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Dr. Michael Dixon – “A Pyromaniac In a Field of (Integrative) Straw Men”

Dr. Michael Dixon, the medical director of the Prince’s Foundation for Integrated Health, wrote an editorial for BBC news that is a densely packed rant of tiresome straw men often trotted out by the defenders of so-called “integrative” medicine. (The reason for the quotes in the headline, by the way, is because I stole that line from George Will who used in on This Week recently – it was too perfect not to co-opt.) Dixon was responding to an excellent commentary by Edzard Ernst, in which he characterized integrative medicine as a”shabby smokescreen for unproven treatments.”

Dixon was writing right out of the playbook of “integrative” propaganda, so it is worthwhile to expose his numerous logical fallacies and mischaracterizations of fact.

The Holism Gambit

Dixon begins:

Integrated health is not a new concept – the best doctors and their clinical colleagues have practised it for years.

It means treating patients as whole human beings – paying attention to body, mind and soul – instead of regarding them as nothing more than a set of symptoms to be got out the door as quickly as possible.

If Dixon wishes to be taken seriously by scientific practitioners he should make more of an effort to more fairly characterize mainstream medical practice. Of course, I must acknowledge up front, that there are mediocre and even bad doctors. There are also good doctors struggling within failing systems. And there are also many excellent doctors with effective practices. However, Dixon makes it seem as if the absolute worst of mainstream medicine is standard and typical. This is insulting, dismissive, and frankly ignorant of the facts on the ground. I find it interesting that defenders of integrative medicine are frequently whining about the dismissive attitudes of scientific practitioners of whom they are dismissive.

But the meat of this comment is the attempt to equate alternative or integrative medicine with holistic medicine, and the straw man that scientific medicine treats only diseases and not patients. That is certainly not how I was taught medicine, it is not how I practice medicine, and not the culture of medicine I find around me.

At Georgetown Medical School where I trained (I graduated in 1991) we were taught the “biopsychosocial” model of medicine – which means we view the patient in the context of their biology, their psychology, and their social situation. This was not just a slogan – it was a central part of the clinical culture that we were taught.  It is simply a straw man to say that scientific medicine does not consider the whole patient – even 18 years ago this was already being fully integrated into mainstream medicine, before it became fashionable among the promoters of dubious treatments.

For years defenders of scientific medicine have been pointing out that the principles of holism – of biopsychosocial medicine – are already part of mainstream medical culture and ethics. We have common ground on this point. Integrative practitioners did not invent this concept and were not responsible for its adoption into medical practice. This transition happened in the 1970s and 80s after the paternalistic model of medical practice was falling out of favor. Integrative proponents have simply taken this concept and made it their own for propaganda purposes – as Ernst very aptly characterizes as a smokescreen for their real agenda (which we will see below).

But, very much like creationists, defenders of integrative medicine will not let go of an argument even after it has been debunked often and publicly.

The Argument from Final Consequences

Dixon continues:

Those who campaign against integrated health seem not to understand that there are many conditions and many patients for whom no conventional treatment will offer a complete cure, ranging from back pain to terminal cancer.

For these patients, treatment is about relieving their symptoms, improving the quality of their lives, perhaps helping them adjust to the restrictions their illness imposes.

Does Dixon really believe that scientific practitioners do not understand the limitations of current medical knowledge and practice? Anyone who practices medicine and is not frankly delusional understands this. But the fact that an effective and proven therapy is not currently available does not justify making up fake therapies and offering them to patients.

The second line is downright laughable, and ironic. In my own practice the majority of my interventions are aimed at relieving symptoms, improving quality of life, and helping patients adapt to their limitations (I am a neurologist).  I find it hard to accept that Dixon actually believes that scientific practitioners do not routinely provide symptom relief for those with incurable illnesses. Again, this is a huge and rather transparent straw man.

It is also ironic because another favorite criticism of proponents of unscientific medicine is that science-based medicine focuses on treating symptoms and does not treat underlying causes (another straw man). This claim is often brought out when promoting a bizarre theory of all disease, for example the straight chiropractic claim that all illness is caused by the block of flow of “innate intelligence” or life force.

Ethics vs Science

Dixon descends further into his fray with an imaginary army of straw men:

Those who aggressively oppose integrated health forget that it is the patient who should ultimately make the decision on their treatment, whether that is conventional or complementary or a combination of both.

Dixon really needs to familiarize himself with common logical fallacies. This statement is a straight up non sequitur – Dixon confuses the ethics of informed consent and patient autonomy with the scientific basis of medical treatments. Medical ethics already dictate that patients are in control of their own medical decisions. Also, as I said above, the old paternalistic model of “doctor knows best” has been gone for a generation. The current model of practice is one of patient collaboration and informed consent.

In the modern model of medical practice the physician is an expert adviser, and decisions are made in collaboration with the patient, who is in ultimate control of their own medical decision-making.  In practice patients defer to varying degrees to their physicians, according to their own inclinations. And again, there is a broad spectrum of practice styles among physicians and many fall short of the ideal. But the standard of practice is clear.

I would add that while patients decide their own health care they do not have a right to demand unethical treatment from their physician. They cannot force a physician to write a prescription, perform a procedure, or make a referral that they think is unethical or bad medicine.

And again I find this straw man to be ironic, for it is the promoters of unscientific medicine who are violating the ethics of informed consent by giving their patients false, misleading, or partial information and advice.

Science-Based Medicine

After distracting his readers with a long and typical list of straw men that have nothing to do with reality, Dixon gets to the real agenda behind his smokescreen – arguing for the use of unscientific modalities. That is what it is all ultimately about – using treatments that are scientifically implausible and lack evidence for safety and efficacy.

But first he has to set up the usual tu quoque logical fallacy – to argue that evidence-based medicine is not so evidence-based either. He writes:

Why? Quite simply because there is no evidence for many conventional treatments. One scientific review found that of 2,500 commonly used conventional treatments, effectiveness was “unknown” for 46%.

Well, at least he didn’t cite the ridiculous 15% figure that is based on a 40 year old terrible survey. But he is still cherry picking his citations.  There are actually several reviews that aim to answer the question of how many mainstream practices are based upon scientific evidence. A more thorough review of such studies shows that more like 78% of medical practices are based upon reasonable scientific evidence.

But again Dixon makes the mistake of confusing what happens in the field vs the accepted standard to which we should all be striving. The goal should be (certainly advocated by SBM) to have the best scientific evidence and plausibility behind every treatment and intervention. The public is best served if we make continual efforts to increase the level of scientific evidence for medical practices. That we fall short (by whatever amount) does not justify abandoning the scientific standard itself.

The Reveal

As with most editorials promoting unscientific medicine (whether you call it integrative or CAM), the long string of logical fallacies, diversions, and factual errors ultimately lead to the same bottom line – an appeal to use modalities that are not based upon scientific evidence. Dixon writes:

Patients are not lab rats on whom “science” can impose its will.

Evidence is there to serve the patient, not the other way round.

Here he is bashing science in the guise of defending patient freedom.  But elsewhere he gives us more insight into his philosophy:

And the test is not whether someone has carried out a scientific trial, but whether the patient’s condition improves.

And there you have it – the appeal to anecdotal evidence over scientific evidence.  It always seems to come eventually, in some form. Proponents of unscientific medicine are very clever in phrasing this appeal in many ways, trying to disguise its essence. But it always comes down to the same thing – the patient’s anecdotal experience trumps scientific evidence. Sometimes they come right out and say it, and other times, like here with Dixon, they are very coy. But the appeal is the same.

Of course, this statement is entirely absurd. It assumes the very question at hand – does a treatment actually work? Is it safe, and do its benefits outweigh its risks? Dixon is foolishly assuming that a treatment works simply because it seems to work, or because a patient believes it has worked. However, a couple of centuries of careful observation has taught us that anecdotal experiences are very deceiving, and are not to be trusted.

In fact we developed the technology of scientific clinical trials specifically to control for the weaknesses of anecdotal experience. Clinical trials are designed to control for as many variables as possible, to control for placebo effects, and to eliminate the biases and desires of the researchers, practitioners, and their patients. The goals of scientific trials is to obtain the most reliable patient evidence possible and to avoid self-deception.

Dixon is dismissive of “scientific trials” as if they are limited to something that happens in a petri dish, ignoring that clinical trials involve real-world outcomes in actual patients – just under carefully controlled observational conditions. Therefore he gets it exactly wrong – the test is whether or not a treatment is safe and effective when observed under controlled scientific conditions, and not anecdotal experience which is inherently misleading.

In a separate interview Dixon was apparently more clear about his position. The Telgraph interview reports:

The efficacy of complementary treatments, he (Dixon) insists, simply cannot be measured by standard scientific “double-blind” tests in a lab.

This is the old “your fancy science cannot test my claims” gambit.  But again, this is just an excuse for those treatments that cannot be shown to work under scientific conditions – because they do not work. They likely do not work because they are based upon bizarre, outdated, or simply wrong ideas. They are at odds with how nature actually works, so it is no surprise that they do not work. Even putting aside their extreme scientific implausibility, the evidence shows that most modalities promoted by Dixon as integrative and rejected by scientific medicine simply do not work.

Conclusion

This conversation between promoters of SBM and promoters of unscientific medicine is reminiscent of the conversation between creationists and scientists (and for those who think I am just poisoning the well with that comparison, I think it is an apt analogy on many levels). Dixon and other “integrative” proponents have their script, and they are sticking to it. And why not, it seems to be working to some degree. But their straw men are just that, and so they are talking past scientific practitioners. If they keep beating their “holistic”drum they should not expect any science-based practitioner to take them seriously. They are attacking nobody – a fiction of their own propaganda – so why should they expect anyone to listen.

And Ernst is exactly correct – their straw men are just a smokescreen for the promotion of scientifically dubious claims.

In order to move this conversation truly forward we need to first agree on some common ground: Treating the whole patient is good – we all agree with biopsychosocial medicine. Patients are partners in their own health care and deserve informed consent. For patients who cannot be cured treatment should focus on relieving symptoms, improving quality and duration of life, and optimizing function. (I feel like I am lecturing to a first year medical student.)

I will go further to say that preventive medicine is very important. Physicians should emphasize and encourage lifestyle practices that promote health and prevent disease. Nutrition and physical therapy have important roles to play in overall health care. Physicians should practice rational pharmacotherapy and need to be very cautious about polypharmacy and overprescribing.

OK – can we call get past these points now? We agree. This is already part of good modern medicine. Stop arguing against positions nobody holds.

But now we need to push the common ground further. Medical interventions should be based upon the best scientific knowledge available. This means that treatments have to be scientifically viable (not completely understood, but just not in violation of the basic and well-established laws of physics, chemistry, and biology). And they need to be based upon high quality evidence.

We should further agree that anecdotal evidence is low-grade evidence. It should be used as a guide to future research only, and not as an ultimate method of deciding what works and is safe. Better evidence always trumps weaker evidence. And we should not make the excuse that a treatment cannot be studied scientifically.

If we can all agree on these principles, then there would be no need for any “alternative” or “complement” and nothing to “integrate.” There will be no double standard in medicine – just one science-based, ethical, and holistic standard.

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33 thoughts on “Dr. Michael Dixon – “A Pyromaniac In a Field of (Integrative) Straw Men”

  1. David Gorski says:

    This conversation between promoters of SBM and promoters of unscientific medicine is reminiscent of the conversation between creationists and scientists (and for those who think I am just poisoning the well with that comparison, I think it is an apt analogy on many levels).

    It is an apt analogy on many, many levels. Other apt analogies include: believers in the paranormal versus scientists, 9/11 Truthers versus scientists and historians, Holocaust deniers versus historians. I don’t often use this last analogy because of its inflammatory “Are you calling me a Nazi?” association, but if for the sake of argument you strip neo-Nazi and anti-Semitic beliefs from Holocaust deniers (and thus the inflammatory nature of the comparison) and leave just their arguments, Holocaust deniers use the very same sorts of logical fallacies as Dr. Michael Dixon. (I know; I’ve had a longstanding interest in Holocaust denial.)

    In fact, you can generalize this to pretty much all supporters of pseudoscience, nonscience over science, and pseudohistory. Because science is so strongly against their positions, they have no good evidence. Consequently, they’re forced to rely upon a very similar armamentarium of arguments, most of which are logical fallacies and/or unscientific and/or antiscientific, yoked to, inevitably, very badly done “scientific” studies. Creationists and quackery proponents are masters of this.

    We should further agree that anecdotal evidence is low-grade evidence. It should be used as a guide to future research only, and not as an ultimate method of deciding what works and is safe. Better evidence always trumps weaker evidence. And we should not make the excuse that a treatment cannot be studied scientifically.

    If we can all agree on these principles, then there would be no need for any “alternative” or “complement” and nothing to “integrate.” There will be n double standard in medicine – just one science-based, ethical, and holistic standard.

    Absolutely. I’ve said it before time and time again. There are only three kinds of medicine: scientifically proven medicine, medicine that hasn’t been proven by science to be effective and safe yet; and medicine that has been shown by science to be ineffective and/or unsafe. The vast majority of CAM modalities fall into one of the latter two categories. Moreover, the CAM modalities that have not been proven yet are often so implausible from basic principles (homeopathy, reiki, distance healing, etc.) that for them to “work” would require multiple major paradigm shifts in some of the most fundamental and well-understood aspects of basic science there are. What that means is that, for us to accept something like homeopathy, the evidence for its efficacy would have to be on the order of the scientific evidence out there that supports our understanding of chemistry and physics that tells us that homeopathy can’t work. Instead, all we see are studies that show either no effect greater than placebo or equivocal effects entirely consistent with random noise–certainly nothing strong enough to support overturning some very basic understanding of physics and chemistry.

    In any case, if an “alternative” medical treatment is validated by science, it will automatically be “integrated” into standard medical practice and cease to be “alternative.” It will just be medicine.

  2. DevoutCatalyst says:

    Holistic? In my experience with the CAM world there was often a demand for fealty to the stuff that from the patient’s perspective didn’t do squat — “it works for everybody” was the paternalistic rebuttal from one clinic. I have been to massage therapists (woo promoters, many) who insisted on doing a less tiresome (for them) “modality” which they had learned, that left me feeling cheated, rather than giving a really physical massage that deeply satisfied. “You don’t need that, you need balancing.” Doctor knows best.

    As far as the “caring bond” CAM practitioners have been touting, I received this more as if it were coming from a used car salesman, meaning an insistent bond with ulterior motives. Like having the patient show up regularly for ongoing therapy, with the evidence based result of lightening the wallet, and goosing the practitioner’s God complex.

  3. durvit says:

    The difficulty is that Dr Dixon and his ilk are winning the rhetorical war to garner the support of the public that is not well-informed about science-based medicine (and, because of controversies surrounding NICE sometimes hostile to EBM and the notion of effectiveness and cost-effectiveness).

    Because of changes to NHS funding and spending discretion it is plausible that they will succeed in having some more of these dubious interventions accepted into more NHS outlets (there are already GP surgeries that offer homeopathy, osteopathy, acupuncture etc.).

  4. DevoutCatalyst – you are absolutely correct. We get caught up defending SBM and countering their antiscientific propaganda, but we also need to go on the offensive more. Even according to their own professed principles, most CAM practitioners fail miserably. They are paternalistic, non-holistic (they often use one modality or theory for everything), dogmatic, dismissive, and decidedly non-evidence-based.

    What they do excel at is salesmanship. They have sold the public a very pretty lie and they need to be increasingly called on it.

  5. There are several tests that confirm that a particular belief (and CAM is a belief, no different than other beliefs like alien abduction, psychic powers, and Noah’s ark, to name a few) is pseudoscience. The one that is my primary test is: Over-reliance on confirmation rather than refutation. In other words, anecdotal information is often given more credence than science, and if the science conflicts with the CAM pusher’s POV, then they reject the science on that basis. Confirmation allows the CAMmies to say “here, this person now walks because of this magic potion” rejecting the 90% who can’t.

    And David Gorski said:

    In any case, if an “alternative” medical treatment is validated by science, it will automatically be “integrated” into standard medical practice and cease to be “alternative.” It will just be medicine.

    Other than a few plants, I really can’t think of a classical alternative treatment that has been integrated. The reason, in my opinion, for this lack of progress is twofold: first, many alternative treatments are just not based on basic science (look at homeopathy, where basic science tell us that homeopathic potions are so dilute as to be nothing more than a vial of pure water), and second, once these treatments are tested scientifically, they fail miserably.

    Samuel Hahnemann, in the early 19th century, made the same arguments as Dixon, that is medicine is “bad.” Hahnemann was right, at the time, but as medicine became more scientific through the 19th century, homeopathy was rejected outright. Dixon is about 180 years too late, and he should be rejected outright too.

  6. Steven Novella said:

    We get caught up defending SBM and countering their antiscientific propaganda, but we also need to go on the offensive more.

    I’ve been pushing this point recently. It is becoming a propaganda war, where the first person to open their mouth sets the tone.

    The problem remains is that scientists can’t predict the future (being constrained by science, we just cannot accept a pseudoscience to help us out). So, we don’t know what’s next on the CAM list. Wakefield, Jenny, and their ilk push the pseudoscience of vaccines=autism. We need David Gorski, if he looks like Brad Pitt (because brains doesn’t seem to matter in this public relations battle), to be out on the front lines blasting any new CAM out there as “killing people.”

    We’re just too nice.

  7. Versus says:

    Here’s a bit of good news on the alt med front:
    The government of the province of Alberta just announced that Albertans will no longer have coverage for chiropractic visits as of this summer, which is estimated to save the provincial government $53 million a year. Some of that money will go towards home-care for senior citizens.

    http://www.chtv.com/ch/chcanews/story.html?id=1476082

  8. TsuDhoNimh says:

    Those who campaign against integrated health seem not to understand that there are many conditions and many patients for whom no conventional treatment will offer a complete cure, ranging from back pain to terminal cancer.

    For these patients, treatment is about relieving their symptoms, improving the quality of their lives, perhaps helping them adjust to the restrictions their illness imposes.

    I agree, and almost every physician I have seen for this sort of condition was definitely concerned about making the quality of my life as high as possible. From the ENT who voted against his pocketbook’s interest and explained why the popular (at least at the time) surgical correction of sinuses was not going to help my chronic sinusitis, the PHS doc whose advice probably saved me from a lifetime of back problems, to the orthopedic surgeon whose treatment – not surgery, just lifestyle advice and non-surgical interventions – kept me working when many people would have had to quit, they were looking past the body part they were treating in to make sure the rest of the person was being taken care of.

    What’s amazing is that they did this without the trappings of “alternative” or “integrated” medicine. They didn’t sell me nutritional supplements from their office, they told me to take “X” from the local pharmacy. They didn’t sell me chelation, live blood analysis, colon detox stuff, or magically activated water to fix me, they worked within the known parameters of the proven problems.

    They didn’t try to adjust my chakras (that’s what the Dalai Lama did), align my qi, or muck with my bioenergy fields.

    Special praise for the doc in Mexico (residency at Johns Hopkins) who drove to my housekeeper’s residence and made sure she was available to take care of me post-typhoid. Yes, he wanted me out of his hospital because they needed the bed, but he knew I wasn’t going to be able to take care of myself for a month or so. Yes, I shoulda got the booster vaccination, so don’t yell at me, ‘kay? At least the hangover from the original series shortened my stay and minimized the severity.

    Extra-special praise for the East Coast trauma center’s ICU docs who called in a shipping company’s rep and explained to the rep that the stress of worrying about being stranded as an invalid in a foreign country was slowing down the healing of a seaman … and that although it was legal to just leave him in the States, the cost of a plane ticket back to his home port was far less than the cost of just a couple days extra in ICU. The shipping rep was on the phone from ICU to get the tickets … and the seaman was discharged far sooner than if he hadn’t been sent home to his family support system.

    Yeah, it’s just anecdotes.

  9. Wholly Father says:

    “”In a separate interview Dixon was apparently more clear about his position. The Telgraph interview reports:”

    The efficacy of complementary treatments, he (Dixon) insists, simply cannot be measured by standard scientific “double-blind” tests in a lab.”"

    The assertion that alt med claims can’t be tested by the usual methods of scientific inquiry, to me, is the most mind-numbing, pernicious claim of all. It is also the most self-serving. It is their Kryptonite against critical inquiry.

    It is a fact that most mechanisms proposed by alt med advocates are not understandable to science, but it is a non sequitur conclude that claims can’t be tested. A claim that the status of disease or health can be influenced by an intervention is a scientifically testable hypothesis. One of the beauties of a clinical trial is that an effect can be observed, confirmed, and quantified. No understanding of how the effect happened is necessary.

    When the alt med folks say their therapies cannot be tested by by scientific methods, what they really mean is their claims cannot be confirmed by scientific methods.

  10. overshoot says:

    And the test is not whether someone has carried out a scientific trial, but whether the patient’s condition improves.

    So he’s justifying leaving displaced fractures untreated, on the grounds that the patient’s condition will improve without any intervention? After all, it almost always will — even if there is a residual deformity, the body will heal the fracture.

  11. khan says:

    Has the term “holistic” been totally appropriated by the woo folks? Does it still have a meaning within SBM?

  12. Tim Kreider says:

    I loved the use of “patients are not lab rats” immediately after arguing that they should be enabled to “test” unproven treatments on themselves.

    The “holistic” claim drives me nuts. Day 1 of medical school we talk about the importance of considering all the patient’s concerns and “treating the patient who has the disease, not the disease the patient has.” The very first mnemonic I learned was CLODIERS, a guide for eliciting information about a patient’s chief complaint, and the last letter stood for “psychosocial” impact. At my school we give awards to students, residents, and faculty for exemplifying “humanism” and compassion; our culture respects for such values. Alt med practitioners have no monopoly on being holistic. However, they are the primary people I ever hear using this word (maybe because it’s a manufactured controversy), so it’s a useful red flag.

    The salience of this claim among the public, though, should make us SBM advocates be wary that we are being portrayed as Spock or House. If comes down to “those hyper-rational scientists” versus someone who preaches holistic care (albeit without justification), we will lose a lot of hearts and minds, just like the “new atheists” do by running roughshod over non-rational reasons for religious faith*. I think the SBM approach is the more compassionate one (because medicine that does not work is not compassionate), but we need to make sure that we don’t appear out of touch with patients’ emotional/spiritual/social concerns. The CAM advocates are very good at emotional framing, and a knock-down intellectual argument is not as widely effective against that as we wish it were.

    * http://www.nytimes.com/2009/04/07/opinion/07Brooks.html?_r=1

  13. LionDancer says:

    This may be off thread, but what is one to do if your spouse or so is totally taken in by this stuff. Whenever I talk to her about the merits, or lack thereof, the treatments she chooses to take I hit a solid wall of….woo. It’s a religion. I mean she has three degrees; I have a high school diploma. Her naturalpathic quacktor is a very engaging fellow that tells her wonderful tales as he sucks the money from our pockets. I speak of evidence and physics and I hear “But it makes me feel better. You don’t understand what I’m going through.” Every penny I spend on this screams mightily as I squeeze it as hard as I can. I don’t know what to do. The only surgery I’ve seen him successfully do is a walletectomy.
    Is there a someone to de-woo a love one.

  14. Regarding “holistic,” don’t forget the best article ever written on the subject, substantially quoted here under “The Physician as Expert Consultant.”

  15. durvit says:

    On the concept of holism, might I recommend the Samuel Gee lecture that Professor Michael Baum has just delivered: Concepts of holism in orthodox and alternative medicine. Not intended that way but an outstanding rebuttal to Dixon and fellow-travellers of, ‘Only integrated medicine attempts holism’ fallacy.

  16. pmoran says:

    “Dixon is foolishly assuming that a treatment works simply because it seems to work, or because a patient believes it has worked. However, a couple of centuries of careful observation has taught us that anecdotal experiences are very deceiving, and are not to be trusted.”

    Correct. Nevertheless we have no basis for assuming that the anecdotal experiences are of no value at all to the patient. All the usual EBM study can tell us is that some treatments don’t work better than a sham treatment of similar impressiveness. Other kinds of study suggest that the benefits of pretend treatments are not entirely illusion and that they will vary considerably depending upon peripheral factors.

    There is a lot of loose and unjustifiable usage of “works” and “don’t work” on both sides of this kind of debate.

    I can understand why Integrative doctors can be so sure that their methods “work” as to express puzzlement at the inability of science to show that. Medicine is full of profound illusion and patients tell them polite lies (1).

    I find it less easy to understand extreme dogmatism (uncharacteristic for scientists) and a somewhat dog-in-the-manger attitude when it comes to patients having placebo medicines available to them. It is the inflexiblity of the EBM stomach. It prevents the head getting past the thought that these silly, unscientific methods have no right to “work”.

    At the end of this piece Dixon is in essence asking “what is important here?” indicating that “here” refers to the kind of patient and condition that is often not well served by the mainstream and its methods despite its good intentions. Yes, I know that the Integrative medicine practitioners may not perform a whole lot better with most cases in the long run, but would you prefer this vulnerable group fell into the hands of *non-integrative* practitioners?

    (1)
    http://www.ncbi.nlm.nih.gov/pubmed/15821939?ordinalpos=7&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

  17. pmoran – Regarding anecdotes – I said they are useful in suggesting directions of future research, but cannot be used to determine if a specific intervention is safe and effective.

    Your appeal to the placebo effect is not compelling. Actually, there are many placebo effects, which include any variable other than the treatment in question. Further – science-based treatments also are accompanied by placebo effects. The question is, does the intervention in question add anything to the non-specific effects of the therapeutic interaction. Bottom line – placebo effects do not justify using inert treatments, and there is good reason to believe that the downside (such as diversion from effective treatments, sowing distrust in mainstream medicine, and instilling bizarre ideas of health and disease) far outweigh any placebo benefits.

    And also – not all placebo effects are benefits. Much of it is just confirmation bias and expense justification – patients convince themselves they feel better when they don’t to justify their choice. This is especially powerful when their choice is unconventional and they believe it needs to be justified.

    And finally, you conclude with a false dichotomy. The choice is not between doing nothing and giving pseudoscientific placebo medicine, or between integrative and non-integrative practitioners.

    The other choice is what happens within SBM – rational and evidence-based symptomatic treatment. While I have told patients there is no cure for their condition, I have never told a patient there is nothing I can do for them. There is always something reasonable to do.

    When no effective treatments are available, then legitimate and ethical experimental treatments are justified – but not lying about magical therapies.

  18. David Gorski says:

    Thanks, Steve. You beat me to it.

    There’s also the issue of not lying to patients, which to me is critical. Back in the days of the paternalistic model of medicine, doctors sometimes prescribed real, honest-to-goodness inert placebos–sugar pills–and told them it’d be good for what ails them. And, guess what? Often patients did feel better because of the placebo effect. However, in this era of a more collaborative model of doctor-patient interaction, deceiving patients by knowingly giving them inert treatments and telling them that they will help or, as in the case of most CAM, telling them that pseudoscience works just isn’t going to fly. The reason is that such deception removes what is considered a cornerstone of patient autonomy, namely informed consent. For a doctor to be truly giving informed consent, he or she would have to say to the patient something like, “I’m going to prescribe homeopathy, but you should know that it’s just water and that there is no active remedy in it anymore, and, by the way, there’s no evidence that it works better than an inert placebo. Probably because it is an inert placebo.”

    That kind of honesty tends to kill the placebo effect, which requires some belief that a remedy will work to be operative. But it is the truth, and the truth is what we should be striving to tell our patients at all times.

  19. This is a great article, but more importantly, BEST TITLE EVER!!! :)

  20. Harry says:

    @LionDanceron 08 Apr 2009 at 9:43 pm
    … what is one to do if your spouse or so is totally taken in by this stuff? Whenever I talk to her about the merits, or lack thereof, the treatments she chooses to take I hit a solid wall of….woo. It’s a religion. … Is there a someone to de-woo a love one?

    My father loves to drink the kool-aid. If it’s woo, he’s done it, used it, sold or sells it. He is a true believer.

    And just like there is no way that he will ever listen to his wannabe physician scientist son about religion, there is no way he’ll listen to me about woo either. They are both beliefs and deeply entrenched in him. It’s not a matter of education, logic or anything else because it’s belief. I have a feeling your wife maybe some what similar. Short of sending her against her will to be deprogramed by someone who usually works with cult members, you are stuck with her and her beliefs. Gotta look at is from the perspective of an interfaith marriage and just accept that it’s part of who she is.

  21. tmac57 says:

    Wholly Father-”When the alt med folks say their therapies cannot be tested by by scientific methods, what they really mean is their claims cannot be confirmed by scientific methods.”
    What I would also conclude is that they are really saying “CAM is NOT science” Why don’t they just drop the facade and openly admit what is evident.
    Also to the placebo argument, why stop with CAM. How about witch doctors, shamans, blood sacrifice, sorcery , voodoo etc. ? All of those modalities have probably worked for someone. Why have any standards at all as long as someone says “hey it worked for me” ?

  22. David Gorski says:

    Have you seen some of the methods under the CAM rubric? A lot of those modalities are already there:

    Shamanism? Check.

    Voodoo. Check. (Remember Tong Ren?)

    Sorcery? Check. (What are reiki and “distant healing”–or virtually all “energy healing methods,” for that matter–but sorcery prettied up with pseudoscientific language about “energy”?)

    Alchemy? Check. (Homeopathy, although admittedly homeopathy could also fall under the rubric of sorcery. It is, after all, an invocation of sympathetic magic.)

  23. pmoran says:

    Your appeal to the placebo effect is not compelling.

    And I fully understand why. It is very difficult for the medical skeptic to accept the notion that ANY kind of medical interaction can be of worthwhile benefit to some patients.

    But a warning — there are trends in recent study that suggest that this is indeed so and that we should be taking placebo and other non-specific influences in medical interactions more seriously, even if are unable or unwilling to exploit them fully ourselves.

    -There are the preliminary studies suggesting that placebo use can trigger neurotransmitter release and activate neural pathways that may be concerned with symptom relief.

    -The Kaptchuk study (below) needs replication and the application of more objective measures of improvement, but it suggests quite dramatic differences in response to a sham treatment depending upon the intensity of care in other respects.

    http://www.ncbi.nlm.nih.gov/pubmed/18390493?ordinalpos=6&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum&log$=freejrpmc

    -And there are many other studies suggesting effects from presumed placebo treatments comparable to those produced by accepted pharmaceuticals.

    e.g. http://www.ncbi.nlm.nih.gov/pubmed/19160193?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

    Combined, this kind of data raises the startling possibility that well-designed placebo treatments could perform better (and probably more safely) than many FDA-approved drugs ( only, of course, in subjective and partly psychosomatic complaints). Get your mind around that!

    Such evidence, even while still somewhat immature, suggests that the decision to dismiss placebo effects from serious consideration in relevant contexts is “what I choose to believe” and not a true evidence-based decision. The mere possibility that important effects are occurring should prompt some caution in expression.

    Can I at least ask that SBM authors using expressions such as “this treatment doesn’t/cannot work”, be explicit concerning the implied “better than placebo” or “via the mechanism claimed”, in the interests of scientific accuracy and of not having too much egg on the faces should such evidence continue to firm up?

  24. pmoran says:

    David, I am still not sure that the best reason for doctors sticking to a rigid science-based platform (when we are sure what that is) lies in ethical considerations. They always involve competing obligations and remote observers placing their own interpretation on the intimate, individual implied contracts between patient and doctor.

    A better reason is this — that this is what the public, who we serve, expects of us, at least most of the time. That is our allotted job in a medical world that just about every last one of the public, regardless of where they put their mouths, knows is confusing and full of crap. They want, and need, and deep-down have respect for a secure, reality-based point of reference.

    But they also don’t want to be confined by it. They preserve the right to be inconsistent, to pursue other avenues whenever it suits them, and to even retreat totally into make-believe if dissatisfied with our offerings. Can we hold their hand part of the way, or not? Which approach has the least unintended adverse consequences?

  25. pmoran wrote:

    It is very difficult for the medical skeptic to accept the notion that ANY kind of medical interaction can be of worthwhile benefit to some patients.

    This is a straw man. It is explicitly not true. We fully accept that there is a positive effect from the therapeutic relationship, and that some placebo effects can be beneficial. I am very interested in placebo effects and how they can be exploited ethically and effectively.

    My points, rather, are:

    - There is no a single placebo effect, but many placebo effects – some beneficial, others just artifacts of observation.

    - The non-specific benefits of a therapeutic intervention occur with ethical and science-based therapies, so there is no need to resort to bizarre unscientific treatments.

    - There is a significant downside to instilling bizarre and unscientific beliefs in patients, reinforced by non-specific placebo effects. This includes, but is not limited to, relying upon placebo treatments for serious illnesses.

    Finally, when saying that a therapy works – “better than placebo” is absolutely implied. In fact, it is redundant. Something that works as well as placebo by definition does not work – because placebo effects ARE DEFINED as any measured effect other than a physiological effect of the treatment in question. In other words, the therapeutic context in which the treatment is given is responsible for the placebo effects, not necessarily the treatment itself.

    And to further clarify, some interventions (like massage, for example) may themselves have non-specific beneficial effects. These are not really placebo effects, they are treatment effects, just not due to a claimed mechanism.

  26. David Gorski says:

    It is very difficult for the medical skeptic to accept the notion that ANY kind of medical interaction can be of worthwhile benefit to some patients.

    Peter, I really can’t believe you wrote that. I really can’t. It’s so obviously, demonstrably incorrect and, as Steve said, it’s a massive strawman. No one–none of us here–is saying that the medical interaction between physician and patient can’t be of benefit to some patients. In fact, none of us, I daresay, even finds it “difficult” to accept the notion that medical interaction with patients can be worthwhile to them. What we point out is that purveyors of unscientific or pseudoscientific “magical” therapies are offering, in essence, only the interaction and thus the placebo effect. As physicians, we should be always striving to do better than just the placebo effect; otherwise, we are no better than the purveyors of placebos, like homeopaths and reiki practitioners. We may not always be able to succeed in doing better than placebo, but that should always be our goal.

    The goal is, as I mentioned earlier, not using placebos that involve either lying or unknowingly misinforming patients (depending on whether you don’t believe or believe, respectively), which is what the vast majority of CAM treatments require. Moreover, there’s lots of research on what makes a good placebo, two of which you cited, but another of which may explain why CAM therapies elicit the placebo effect .For example:

    http://scienceblogs.com/insolence/2008/03/some_placebos_are_more_equal_than_others.php

    And it’s not as though we haven’t discussed the placebo effect on this blog on multiple occasions. For example:

    http://www.sciencebasedmedicine.org/?p=268

    As for your other comment about “hand-holding” a patient during a retreat into “make believe” (as good a characterization of CAM as I have heard. As Steve points out, it is not necessary to collaborate in woo with a patient in order to elicit the placebo effect. That is, as far as I’m concerned, taking the easy way out. It’s far easier to “go with the flow” when it comes to patient beliefs than it is to try to educate them about the placebo effect. Personally, the uneasy compromise I make is that I will sometimes tell patients that I don’t really care if they use “alt-med” as long as (1) they tell me about it so that I can assess the potential for interfering with treatment; (2) they aren’t using it instead of scientific medicine but rather in addition to it; and (3) they understand the evidence base for its use, which almost always is close to zero. When appropriate I’m also quite blunt in telling them that there is no evidence that an alt-med therapy does any good above that of a placebo.

  27. pmoran says:

    Selected points–

    Steve ” Finally, when saying that a therapy works – “better than placebo” is absolutely implied. In fact, it is redundant.Something that works as well as placebo by definition does not work – because placebo effects ARE DEFINED as any measured effect other than a physiological effect of the treatment in question. In other words, the therapeutic context in which the treatment is given is responsible for the placebo effects, not necessarily the treatment itself. ”

    Technically and semantically almost true, but we know the type of placebo will influence apparent response rates and it is not at all clear that similar results can be achieved without the addition of some kind of treatment ritual.

    My concern is that much of the time we are talking to people for whom the testimonial evidence is very compelling. They quite reasonably ask what all the fuss is about so long as patients seem to be being helped. It creates considerable dissonance, as well as being not wholly accurate (if you DO accept the possibility of significant placebo effects and are not just paying lip service to the notion) to make bald “that doesn’t work” pronouncements. It is denying such claims validity of any kind, in contradiction of some very suggestive science.

    This is what I am mainly about — how we talk to people about alternative methods. I think talk that may be OK in scientific circles can be unnecessarily abrasive and misinterpreted elsewhere.

    Steve ” The non-specific benefits of a therapeutic intervention occur with ethical and science-based therapies, so there is no need to resort to bizarre unscientific treatments.”

    Steve’s discussion of holistic medicine revealed a similar desire to be judged by what medicine aspires to, and what it thinks of itself, rather than what is delivered in practice via practitioners of varying quality under widely different conditions at this point in history.

    For alternative medicine is in a very real sense a manifestation of the inadequacies of some doctors and of the methods available to them. It would scarcely have a reason to exist if everyone who saw a doctor or used a conventional treatment was promptly fixed up with no ill effects.

    So another thing I am calling for is a more realistic understanding of the AM phenomenon. Yes, it is partly a product of the unscrupulous, but an eager market pre-existed.

    It is also not that easy for mainstream doctors to fully elicit placebo/non-specific influences. We like to stick close to truth as we see it, and we have the added onus of supposedly fully informed consent.

    Steve “- There is a significant downside to instilling bizarre and unscientific beliefs in patients, reinforced by non-specific placebo effects. This includes, but is not limited to, relying upon placebo treatments for serious illnesses.”

    True, but containing a straw man that I have never come close to expressing.

    In reality, in Western societies that have high acceptance of methods like acupuncture and homeopathy there seems to be little tendency for their use as stand-alone treatments of serious conditions. The fact that many doctors are using them may even reduce their attractiveness for more irresponsible elements in AM.

    I am in any case asking no more than that alternative methods be subjected to the same cost/risk/benefit analysis that we apply to drugs and procedures. The usual skeptical position assumes that placebo benefits are too small to be worthy of consideration, thus tipping the equations irrevocably against AM.

    The Linde study is food for thought, although I am sure that in most instances we will find that the results are not good enough to warrant the provision of the methods at public expense or for mainstream institutions to offer them. The latter will nearly always have more worthy demands on their resources.

  28. Blue Wode says:

    Steven Novella wrote: “After distracting his readers with a long and typical list of straw men that have nothing to do with reality, Dixon gets to the real agenda behind his smokescreen – arguing for the use of unscientific modalities. That is what it is all ultimately about – using treatments that are scientifically implausible and lack evidence for safety and efficacy.”

    Another glimpse behind his smokescreen…
    “…if you are going to win the game, you have to not always play be the rules of other people. We are going to have to invent our own set of rules…”

    See pages 3-5 of this document:
    http://www.wmin.ac.uk/sih/pdf/1st%20seminar%20report%20-%20CGCAMN.pdf

    More about Dr Dixon here…
    http://www.quackometer.net/blog/2009/02/graceless-dr-michael-dixon-obe.html

  29. Dr Benway says:

    pmoran:

    My concern is that much of the time we are talking to people for whom the testimonial evidence is very compelling. They quite reasonably ask what all the fuss is about so long as patients seem to be being helped. It creates considerable dissonance, as well as being not wholly accurate (if you DO accept the possibility of significant placebo effects and are not just paying lip service to the notion) to make bald “that doesn’t work” pronouncements.

    At every team meeting involving family, funders, etc., I say stuff like this: “Jonnie seems to be doing better since we increased the dose of X. This may mean the higher dose is helpful. But I wonder if some other factor might be helping…” We round up the usual bio-psycho-social suspects: new friend at school, change in behavioral protocol, coming down with a virus, etc. And I add, “The improvement might just be a coincidence. Everyone has their ups and downs.”

    I keep a couple anecdotes handy to illustrate the problem with compelling testimonials. Example: I increased the dose of Risperdal for one patient. Over the following month, teachers, family, staff all noted great improvement. However, the increase never went into effect as we never got approval from the state guardian.

    Over time, people gradually pick up this skeptical way of working, and the power of the testimonial wanes a little.

    “The fuss,” in my opinion, is the precedent that any clinical decision sets. Precedents shift the meaning of practice guidelines or standards.

    Imagine you’re watching an unfamiliar game. Several players are on the field kicking a ball around. You notice no one is picking up the ball, and you guess there’s a rule against touching the ball with one’s hands. But then someone does pick up the ball. Now you’re puzzled. Did he break a rule and people decided to let it go, or is handling the ball allowed under certain conditions?

    If we pretend homeopathy might help something like itchy scalp, that’s probably harmless enough in itself. But if homeopathy can be justified, why not excorcism for demon posession? Why not e-meters to remove body thetans? All three practices have the same level of evidential merit.

    Let CAM exist. Let patients with incurable problems seek out the unlikely in desperation. But let there also exist doctors who try to be as honest as possible.

    I dislike the integration of CAM with medicine more than I dislike CAM.

  30. Mojo says:

    I dislike the integration of CAM with medicine more than I dislike CAM.

    Why stick at “integrating” CAM as currently defined? Why not also “integrate” 18th and 19th century “heroic medicine” with its purging and bloodletting?

    The point should be to “integrate” medicine that actually works, and discard the stuff that doesn’t. But of course, that’s how we arrived at the distinction between medicine and CAM in the first place.

  31. edzard ernst says:

    spooky!
    i submitted very similar comments about dr dixon’s article as s novella posted here and submitted them to the bbc – after all, dixon’s diatribe was a response to my previous article written upon invitation from the bbc! sadly they never posted them.
    can i invite [urge might be the better word] all of you to contribute to my new blog before it gets over-run by the feeble-minded? you just google”edzard ernst blog” and find it very easily.everyone can register,you don’t need to be a gp.

    see you there.

  32. Mojo says:

    can i invite [urge might be the better word] all of you to contribute to my new blog before it gets over-run by the feeble-minded?

    Judging by the number of times that “only 13% (or 15%, or whatever) of medicine is evidence-based” has already been bandied about in the comments there, I think the invitation might be a little late.

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