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Dummy Medicine, Dummy Doctors, and a Dummy Degree, Part 2.2: Harvard Medical School and the Curious Case of Ted Kaptchuk, OMD (cont. again)

“Strong Medicine”: Ted Kaptchuk and the Powerful Placebo

At the beginning of the first edition of The Web that has no Weaver, published in 1983, author Ted Kaptchuk portended his eventual academic interest in the placebo:

A story is told in China about a peasant who had worked as a maintenance man in a newly established Western missionary hospital. When he retired to his remote home village, he took with him some hypodermic needles and lots of antibiotics. He put up a shingle, and whenever someone came to him with a fever, he injected the patient with the wonder drugs. A remarkable percentage of these people got well, despite the fact that this practitioner of Western medicine knew next to nothing about what he was doing. In the West today, much of what passes for Chinese medicine is not very different from the so-called Western medicine practiced by this Chinese peasant. Out of a complex medical system, only the bare essentials of acupuncture technique have reached the West. Patients often get well from such treatment because acupuncture, like Western antibiotics, is strong medicine.

Other than to wonder if Kaptchuk had watched too many cowboy ‘n’ Native American movies as a kid, when I first read that passage I barely blinked. Although the Chinese peasant may have occasionally treated someone infected with a bacterium susceptible to his antibiotic, most people will get well no matter what you do, because most illnesses are self-limited. Most people feel better even sooner if they think that someone with special expertise is taking care of them. If you want to call those phenomena the “placebo effect,” in the colloquial sense of the term, fine. That, I supposed, was what Kaptchuk meant by “strong medicine.”

Turns out I was mistaken. Let’s briefly follow Kaptchuk’s career path after 1983. In the 2000 edition of The Web, he wrote:

In the almost 20 years since the first edition, I have continued to learn and study. I have treated many patients and worked in many hospitals. I have come into contact with the many other health care systems. For the last ten years I have had a full-time academic appointment at Harvard Medical School (HMS). For four years I worked as a series consultant for a nine-hour British Broadcasting Company (BBC) television series on health care and I was sent to visit various healers on three continents. Currently, I am serving a term on the National Advisory Council of the National Center for Complementary and Alternative Medicine (NCCAM) at the National Institutes of Health (NIH) where I have the opportunity to contribute to the evolving reconfiguration of America’s pluralistic medical environment.

Kaptchuk used his newfound academic stature to celebrate all sorts of practices in that “pluralistic environment” that had, only a few years before, been widely recognized as quackery. We’ve seen his views on “Chinese medicine”; here, he and co-author (and boss) David Eisenberg wax eloquent on chiropractic:

Treatment by a chiropractor can generate a sense of understanding and meaning, an experience of comfort, an expectation of change, and a feeling of empowerment. Chiropractic’s combination of vitalist “innate intelligence” and simple mechanical explanation can give rich vocabulary for just those illnesses conventional medicine remains poorly equipped to address.

Chiropractors never have to put a patient’s pain in the category of the “mind.” They never fail to find a problem. By rooting pain in a clear physical cause, chiropractic validates the patient’s experience.

Chiropractic is in no sense passive; it is, from the start, engaged. Except when contraindicated (as in patients with neoplastic disease and those with extreme osteoporosis), some form of therapy is almost always indicated. For most symptoms, there is a suitable manipulation or a designated mode of redress.

From the first encounter on, chiropractors generate different expectations from conventional physicians. Because conventional practitioners assume that back pain, in the absence of systemic signs, is likely to be self-limited, it is not unusual for a patient to wait weeks for an appointment with a specialist or for a radiographic diagnostic assessment. Because a chiropractor believes that back pain is both explicable and amenable to treatment, a patient can usually obtain an appointment within 24 hours of a telephone call. The message of empathy, urgency, comprehension, and support conveyed by such a rapid response is reassuring and provides a heightened sense of care and compassion.

Chiropractic’s ultimate lesson may be to reinforce the principle that the patient-physician relationship is fundamentally about words and deeds of connection and compassion. Chiropractic has managed to embody this message in the gift of the hands.

Did the authors realize that they were writing a perfect description of quackery? Apparently not: in the fashion of duplicity-by-euphemism that is standard for quackademia, they refer to the overwhelming evidence that chiropractic is a pseudoscience as “contradictions and tensions [that] exist…between chiropractic and mainstream medicine.”

At some point during the nearly 20 years between the first and second Web, Kaptchuk seems to have begun to wonder if acupuncture and other offerings of ‘various healers’ act via “enhanced placebo effects.” Well, duh. But wait: for Kaptchuk, “placebo” doesn’t mean what it means to me or Mark Crislip or even to Peter Moran or Fabrizio Benedetti. For Kaptchuk, as we’ve already seen, placebo seems to mean something similar to what it means to Daniel Moerman. Placebo is “strong medicine”—maybe even stronger than “Western” medicine. When a trial of “EDTA Chelation Therapy for Coronary Artery Disease” was proposed at a 2000 meeting of the NCCAM Advisory Council,

Dr. Kaptchuk noted that they could find the equivalent of the placebo effect at work here, but both could be more beneficial than conventional therapies…The vote was 11 in favor, none opposed, and two abstentions, so the concept passed for funding.

Thus was spawned the most dangerous, unethical, and expensive boondoggle yet wrought by that August Body, paid for by you and me (Dr. Briggs, are you reading this? Are you, Dr. Nabel?).

Placebo Power and “Power Relationships”: a Postmodern Deconstruction of the RCT

Kaptchuk’s interest in the placebo seems to have arisen from his displeasure with modern medicine’s ‘privileged’ status, which had presented a barrier to establishing himself as a ‘doctor’ back in the USA. It must have been particularly rankling to take a back seat to the despised, reductionist paradigm, with its insistence on evidence from randomized, often placebo-controlled trials (RCTs). In the 2001 HMS conference to which I alluded at the end of the previous part of this series, Kaptchuk referred to the aforementioned “well, duh” attitude as an “accusation of placebo therapy,” and to “CAM” as a “domain for methodological doubt.” He based this on his suggestion that various “CAM” treatments may have “enhanced placebo effects,” effects that are even stronger than specific biomedical treatments. “Is a placebo effect,” he asked, “only a placebo?” He explains this further in an appendix to the 2000 edition of The Web:

Until about 1955, both East Asian medicine and biomedicine shared similar explicit standards for determining the acceptability of a medical intervention: legitimacy was determined by beneficial outcome. While physicians in both traditions also spoke of medicine based on ‘proven’ or ‘recognized’ principles, and inevitably were influenced by cultural assumptions, acceptable therapy was ultimately expected to deliver relief if not cure.¹

In the years after World War II, biomedicine underwent a dramatic shift. Major reforms were undertaken in medical research that sought to free therapeutic evaluations from human judgment based on clinical experience and impressions…The apparatus of the double-blind randomized controlled trial (RCT) gradually established itself as the ‘gold standard’ for determining legitimate therapy.

A major shift had occurred. A medical intervention was now scientifically justifiable only if it was superior to a placebo: method became more important than outcome. Superiority to placebo replaced ability to confirm health benefits as judgment criteria in medicine. Ideally, an acceptable treatment was now a relative outcome that could be isolated, disguised, and compared to the entire matrix of effects embodied in an identical healing ritual lacking this single ingredient.* Healing was no longer an absolute outcome that comprised multiple interactive dimensions. Biomedicine reconceptualized legitimate healing as “a cause and effect relationship between a specific agent or treatment and a specific biological result” [citation to 1998 article titled “Powerful Placebo: the dark side of the randomised controlled trial,” Kaptchuk characterizes the RCT as “self-authenticating”:

In a self-authenticating manner, the double-blind RCT became the instrument to prove its own self-created value system. This shift from emphasizing outcomes to the purity of the means directly parallels developments in medical ethics where ‘informed consent’ replaced ‘beneficence’ as the pinnacle of the value system.

(Hmmm? He offers no support for the last assertion). In that article he also asserts, with justification, that the premise for the placebo-controlled trial, as advanced by Beecher in 1955,

…took for granted that the active drug response results partly from a placebo effect and that the placebo effect buried in the active arm is identical to the placebo effect of the dummy treatment. The placebo was a single and stable ‘power’ that behaved in a consistent manner.

Kaptchuk, with reason, disagrees with that assumption. With less reason he calls for research to “disentangle the ‘non-specific’ and ‘art-of-medicine’ aspects of healing and therapeutic evaluation.”

In a 2001 article titled “The double-blind, randomized, placebo-controlled trial: gold standard or golden calf?” Kaptchuk again characterizes the RCT as “authenticating itself.” He quotes the philosopher Ian Hacking:

The truth is what we find out in such and such a way. We recognize it as truth because of how we find it out. And how do we know that the method is good? Because it gets at the truth.

In that article Kaptchuk tries to make what might seem, at first glance, a good case for the RCT not being all it’s cracked up to be. He begins with a mildly surprising statement:

Until very recently, there was a widespread perception that the absence of the usual components of the masked RCT will “exaggerate estimates of treatment effects“…It was generally believed that identical treatments “are much less likely to be judged efficacious in double-blind, randomized trials than in uncontrolled case series or unblinded, ‘open’ comparisons with contemporaneous or historical series of patients.”

Yes, but there is still that widespread perception. This “discrepancy argument,” as Kaptchuk calls it, is the basis for the RCT’s sitting atop the Evidence-Based Medicine (EBM) evidence hierarchy, and if it weren’t true it would certainly throw the whole project into disarray. Kaptchuk appears to do exactly that by citing several reviews (here, here, here, here, and here, for example) that “make a compelling case that poor methodology could either overestimate or underestimate treatment effects” (emphasis added). He asserts that such findings have led to a “modified challenge to the discrepancy argument,” such that one study’s authors have argued that “research design should not be considered a rigid hierarchy.” He mentions that the editorial accompanying that and a similar study “has cast doubt on the validity of these conclusions,” without revealing the basis of that doubt; according to Kaptchuk, this shows that “The discrepancy debate has intensified.”

Reading Kaptchuk’s essay you might think, if you were unaware of the crescendo of EBM-chatter in the medical literature over the previous 10 years, that he had discovered a heretofore barely acknowledged, critical, even subversive (as he might put it) Truth about the nature of ‘evidence’ in modern medicine; a truth that would, among other things, liberate “CAM” from the ‘microfascism’ of EBM. Just at that point, however, Kaptchuk adds an afterthought:

In terms of blinding, recent comparative assessments remains [sic] consistent with the older evidence. Three studies showed that double-blind RCTs yielded significantly smaller treatment results than trials that were not double-blind. Also, three studies showed that successful concealment of randomization (compared with inadequate concealment of randomization) produces smaller treatment outcomes. Proper masking seems to create distinct outcomes; the discrepancy argument is intact in this domain.

In this domain? IN THIS DOMAIN? Excuse the yelling, but what “domain” was he talking about in the first place? In other words, after spending about 1000 words trying to convince us that “the usual components of the masked RCT” don’t do what we think they do, he off-handedly mentions that, er, the RCTs that he’d been talking about didn’t have those usual components; meaning, like, they weren’t masked. Which was exactly the point that the mysterious “accompanying editorial” had made.

The discrepancy debate has fizzled. And so, to the satisfaction of most observers, has the “self-authenticating” gambit.

Never mind: in that and other essays, Kaptchuk goes to great lengths to argue that masking, “investigator self-selection,” randomization, informed consent, and other standard research methods introduce “possible systematic errors intrinsic in even an ideal RCT” (in a term reminiscent of another current pseudoscience that closely resembles Quackademia, he dubs this process “irreducible uncertainty”). In this he is undoubtedly correct to an extent, but not to the extent that RCTs must be judged no more valid measures of efficacy than are less rigorous tests claiming larger treatment outcomes. Kaptchuk might protest that he does not explicitly make that claim, but I would respond that he certainly implies it, over and over again.

Kaptchuk is in the company of other influential academic “CAM” advocates, such as Andrew Weil, David Katz, Wayne Jonas, and Mehmet Oz, who’ve been making similar, special pleadings for years.

“The Need to Act a Little More ‘Scientific’ “

We’ve previously heard this from Kaptchuk:

When people became interested in alternative medicines, they asked me to help out at Harvard Medical School. I realized that in order to survive there, one had to become a scientist. So I became a scientist.

I won’t take Kaptchuk too much to task for the obvious faux pas in that statement, even though it is entirely consistent with everything that you’ve read above; he has cultivated a pseudo-bumbling, Columbo-like persona for the purposes of some public presentations, and he came of age during the 1960s, when it was fashionable to be utterly serious while pretending not to be (think: Bob Dylan). So it’s quite possible that he pursued science not merely to survive at Harvard Medical School, but because he hoped to learn something about nature—a ‘domain’ about which, as demonstrated by the first edition of The Web, he’d been quite naive. But did Kaptchuk become a scientist? He seems to have learned a fair amount about clinical trial design and probably a fair amount about frequentist statistical inference. Does that make someone a “scientist” these days? What about nature?

I’m doubtful. In addition to his difficulty in distinguishing science from cultural ‘narrative,’ Kaptchuk stumbles in other fundamental ways. In a 2003 article titled “Effect of interpretive bias on clinical research,” he offers this list:

Definitions of interpretation biases

Confirmation bias—evaluating evidence that supports one’s preconceptions differently from evidence that challenges these convictions

Rescue bias—discounting data by finding selective faults in the experiment

Auxiliary hypothesis bias—introducing ad hoc modifications to imply that an unanticipated finding would have been otherwise had the experimental conditions been different

Mechanism bias—being less sceptical when underlying science furnishes credibility for the data

“Time will tell” bias—the phenomenon that different scientists need different amounts of confirmatory evidence

Orientation bias—the possibility that the hypothesis itself introduces prejudices and errors and becomes a determinate of experimental outcome

Some of his discussion is perfectly reasonable; some is further conflation of science and cultural narrative; some is confusing and even contradictory; some is selective in a way that suggests an agenda:

Good science inevitably embodies a tension between the empiricism of concrete data and the rationalism of deeply held convictions. Unbiased interpretation of data is as important as performing rigorous experiments. This evaluative process is never totally objective or completely independent of scientists’ convictions or theoretical apparatus…

Well, which is it? How can unbiased interpretation be so important if it never happens?

Science demands a critical attitude, but it is difficult to know whether you have allowed for too much or too little scepticism. Also, where is the demarcation between the background necessary for making judgments (such as theoretical commitments and previous knowledge) and the scientific goal of being objective and free of preconceptions?…

Interpretation is never completely independent of a scientist’s beliefs, preconceptions, or theoretical commitments.

Again, which is it? Why propose a goal of being free of preconceptions if scientists always have preconceptions?

Evidence is more easily accepted when supported by accepted scientific mechanisms. This understandable tendency to be less sceptical when underlying science furnishes credibility can give rise to mechanism bias. Often, such scientific plausibility underlies and overlaps the other biases I’ve described. Many examples exist where with hindsight it is clear that plausibility caused systematic misinterpretation of evidence. For example, the early negative evidence for hormone replacement therapy would have undoubtedly been judged less cautiously if a biological rationale had not already created a strong expectation that oestrogens would benefit the cardiovascular system. Similarly, the rationale for antiarrhythmic drugs for myocardial infarction was so imbedded that each of three antiarrhythmic drugs had to be proved harmful individually before each trial could be terminated. And the link between Helicobacter pylori and peptic ulcer was rejected initially because the stomach was considered to be too acidic to support bacterial growth…

Let me explain. Kaptchuk is correct that unbiased interpretation can never happen, so it makes no sense for him to propose otherwise on the same page. Biased interpretation is inevitable, moreover, not merely for the mundane or mischievous reasons that Kaptchuk implies, but because it makes no sense to attempt “unbiased interpretation.” That was shown by Thomas Bayes more than 200 years ago.

Kaptchuk seems to know something about this: in the Comments section he writes, without further explanation, “the arguments presented are obviously compatible with a subjectivist or bayesian framework that formally incorporates previous beliefs in calculations of probability.” If he understands what Bayes demonstrated—that attempting to interpret the results of an experiment without regard to previous knowledge is logically incoherent—he withholds it from his readers, whom he has nevertheless presumed to be largely naive.

My view: if he understood the point when he wrote his treatise, he was dishonest in not explaining it and in not citing at least one pertinent article, such as Steven Goodman’s (which I’m willing to bet he had read). If he didn’t understand the point he should have withheld his paper.

Kaptchuk’s portrayal of interpretive bias being based on “beliefs, preconceptions, or theoretical commitments” implies that such bias is more about cultural assumptions and “power relationships” than about science. That, I believe, is his agenda: to suggest that such ‘commitments’ are likely to ‘privilege’ the status quo and to distract from the truth, thus casting enough doubt on the entire project to give at least a tentative free pass to, well, almost anything.

The reality of science is somewhat different: While it is undoubtedly true that an individual scientist’s biases often reflect personal wishes (not so much cultural assumptions), many of the biases of scientists are not only inevitable, but desirable. Kaptchuk’s discussion of “mechanism bias” is notable for its selection of examples that serve only to condemn such bias. A different sort of example would demonstrate an important truth about science, a truth that Kaptchuk either doesn’t understand or would prefer to conceal from his readers.

Such an example would be a ‘positive’ trial of a claim that, if deemed valid, would require discarding a firmly established principle of nature, such as the 2nd law of thermodynamics—a principle that is not merely a preconception or a “theoretical commitment,” but a fact based on data vastly more rigorous and voluminous than the entire body of biomedical literature. In such a case, not to invoke plausibility would (and has, many times) “cause systematic misinterpretation of evidence.”

The inverse of what Kaptchuk calls “this understandable tendency to be less sceptical when underlying science furnishes credibility” is “this understandable tendency to be more sceptical when underlying science furnishes no credibility,” which I would call “good science.” Does Kaptchuk even have a sense of what to look for in a hypothesis? Simplicity, conservatism, fruitfulness, and scope, for example?

Kaptchuk seems to believe his own hype: “method” is more important than science itself. I don’t think that he appreciates, or at least acknowledges, some of the fundamental aspects of science. I also suspect that he isn’t forthcoming about some of the things that he does know, if they don’t suit his agenda.

To be fair, I’ll report that Kaptchuk specifically denies, in the final paragraph of his “interpretive bias” paper, one of the accusations that I’ve made against him:

I do not mean to reduce science to a naive relativism or argue that all claims to knowledge are to be judged equally valid because of potential subjectivity in science. Recognition of an interpretative process does not contradict the fact that the pressure of additional unambiguous evidence acts as a self regulating mechanism that eventually corrects systematic error.

I can’t help but be reminded of another of Kaptchuk’s articles, quoted here a couple of years ago. Its abstract:

The advent of scientific research on complementary and alternative medicine (CAM) has contributed to the current state of flux regarding the distinction between biomedicine and CAM. CAM research scientists play a unique role in reconfiguring this boundary by virtue of their training in biomedical sciences on the one hand and knowledge of CAM on the other. This study uses qualitative interviews to explore how CAM researchers perceive and negotiate challenges inherent in their work. Our analysis considers eight NIH-funded CAM researchers’: (1) personal engagement with CAM, (2) social reactions towards perceived suspiciousness of research colleagues and (3) strategic methodological efforts to counteract perceived biases encountered during the peer review process. In response to peer suspicion, interviews showed CAM researchers adjusting their self-presentation style, highlighting their proximity to science, and carefully ‘self-censoring’ or reframing their unconventional beliefs. Because of what was experienced as peer reviewer bias, interviews showed CAM researchers making conciliatory efforts to adopt heightened methodological stringency. As CAM researchers navigate a broadening of biomedicine’s boundaries, while still needing to maintain the identity and research methods of a biomedical scientist, this article explores the constant pressure on CAM researchers to appear and act a little more ‘scientific’.

Placebo Research: a Critical Positive Impact on Health Care?

What about Kaptchuk having mostly (not entirely) abandoned his advocacy of the purported specific effects of highly implausible medical claims, in the last decade or so, in order to pursue his interest in their non-specific effects? Well, perhaps that has separated him from the rest of the quackpack, to an extent, and for that, some observers feel he deserves credit (Peter?). On the other hand he is no Fabrizio Benedetti, who can call quackery “quackery,” who insists that real, neurobiological placebo effects can’t be studied in clinical trials, not only because of regression to the mean and spontaneous remission, but because of biases introduced by both investigators and subjects (as was likely the case in Kaptchuk’s albuterol vs placebo for asthma trial that triggered this series), and who recognizes that any potential clinical applications beyond the obvious “caring for the patient” are apt to be elusive:

I use the placebo response as a model to understand how our brain works. I am not sure that in the future it will have a clinical application. This is a very important point—a translational research: can we use placebo in routine clinical practice? Well, sometimes it works; but that’s not the important problem. The important thing right now is to understand how our brain works. And I would say the placebo response is a fascinating phenomenon, because it is a sort of melting pot of concepts, of ideas for neuroscience. So, if you use a placebo response, you can understand a lot of brain functions, like anxiety, like social learning, classical conditioning, reward mechanisms, and so forth. So, the clinical application is—I think in English you say it is a ‘different kettle of fish.’

Kaptchuk, on the other hand, in keeping with his belief that the placebo is ‘strong medicine,’ argues that

Learning how to enhance medical outcomes via placebo research could have a critical positive impact on health care and scientific knowledge.

It takes only a bit of perspective to realize that learning how to enhance medical outcomes via placebo research, questionable in itself, is unlikely to have more than a minor impact on health care. That perspective consists of the state of health anywhere in the world prior to the advent of scientific medicine and public health. Kaptchuk, who cut his teeth on “Traditional Chinese Medicine,” might review, in William H. McNeill’s Plagues and Peoples, the appendix titled “Epidemics in China” (part of it can be found here). Does Kaptchuk really believe, or expect the occasional sophisticated reader of The Web to believe, that “biomedicine was adopted by Asian and African countries most often not because of medical outcomes but because of the prestige associated with the other developments of science”?

On Contradiction

For a preview of the final posting in this series, consider these statements:

In clinical practice a sham medical procedure would be fraudulent and deplorable; in research such activities can be legitimate, and this outlying research practice underscores the important ethical differences between clinical trials and medical care.

—Miller and Kaptchuk, “Sham procedures and the ethics of clinical trials

…both traditional and sham acupuncture were shown to provide clinically significant improvement in back pain and function, as compared with either no treatment or usual medical care, suggesting that the benefit from acupuncture probably derives from the placebo effect. Although this alternative standard for evidence-based validation deserves critical scrutiny and serious debate, we believe that it reflects a more patient-centered perspective for symptomatic treatment. Patients who have continuing pain are interested in pain relief; they are unlikely to care whether this derives from the inherent ability of a treatment to modify pathophysiology or its propensity to promote a significant placebo response.

—Miller and Kaptchuk, letter to the New England Journal of Medicine following the report discussed here, here, and here.

 

The Dummy Series:

  1. Dummy Medicines, Dummy Doctors, and a Dummy Degree, Part 1: a Curious Editorial Choice for the New England Journal of Medicine
  2. Dummy Medicine, Dummy Doctors, and a Dummy Degree, Part 2.0: Harvard Medical School and the Curious Case of Ted Kaptchuk, OMD
  3. Dummy Medicine, Dummy Doctors, and a Dummy Degree, Part 2.1: Harvard Medical School and the Curious Case of Ted Kaptchuk, OMD (cont.)
  4. Dummy Medicine, Dummy Doctors, and a Dummy Degree, Part 2.2: Harvard Medical School and the Curious Case of Ted Kaptchuk, OMD (cont. again)
  5. Dummy Medicine, Dummy Doctors, and a Dummy Degree, Part 2.3: Harvard Medical School and the Curious Case of Ted Kaptchuk, OMD (concluded)

 …

The Harvard Medical School series:

  1. Dummy Medicine, Dummy Doctors, and a Dummy Degree, Part 2.3: Harvard Medical School and the Curious Case of Ted Kaptchuk, OMD (concluded)

Posted in: Acupuncture, Basic Science, Book & movie reviews, Chiropractic, Clinical Trials, Homeopathy, Medical Academia, Science and Medicine

Leave a Comment (48) ↓

48 thoughts on “Dummy Medicine, Dummy Doctors, and a Dummy Degree, Part 2.2: Harvard Medical School and the Curious Case of Ted Kaptchuk, OMD (cont. again)

  1. windriven says:

    “So I became a scientist.”

    Hah!

    I am reminded of the Southpark episode where drivers of Priuses repeatedly sniff their own flatulence and find it enchanting.

  2. WilliamLawrenceUtridge says:

    Yup, all medicine is just a matter of perspective. That’s why natalizumab and advil are identical in their treatments of multiple sclerosis and back pain. The important thing is to be convincing, not that you base your interventions on evidence.

  3. cervantes says:

    In the end, to the extent that there is a placebo response that can actually benefit patients, it would be entirely incorporated within the provision of efficacious treatments in the context of an attentive, empathetic, patient centered relationship. So why bother with the woo? Let’s just have evidence based medicine provided by doctors who know how to listen, understand patients’ needs and preferences, and interact humanely. The “CAM” part is just a distraction, and a crock.

  4. rork says:

    Alternative standard “reflects a more patient-centered perspective for symptomatic treatment”

    Springtime for quackery. Let a thousand flowers bloom.

  5. Quill says:

    That whole “domain” thing has me laughing. It’s simply the use of a physical metaphor to either avoid talking about something or fooling yourself into thinking this imaginary place, by virtue of its alleged existence, somehow explains the point you think you were making. Along with the aptly-described “duplicity-by-euphemism” perhaps there needs to be another category like “the imaginary hideout” or “the imaginary realm refuge.”

    English is a funny language with which discuss abstract concepts but it is nevertheless interesting how these concrete metaphors stand for so much in things written by people who think the material world is just a matter of opinion.

  6. ConspicuousCarl says:

    Kimball Atwood said,
    it makes no sense to attempt “unbiased interpretation.” That was shown by Thomas Bayes more than 200 years ago.

    We should note the difference between the experience-based “bias” of bayesian analysis of the data after the experiment is done, vs. the double-blind prevention of bias during the recording of the data (which is the undesirable bias he unwittingly describes in terms of the patient’s experience). Bayesian analysis good, bayesian recording bad.

  7. Jann Bellamy says:

    I had to go to the HMS website to see for myself that this guy is really a professor and, yes, there he is: Ted Jack Kaptchuk, B.A. At least they don’t allow the “OMD.” http://connects.catalyst.harvard.edu/profiles/profile/person/84972
    Just curious: how long can one stay afloat in ivy league medical academia with a B.A., authoring — mostly as the middle-to-last author — articles of no particular relevance to medicine, many published in low-impact journals, and not doing any important research? Is it just much, much easier than I thought to be an associate professor of medicine at Harvard?

  8. Jurjen S. says:

    I’m extremely skeptical about the veracity of that story of the hospital maintenance man, for the simple reason that any missionary hospital in China wouldn’t have had access to antibiotics until after 1945, but it’s exceedingly unlikely anyone would be establishing a new missionary hospital between 1946 and 1949, while the Chinese civil war was in full swing, or after 1949, when the communists had taken control. Even if they had, it’s highly doubtful they had enough antibiotics that the guy could have just made off with a sizable supply without anybody noticing.

  9. ConspicuousCarl says:

    Jann Bellamy on 14 Oct 2011 at 6:59 pm

    I had to go to the HMS website to see for myself that this guy is really a professor

    The ‘News of the Weird’ website, which collects exactly what its name implies, keeps a list of situations which once seemed weird, but have technically become non-weird because they are actually very common (e.g., burglars who get stuck in chimneys) and are therefore no longer reported on the website.

    So far I know of two people (Oz and Kaptchuk) I would categorize as “people in seemingly-respectable academic positions who are actually nuts”. The first was a shock. The second was still “OMG”, though my dissonance and disbelief was reduced. Who comes third, and how will I feel about it?

  10. ConspicuousCarl says:

    ..and, I forgot to ask, how many will it take before News of the Weird declares it boring?

  11. nybgrus says:

    @cervantes:

    Precisely what I have been advocating. There is nothing preventing caring compassionate delivery of real medical care. I am so tired of the “Well doctors don’t have time” or “Doctors are insensitive and have bad bedside manner” arguments as a justification for the existence of CAM. Then we change the system to make more time and teach our medical students the importance of caring and compassionate. But either way, those failings in no way posit evidence for CAM anymore than trying to disprove evolution posits evidence for creationism/ID.

  12. nybgrus says:

    oh and once again I need to add that reading excerpts from Kaptchuk brings my blood close to boiling. The rhetoric is just so identical and canned from my med anthro undergrad degree that all I can picture is a bunch of mindless parrots squawking the same garbage over and over, changing the details ever so slightly as the current rhetorical framework demands. It is so blatantly easy to see through for me, forget about the clothes – I can see right through the emperor.

    All of this rhetoric – ALL of it – is an appeal to cultural relativism as an absolute and immutable Truth&#0153 and an advocation to return to mysticism and shamanism, since that is what entranced the original anthropologists of the colonial era.

  13. I’m always interested in how often patient empowerment is cited as a criticism against actual medicine. I can sympathize. I would find deeper meaning in my annual pulmonary function tests if there was a barista in the office.

    @Nybgrus: Back in the day mysticism and shamanism were deliciously exotic. (Still deliciously interesting IMO.) The current CAM fetish reminds me of American Indian Princess Syndrome. I keep thinking that CAM patients will eventually reach some sort of saturation point in the population and CAM will no longer be Other. At that point, I will be one of the nouveau-cool kids who saw a real doctor the whole time.

  14. nybgrus says:

    @ AU:

    Oh I agree fully – they are fascinating topics. But from a learning and cultural perspective, not a scientific medical standpoint.

    And I may be reading you wrong, but it sounds like you are suggesting a sort of neo-hipsterism will flip-flop back to “western” medicine after the CAM fetish reaches critical mass. “Well, I was seeing REAL doctors before you thought they were cool.” LOL.

    BTW – why did the hipster burn his mouth? He ate the pizza before it was cool.

  15. @ Nybgrus:

    Yes, the neo-hipsterism/CAM fetish critical mass paradigm is exactly what I am suggesting. Maybe we can hasten the process by framing actual medicine as somehow ironic ;)

  16. pmoran says:

    Kaptchuk: A major shift had occurred. A medical intervention was now scientifically justifiable only if it was superior to a placebo: method became more important than outcome.

    An outlandish assertion to most doctors. But Kaptchuk is proposing a tenable hypothesis that raises this exact point.

    Along with Andrew Weil, the homeopath Peter Fisher (I think), Moerman and others he is toying with a fairly plausible, modestly supported scientific hypothesis — i.e. that CAM is well-suited to helping some kinds of patient with some conditions* via enhanced placebo influences.

    While placebo-controlled RCTs rightly provide a logical foundation for most modern medical practice, is it not obvious to all that they are not designed to answer that question? They ask only (usually) “does this treatment have intrinsic therapeutic activity?.”

    They provide no information at all about what is going on in the placebo group or about “placebo potential” in its broadest sense.

    In fact, no simple clinical trial design can do so unequivocally because of the difficulty of mimicking real world factors governing psychological responsiveness to non-specific aspects of medical attentions, including cultural factors, patient selection and self-selection and the fact that any way of trying to enhance placebo influences is likely to also increase patient reporting biases.

    So when these persons say “you need to look at our methods differently” they are not necessarily invoking post-modernist views of science, seeking a double standard, or challenging the logic of modern medical science.

    We, in fact, DO need to look at them differently if we are to find evidence that would directly refute or support the hypothesis.

    (*The “some patients with some conditions” in the above is, I admit, my qualification, as these authors typically speak in broad generalities, rarely ever specifying exactly what their methods do or don’t do in terms of human symptoms and patho-physiology.

    If we allowed ourselves to get into a proper dialogue with them we may be able to persuade them to start setting such limits. That is where patients mainly come to grief, when they are allowed to seek extremely improbable outcomes.)

    PS Oh, and it is not that the placebo controlled trials have not been of value in the above scenario. They have forced upon CAM the need to find different explanations for what they believe they are observing in their patients.

  17. JPZ says:

    I have been doing a little reading about studies comparing acupuncture, sham acupuncture, and standard of care. There appear to be some studies saying that their randomized clinical trial found no difference between acupuncture and sham acupuncture in the outcome (nausea for one) but both are better than standard of care. I could post some references, but I imagine that the community here has dealt with these studies and assertions many times before. What are your impressions about these kind of results – are there biases, design flaws, methodology issues, etc.? I really haven’t formed an opinion, but it is kind of interesting to think of “poking people with sharp things, general” as a new standard of care – do they have an ICD-9 code for that (lol)?

  18. nybgrus says:

    @JPZ:

    Those studies have indeed been tackled here numerous times. In brief, the reason why (at least as I see it) acupuncture and sham acupuncture work better than standard of care has to do with the specific pathology in question. The only studies that I have come across demonstrating that in anything approaching a robust fashion are those dealing with back pain, particularly lower back pain. Nausea has some data but not quite as robust.

    The thing with back pain is that standard of care is pain meds, rest, and early mobilization. The latter is the most difficult since people gaurd their pain, especially when it is so great as it is in back pain. Going into any trial, especially an acupuncture one that promises something “different” motivates people to actually go through with that last part – early mobilization. It gives a placebo effect wherein their pain is perceived differently and as they are already willing to try something new and more, they actually move around and Robert’s your mother’s brother.

    In my opinion, acupuncture itself does nothing – and neither do the “non-specific” effects of interaction do anything unique. They simply are a different way to motivate people to actually follow the standard of care and resolve their back pain.

    Peter Moran would have us believe that as a physician I (we) would lack the ability to motivate our patients in the same way. That somehow sCAMsters have some unique je ne sais quoi to motivate people that we simply cannot achieve. I think not.

    So while he continues to postulate some if, then, maybe, somehow of CAM addressing some sort of ill defined subset of people, I’m happy to actually engender a good therapeutic relationship and fix up back pain just as effectively as an shamupuncturist.

    As Mitchel and Webb said, “When there is someone with a vague sense of unease and more money than sense…” a homeopath will be there to help them. That’s about the only population that can be served by such placebo methodology.

  19. JPZ says:

    @nybgrus

    Ah, I see you have adopted “Bob’s your Uncle.” Have you adopted “suck it and see” as well? My postdoc advisor was from Oz, and I always felt a little degraded when he called my experiment a “suck it and see” once I understood the pun.

    I am more familiar with emesis research based on how ginger has performed in clinical trials. But, if I understand what you are saying, in the cases where “doing something special and unusual” produces better results than standard of care, then we can call that outcome a “treating people special” effect and stick to doing one’s best with standard of care? It would seem that one could use scientifically-sound psychology methods (or studies even) to harness this “treating people special” effect to upgrade the standard of care. It doesn’t strike me as a doctor-patient relationship issue or the placebo “rub a lemon on your lower back three times a day” issue. But if poking people with pointy things works better than standard of care, wouldn’t you want to harness that effect once you understood the psychology of it (and not having to poke people with pointy things)?

  20. JPZ says:

    @nybgrus

    BTW, Mitchell and Webb, homeopathic beer had me LMAO.

  21. nybgrus says:

    @JPZ:

    LOL. Indeed, I have picked up some of the lingo here. Kind of hard not to. “Suck it and see” is not one I am familiar with though. But some of the colloquialisms here are tough to get a handle on like “taking the piss.” I still don’t think I use that one quite right all the time.

    As for the ginger – yes, I have seen a few studies that show it seems to have some effect. And it is innocuous enough that I see no harm in using it over say, scopalamine, if it works well enough for someone.

    But in regards to the back pain/standard of care issue – I think you are understanding me exactly right. And I am indeed advocating for harnessing the understanding of the underlying psychology in a science based manner to improve standard of care. But teaching human interaction, especially of the type that engenders trust, is hard to learn and even harder to teach. I was actually very (very) socially inept most of my life and indeed at times was almost anti-social. It has only been through years of very intentional practice in a variety of social situations (coupled with the esteem boost of dropping 35kg) that I can interact well with other human beings. And people still describe me as “unique” in a slightly euphemistic sense. LOL.

    That is where I see a healthcare team being extremely vital. That way someone along the way could hopefully have the skill and rapport to motivate patients to take better care of themselves. You have to give people a reason to take their health seriously – and I find that empowering them with knowledge often works to that end, as does genuinely caring about it yourself (as the HCP).

    I am also of the opinion that sCAMsters are not particularly skilled in such interpersonal interactions. Most of their “success” in that regard stems from the novelty and “mystique” of the approach. Demystification, patient education, and genuine caring on the part of the physician can and will evaporate that very easily. People are people – and some physicians can be very empathic and charismatic and some sCAMsters can be complete jerkoffs. I see no reason to believe, nor evidence to support, that somehow the community of sCAMsters is, on the whole, more skilled in patient communication.

    At least, that has been my experience and it is confirmed with much of what I read.

    And yes, Mitchell and Webb are hilarious. Though something tells me that if I write “crushed up blue Ford Mondeo” as the correct treatment for acute hemorrhagic shock after an MVC on my medical boards (which I will be taking scarily soon!) that won’t go over well ;-)

  22. DDH says:

    @nybgrus

    ‘Taking the piss’ is right in all contexts except the literal … unless you’re *very* good friends.

    (Can’t believe what moves me to post finally is aussie slang!)

  23. qetzal says:

    pmoran:

    Kaptchuk is proposing a tenable hypothesis that raises this exact point.

    Along with Andrew Weil, the homeopath Peter Fisher (I think), Moerman and others he is toying with a fairly plausible, modestly supported scientific hypothesis — i.e. that CAM is well-suited to helping some kinds of patient with some conditions* via enhanced placebo influences.

    I agree that enhanced placebo influences is a tenable hypothesis and that medicine should seek to maximize such positive influences. I don’t agree that CAM is well-suited to do that. CAM tries to convince patients of blatant falsehoods – that water has memory, that nerves carry innate intelligence, that mystical energy flows through meridians, that internal organs can be ‘remote controlled’ by pushing points (“buttons”) on the feet or ear, etc. And most importantly, CAM tries to convince patients that they should pay for the privilege of being fooled. CAM may well make some patients feel better through enhanced placebo influences, but that doesn’t excuse its fundamental dishonesty.

    I also disagree that folks like Kaptchuk, Weil, or Moerman are honestly just trying to pursue the enhanced placebo hypothesis. If they were, they wouldn’t be defending fraudulent practices like acupuncture, homeopathy, reiki, etc. They’d be focused solely on how to maximize the placebo effect in the context of true medicine.

  24. JPZ says:

    @nybgrus

    OK, this is speculation on my part, but patients in a clinical trial are getting huge amounts of attention each visit by (ideally) very empathetic clinical trial staffers. These are the same staffers no matter which arm of the trial you are in. Wouldn’t any interpersonal interaction effect get washed out? We call it the “being in a clinical trial” effect, and it has a huge effect on weight loss studies. Perhaps the acupuncturist has some additive interpersonal interaction effect, but I am still curious if it is “poking people with pointy things” acting as the psychological/physiological stimulus. I haven’t read enough in this area to support that assertion strongly, but I thought it worthwhile to point out the “being in a clinical trial” effect modifier of interpersonal interaction.

    @everyone

    Thank you for your patience with this discussion. I imagine it has already been hashed out dozens of times on SBM, and I am probably bringing up very tired topics. I’ll try to wrap up quickly.

  25. pmoran says:

    Doctors will be able to harness the same influences?

    While the mainstream should try, success will be limited, and not only because of time constraints upon doctors and the fact that it would take some kind of “Superdoctor” to satisfy all patient tastes.

    If you look at Harriet’s very incomplete list of factors which might encourage non-specific responses to acupuncture,
    http://www.sciencebasedmedicine.org/?p=12523
    very few of them can operate without some form of deception, or the use of some other kind of mainly-placebo therapeutic ritual.

    So the usual ethical constraints will presumably forbid them.

  26. JPZ says:

    @pmoran

    I read Harriet’s post via your link. I hear the arguments about provider charisma, therapeutic ritual and deception all making a difference in outcome. But in clinical trials, I would think that such effects would be minimized or eliminated – other that poking people with pointy things. So, either the clinical trials are biased in some fashion (maybe?), or the effects are more related to something proximal to poking people with pointy things. I have trouble calling this a placebo effect that needs to be harnessed. I just wonder if there is some psychological/physiological process and response that can be studied to determine if it has therapeutic potential. This isn’t a study of why acupuncture works or a justification for acupuncture – it is a study of why poking people with pointy things works better than standard of care.

  27. nybgrus says:

    @JPZ:

    Yes, I am well familar with the Hawthorne effect. In the acupuncture studies you find one of two scenarios. The first is that the “standard of care” arm is not actually a separate experimentally controlled arm within the study – it is taken from patients already just seeing their regular physician. The better studies, of course, do have an experimentally controlled SoC arm. In that case, the expectation is different. First off, we know that people view being injected by something as a much more serious and “big” intervention than taking a pill. Secondly, people in the SoC arm know they are in boring old standard of care because the studies are done on people with existing chronic back pain. There is no good data on acute back pain (as Cochrane notes here and in fact only one proposed study of acupuncture on acute back pain that is not yet enrolling participants. So these are people that have already been babying their backs and avoiding movement and relying on the analgesic/muscle relaxant portion of the SoC and know it isn’t working for them. Then a new treatment, that seems more invasive, has the promise of being “something new,” and has a little Eastern mysticism thrown in to boot comes along and lo and behold they are ready to start moving their backs and resolve their pain. Plus, the people that would sign up for such trials are the ones that are self selected as wanting their back pain to resolve somehow.

    And if that wasn’t enough, we have once again a statistically significant difference which, as is noted in the Cochrane review, has small effect sizes. This is all precisely what I would predict using good motivational techniques for patients in chronic low-back pain.

    As for the acute pain trial – I would predict that there will be almost no effect whatsoever. When compared to SoC acupuncture will have almost exactly the same outcomes on acute back pain. Compared to no treatment, I think it would have some effect, but I would be willing to bet the effect size will once again be small. This is because I’ve learned the major reasons why back pain become chronic and it is mostly patient driven (we had an entire week on it in school last year). Those patients that will recover fully and quickly from their LBP (like me – I suffer from acute spasms that leave me crippled on average once a year) will do so regardless of SoC, no treatment, bad treatment, or ritual goat sacrifice. Those that will go onto chronicity will also do so regardless. There is a small gray area though that could be swayed and depending on the population involved in the study would vary in size but always be small (on the order of 10-20% give or take).

    So yeah, the “poking people with sharp things” is part of it – needles are scarier and much more invasive so they must be doing more than a stupid ol’ pill – but a much bigger part is the internal motivation of the patient (and in fact in some cases giving a person who fell into chronicity a psychological and social “out” for the back pain to get better – we can’t neglect the sick role in the pathogenesis of all this). Hopefully that makes sense to you why poking people works better than SoC (and why it has nothing to do with acupuncture and very little to do with psychogenic placebo effects). And of course note that the effect is actually pretty small, unlike some would have us believe.

  28. nybgrus says:

    @pmoran:

    Guess I’ll be a superdoc then.

    But seriously – that is your argument against it? And more importantly for CAM? Not all CAM practitioners will be able to harness it either – sure, they have less ethical constraints (i.e. they don’t adhere to good ethics), but as I said before – they are people and some will resonate with patients better than others.

    Yet you still manage to try and justify pawning off your patients to an acupuncturist because a) they are less ethical than you and so can lie to your patients and b) you assume they will be good at or even be able to harness those interpersonal skills which you claim we either lack or lack the time to employ. That’s pretty weak Peter.

    I also hate the “because we don’t have time argument.” Yes, physicians are busy and under severe time constraints. Yes, that makes it difficult to have a properly caring and empathic relationship. But in my (albeit limited) experience, it is the laziness and/or lack of caring on the part of the physician that is the limiting reagent in that equation. Time relatively rarely becomes a factor. But even if that were 100% the case, that is still not an argument for utilization or referall to sCAMsters.

    A car analogy since it popped into my head. That is like saying that your convertible roof won’t go up, so every time it rains you need to tell your family to take a bus or someone else’s car. No! Fix your damned roof!

    You also reference Dr. Hall. Yes, there are things there which I personally have clearly said would be unethical to employ (pure placebo, lying, etc). You seem to think that being unable to employ those is such a detriment in our ability to treat patients that it outweighs a good, honest, ethical, caring therapeutic relationship entirely within evidence based guidelines. Where’s your evidence for that? I see none.

    I argue that the small loss of therapeutic benefit we lose by being ethical is completely and utterly insignificant compared to the rest of what we do and could offer patients. And I have yet to see you make any argument that is even remotely convincing to refer patients to sCAMsters of any kind, nor tolerate their existence.

  29. nybgrus says:

    my link to the one clinical trial on acupuncture in acute LBP didn’t seem to work. Here it is. Of course, I would argue it needn’t be done, since the premise is stupid, but who am I?

  30. pmoran says:

    JPZ:I read Harriet’s post via your link. I hear the arguments about provider charisma, therapeutic ritual and deception all making a difference in outcome. But in clinical trials, I would think that such effects would be minimized or eliminated – other that poking people with pointy things.

    I am not quite sure what you are getting at, I am afraid. The answer may lie in that there are many possible study designs, depending upon what precise question you are trying to answer.

  31. JPZ says:

    @nybgrus

    Well, I did dismiss placebo effect and the full mysticism of acupuncture in my earlier post based on the science as I saw it. The “poking people with pointy pins” alliteration had to change after I heard about the toothpick trials – but I do get a small smirk every time I type it. I as well have had lower back issues (one brought on by putting on a sock), but I have been well served by muscle relaxants and OTC analgesics as well as a desire to get back on my feet.

    If there are study design issues with acupuncture studies, then I can readily accept that they introduced biases into the study design. I make the assumption that a well-designed clinical trial will remove many of the irrelevant trappings of an acupuncturist session and will upgrade the patient interaction during SoC through the trial staff. Maybe I assume too much, and I may have a bias from doing too many GCP/ICH compliant clinical trials on nutritional products – many of which were done with the two pharmaceutical companies that have employed me.

    With regard to small effect sizes, I am not in a position to evaluate whether an outcome is clinically significant – only the Medical Director or other informed physicians can make that call. If there is a statistically significant improvement over the SoC, I would present the viewpoint that we should consider how to improve the SoC without compromising the validity of the overall treatment.

  32. JPZ says:

    @pmoran

    A well-controlled clinical trial would limit provider-patient dialogue to a fairly narrow range to minimize the distinction between acupuncture and sham. This minimizes provider charisma effects. The setting would not be filled with mystical music and incense, but more a neutral environment where the clinical staff explained a scripted procedure the patients would undergo followed by pointy manipulation. This minimizes the therapeutic ritual effect. And deception is distributed equally across treatment groups by the simple fact of randomization. By these and other controls, a clinical trial may minimize the influence of factors cited by Harriet and others.

  33. nybgrus says:

    @JPZ:

    There are massive issues with study design of pretty much all CAM trials. It is the likes of Kaptchuk and Weil that argue that their woo only works with all the trappings (including pre-scientific diagnostic and outcomes criteria) intact. That includes the incense and Enya playing in the background in the woo setting but not the SoC.

    As I said above, it is these extra trappings that motivate people to be active and it is the activity that alleviates their symptoms. Also of important note is the expectation as I said above – these trials enroll people that expect SoC not to work since (for whatever reason) it hasn’t been working for them. I would bet that just about any even remotely superficially credulous alternative “treatment” would have similar effects to acupuncture for that very reason – it is something new to motivate people.

    As for the effect sizes, indeed. I am also not currently in a position to evaluate how meaningful they are in a vacuum. But taken in context of the rest of the issues surrounding the application of acupuncture I feel reasonably safe to say they are mostly clinically irrelevant. They are, however, useful for learning from and applying to SoC in order to improve that.

    In other words, it is all placebo effects of one kind or another. Nothing I see as unusable in the context of real, proper, and honest medical care.

  34. pmoran says:

    JPZ: @pmoran

    A well-controlled clinical trial would limit provider-patient dialogue to a fairly narrow range to minimize the distinction between acupuncture and sham. This minimizes provider charisma effects. The setting would not be filled with mystical music and incense, but more a neutral environment where the clinical staff explained a scripted procedure the patients would undergo followed by pointy manipulation. This minimizes the therapeutic ritual effect. And deception is distributed equally across treatment groups by the simple fact of randomization. By these and other controls, a clinical trial may minimize the influence of factors cited by Harriet and others.
    ————————————————
    That is so. By such studies we have been able to demonstrate that it doesn’t matter much whether you penetrate the skin or not, or whether you stick the needles at precise “acupuncture points” or not.

    These are are serious blows for TCM theory but they are trivial observations if your “theory of acupuncture” happens to be that it is mainly placebo. That is why Kaptchuk can see the placebo controlled study as (sometimes) prizing method (mechanisms) over outcomes.

    Acupuncture seems to be a better than average placebo, to judge from studies that include an untreated group i.e. where placebo influences are given free rein, where effects sizes in the moderate range are not unusual with some conditions and settings. There are lots of potential errors and biases in those studies but they go both ways, so it is unwise to be too dogmatic as to those studies prove.

  35. JPZ says:

    @nybgrus

    If studies leave in the trappings of acupuncture and compare it to a 15 min primary care visit, then that is poor study design. I saw an example of a low trappings acupuncture session in this news report (http://wm.kusa.gannett.edgestreams.net/ads/sales/COCO/1273524370490-university%20of%20colorado%20hospital%20051010.wmv) – the first example is around 1:10. If NCCAM (or some other group) can do a proper subtractive study design (no trappings, no skin penetration, reduced contact time, no meridians, etc.), this should be a testable hypothesis that can isolate effective components and test your hypothesis that it is the setting and expectations that create efficacy. Neuroscience research has shown us that there are really impressive ways to experimentally produce desired mental states (e.g. raised expectations about a novel treatment) without using any of the language of acupuncture. If acupuncture supporters insist that all elements must be included for acupuncture be testable, then the use of acupuncture has already been debunked by studies disproving the importance of meridians and skin penetration.

    OK, I am starting to catch on…

  36. CarolynS says:

    The following is in quotation marks above and seems to be attributed to Hacking “The truth is what we find out in such and such a way. We recognize it as truth because of how we find it out. And how do we know that the method is good? Because it gets at the truth.” But I found the Hacking chapter that Kaptchuk cited and it doesn’t actually have those words in it or really anything that comes very close. Are those words actually from Kaptchuk not from Hacking? Anybody have insights on this? I Googled the phrases and came up empty-handed.

  37. JPZ says:

    @CarolynS

    Try some of the cheating detection websites that educational institutions use. Sometimes students will change a few words to avoid getting caught, and these engines are able to detect that trick. Unfortunately, I can’t direct you to that many websites, but perhaps you can find more with an online search. The one we use to check manuscript submissions to scientific journals is http://www.ithenticate.com/. I am not sure how useful it will be in this instance, though. Good hunting!

  38. PJLandis says:

    “Does Kaptchuk really believe, or expect the occasional sophisticated reader of The Web to believe, that “biomedicine was adopted by Asian and African countries most often not because of medical outcomes but because of the prestige associated with the other developments of science”?”

    I would like to think I’m a sophisticated reader and I don’t find that ridiculous. At least the initial adoption was probably heavily influenced by other experiences with modern or Western science. I bet Western, or modern, medicine was being practiced in China and elsewhere before they were widely understood at least partly based on reputation.

    On the other hand, I don’t find it plausible that Chinese and Japanese scientists continue to adhere to scientific methods largely developed or popularized in the West simply because of unrelated scientific developments. The scientific method(s) should speak for themselves when applied independently, right?

  39. I bet Western, or modern, medicine was being practiced in China and elsewhere before they were widely understood at least partly based on reputation.

    (Sorry, I just noticed this comment now). PJLandis, I suspect that I didn’t make myself entirely clear. The key word in Kaptchuk’s sentence is “prestige.” In the (extreme) postmodern view, no “way of knowing” is better, in an objectively demonstrable way, than any other; thus whichever “system” of medicine might be “privileged” is done so only because the “dominant” class so chooses, based on strategies to maintain its dominance. You suggest, if I read correctly, that China may have first sought science-based medicine because of the rapidly spreading reputation of science to make accurate predictions about nature in general, and to lead to useful technology.

    I agree with you that this is not a ridiculous historical theme, but I don’t think that this is what Kaptchuk was arguing. By “prestige,” Kaptchuk was implying not that Asian and African countries sought ‘biomedicine’ because science had a reputation for working (“not because of medical outcomes”), but because science had a reputation for being favored by rich, powerful, Western fat-cats. There were, after all, “medical outcomes” in the 19th century that were well known to the Chinese, such as those due to small pox vaccinations, surgery, asepsis and antisepsis, anesthesia, and anti-serum for some toxins and infections. I believe, and I think you do too, that it was those sorts of things, and other useful manifestations of science and technology, that drew the Chinese to modern medicine and to science in general. This is quite different, I believe, from the “prestige” that Kaptchuk cited.

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