscience (iUniverse; 2006) and Gods, Genes, Conscience: Global Dialogues Now (blogging avidly since 2006).
    ——————–

    Meanwhile, I also have a tinnitus syndrome, that keeps ringing in my ears for over a decade now since I turned over 50! I would venture to theorize that it is just a sign of our normal aging process: at a midlife time, when our hair cells in the apical cochlea begin to fire consistently by themselves, probably due to their naturally aging (or leaky) ion exchange potentials!? As long as my mind is busy with something else, my tinnitus syndrome doesn’t border me at all — only to remind me of the fact that I’m getting old, biologically and audio-physiologically, passing through my midlife prime — or crisis (for some other lucky people on Earth)!?

    Best wishes, Mong 11/15/12usct4:09p; practical science-philosophy critic; author “Decoding Scientism” and “Consciousness & the Subconscious” (works in progress since July 2007), Gods, Genes, Conscience (iUniverse; 2006) and Gods, Genes, Conscience: Global Dialogues Now (blogging avidly since 2006).

Comments are closed.