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Dummy Medicines, Dummy Doctors, and a Dummy Degree, Part 1: a Curious Editorial Choice for the New England Journal of Medicine

Background

This post concerns the recent article in the New England Journal of Medicine (NEJM) titled “Active Albuterol or Placebo, Sham Acupuncture, or No Intervention in Asthma.” It was ably reviewed by Dr. Gorski on Monday, so I will merely summarize its findings: of the three interventions used—inhaled albuterol (a bronchodilator), a placebo inhaler designed to mimic albuterol, or ‘sham acupuncture’—only albuterol resulted in a clinically important improvement of bronchial airflow; for that outcome the two sham treatments were equivalent to “no intervention.” For all three interventions, however, self-reported improvements were substantial and were much greater than self-reported improvements after “no intervention.” In other words, dummy treatments made the subjects (report that they) feel better, whereas real medicine not only made them feel better but actually made them better.

Before proceeding, let me offer a couple of caveats. First, the word ”doctors” in the flippant title of this post refers mainly to two individuals: Daniel Moerman, PhD, the anthropologist who wrote the accompanying editorial, and Ted Kaptchuk, the Senior Author of the trial report. It does not refer to any of the other authors of the report. Second, I have no quarrel with the trial itself, which was quite good, or with the NEJM having published it, or even with most of the language in the article, save for the “spin” that Dr. Gorski has already discussed.

My quarrels are the same as those expressed by Drs. Gorski and Novella, and by all of us on the Placebo Panel at TAM. This post and the next will develop some of those points by considering the roles and opinions of Moerman and Kaptchuk, respectively.

A True Story

Late one night during the 1960s a friend and I, already in a cannabis-induced fog, wandered into a house that had been rented by one of his friends. There were about 8-10 ‘freaks’ there (the term was laudatory at the time); I didn’t know any of them. The air was thick with smoke of at least two varieties. After an uncertain interval I became aware of a guy who was having trouble breathing. He was sitting bolt upright in a chair, his hands on his knees, his mouth open, making wheezing sounds. He took short noisy breaths in, followed by what seemed to be very long breaths out, as though he was breathing through a straw. You could hear the wheezing in both directions. Others had also noticed that he was in distress; they tried to be helpful (“hey, man, ya want some water or somethin’?”), but he just shook his head. He couldn’t talk. My friend, who had asthma himself, announced that this guy was having an asthma attack and asked if he or anyone else had any asthma medicine. No one did.

No one had a car, either, and for obvious reasons no one, not even the wheezing guy himself, was about to call 911. The nearest hospital was about 5 miles away. My friend said that the thing to do when someone has an asthma attack is leave him alone so he won’t get too excited, and he’ll get through it. Yeah, that must be right, we all figured; he has asthma too so he knows. We were all blowing smoke into the wheezing guy’s face as we expressed our concern.

At some point my friend and I left. The next day I heard that the guy with the asthma attack was eventually taken to the ER after another freak had come along who happened to have a car. The guy did all right, I guess. I don’t really know, but if he’d died I probably would’ve heard about it.

Several years later I went to medical school and began to learn about asthma, and as an internal medicine resident I saw enough patients with acute asthma attacks to realize, in a way that still makes me cringe, just how sick that guy had been and how totally clueless and selfish were we, his supposedly concerned companions. If the freak with the car hadn’t shown up…

Cultural Anthropology and Cultural Relativism

All of which has something to do with the surprise I felt a few days ago upon reading the following in the aforementioned editorial in the NEJM, the world’s most prestigious medical journal:

For subjective and functional conditions — for example, migraine, schizophrenia, back pain, depression, asthma, post-traumatic stress disorder, neurologic disorders such as Parkinson’s disease, inflammatory bowel disease and many other autoimmune disorders, any condition defined by symptoms, and anything idiopathic — a patient-centered approach requires that patient-preferred outcomes trump the judgment of the physician. Under these conditions, inert pills can be as useful as “real” ones…

Let’s see: asthma is a “subjective and functional condition”? In the bad old days of paternalistic medicine, the term “functional” meant “without demonstrable pathology.” It was usually synonymous with ”in your head”—whether the physician openly expressed that opinion or not. Doesn’t sound very “patient-centered” to me. I’m happy to report that you hardly ever hear ”functional” anymore, which reflects at least some measure of social progress for the profession. Since the term’s other possible meanings are nearly limitless and therefore vague beyond utility—every complaint or medical condition is in some way “functional,” after all—it seems reasonable to assume that the editorial’s author intended the old meaning, even if it and “subjective” are redundant.

Yet asthma is based in demonstrable pathology, as are most of the other named conditions, and in most of those (migraines, Parkinson’s disease, inflammatory bowel disease, and “many other autoimmune disorders”) there are specific treatments based on pathophysiology that, like albuterol for asthma, effect substantial, objective and subjective improvements. ”Idiopathic” refers to any condition whose cause is unknown, which includes most of those already mentioned and many other diseases for which medicines are effective for both objective and subjective outcomes (diabetes, Grave’s disease), and even some that are, for practical purposes, curable: Hodgkin’s disease, acute lymphocytic leukemia in children, some testicular cancers (remember Lance?), temporal arteritis, pernicious anemia, and many more. How could the author of a NEJM editorial be unaware of such commonplace medical facts?

The answer is that the author, Daniel Moerman, is not a doctor or even a biomedical scientist. He’s an anthropologist who seems to have confused sentimental and poetic aspects of his major academic interests—native American culture, medicinal plants, and healing rituals—with modern science and medicine. I urge you to consider his CV and the excerpts from his book Medicine, Meaning and the “Placebo Effect,” discussed by Dr. Gorski a few days ago. In the very first chapter he betrays more ignorance of medicine when he expresses surprise that a gastroenterologist didn’t find it odd that in a cohort of experimental subjects given only placebos for peptic ulcer disease, nearly half demonstrated healed ulcers after 4 weeks—about the percentage, I’d wager, whose ulcers would have healed with no trial intervention.

Regarding Prof. Moerman’s view of the sort of science that physicians need to know, along with Dr. Gorski I detect shades of Deepak Chopra, although I also detect a bit of down-home, folksy, isn’t-he-wise midwestern ambiguity, possibly delivered in a Mr. Ed voice, such as to give the good professor a way to deny it all. Consider this excerpt from the NEJM editorial, also noted by Dr. Gorski:

What do we learn from this study? The authors conclude that the patient reports were “unreliable,” since they reported improvement when there was none — that is, the subjective experiences were simply wrong because they ignored the objective facts as measured by FEV1. But is this the right interpretation? It is the subjective symptoms that brought these patients to medical care in the first place. They came because they were wheezing and felt suffocated, not because they had a reduced FEV1. The fact that they felt improved even when their FEV1 had not increased begs the question, What is the more important outcome in medicine: the objective or the subjective, the doctor’s or the patient’s perception? This distinction is important, since it should direct us as to when patient-centered versus doctor-directed care should take place.

Does he really believe that the subjective is the more important outcome? It certainly seems so; next he writes:

In a number of other trials in which both sham and actual treatments were evaluated, results were very similar. In one study of major depressive disorder, placebo, hypericum (St. John’s wort), and sertraline all resulted in about the same level of improvement on the Hamilton Rating Scale for Depression. Similarly, in studies of low back pain in both the United States and Germany, true acupuncture and sham acupuncture had about the same effectiveness yet were substantially better than usual medical care in relieving the pain. A number of surgical procedures — such as arthroscopic knee surgery and spinal vertebroplasty — have led to similar results with actual and sham treatments. In these studies and many more, inert treatments have had effects similar to their “active” analogues.

Woah! Sure, the subjective results of those trials “were very similar” to those of the albuterol trial, but so what? What distinguishes those trials from the albuterol trial is that there were no objective outcomes to measure! Moerman has missed the point of the distinction. He seems to prefer that medicine be about “a profound meaning response,” as he explained in an article written jointly with homeopath Wayne Jonas a few years ago, which comes awfully close to asserting that all “healing” is culturally determined:

Anthropologists understand cultures as complex webs of meaning, rich skeins of connected understandings, metaphors, and signs. Insofar as 1) meaning has biological consequence and 2) meanings vary across cultures, we can anticipate that biology will differ in different places, not because of genetics but because of these entangled ideas…

In the NEJM editorial Prof. Moerman doesn’t seem bothered by an inconvenient truth about objective outcomes. That is, maybe he doesn’t:

Maybe it is sufficient simply to show that a treatment yields significant improvement for the patients, has reasonable cost, and has no negative effects over the short or long term. This is, after all, the first tenet of medicine: “Do no harm.”

Prof. Moerman, what about the harm that comes from the NEJM seeming to judge treatments that offer favorable subjective outcomes as being equivalent to those that offer favorable objective outcomes? This kind of harm, for example. Asthma isn’t just a “subjective and functional condition,” whatever that is. It’s a real and potentially lethal disease. Oh, but you wrote “maybe.” Silly me.

Dr. Drazen, Where art Thou?

It is especially puzzling, considering the identity of its Editor-in-Chief, that the New England Journal of Medicine asked Daniel Moerman to write the editorial to accompany the report of the albuterol study. Jeffrey Drazen is not only a pulmonologist, but an expert in the pathophysiology of asthma. He has been instrumental in developing new drugs for asthma, drugs whose effects—I’m willing to bet, but I’ve no time to research right now—have been demonstrated objectively. If memory serves, Dr. Drazen trained at the old Peter Bent Brigham Hospital under ‘Reggie’ McFadden, whose chapter on asthma in my 2001 edition of Harrison’s Principles of Internal Medicine includes this passage:

The most effective treatment for acute episodes of asthma requires a systematic approach based on the aggressive use of sympathomimetic agents and serial monitoring of key indices of improvement. Reliance on empiricism and subjective assessment is no longer acceptable.

I’d be surprised if Dr. Drazen had ever heard of Moerman before the albuterol report was accepted for publication, and I wonder who recommended him. Kaptchuk, perhaps? Heh.

Unfortunately, someone isn’t minding the NEJM store when it comes to certain dubious topics, as Dr. Gorski mentioned and as I’ve written about previously.

Good News, Bad News

Perhaps Dr. Drazen imagines that the editorial won’t do any real damage, because real doctors will immediately identify it for what it is: Bullshit. That is probably true, except for the small but possibly growing number of “integrative” aficianados out there. I worry more about other Dummy Docs, such as naturopaths (ND=Not a Doctor, according to one apostate), who already believe wholeheartedly what Prof. Moerman “maybe” believes, and a lot more:

For an acute asthma attack try a steam inhalation (draping a towel over your head and a bowl of hot water) with a few drops of eucalyptus oil in the water. Be careful that the water is not so hot that the steam burns your face.  Some doctors recommend taking baths with a cup or so of 3% hydrogen peroxide in the water to bring extra oxygen to the entire surface of the skin, thus making the lungs somewhat less oxygen hungry. This method  can be performed preventively. Another technique for an acute attack is to drink some hot water with the juice of one clove of garlic. [etc.]

And:

How Can Homeopathy Help Asthma?
Like with Traditional Chinese Medicine, each individual is analyzed for their specific symptoms and an appropriate  therapy is chosen, not for the disease, but for the person displaying signs of health out of balance.  This is a very  important distinction, and, very generally speaking, one of the main differences between conventional and  “complementary” approaches to health care.

After the homeopath, naturopath or medical doctor trained in homeopathy (they should have the title “Diplomat  of Homeopathy” after their other credentials) listen carefully to your story, one of the following remedies are likely to  be prescribed. [etc.]

What Kind of Subtle Energy Techniques Are Useful for Asthma?
Some folks like to work with flower essences.  Some of the more popular ones to help with asthma are:

  • oak
  • mimulus
  • larch
  • wild rose
  • hornbeam
  • crab apple
  • impatiens
  • gentian
  • Shasta daisy
  • blackberry
  • chamomile
  • agrimony
  • clematis

Other people find it useful to work with color, either by using thin plastic filters over light sources in their home or office environment, or by wearing clothes of specific colors.  The following serves as a guide to experiment with color therapy to help asthma.

During an asthma attack try:

  • purple (raises the threshold of pain and is soporific; is a vasodilator; slows heart rate) on face, throat and chest
  • scarlet (acts as a stimulant to the kidney and adrenals) on kidneys
  • orange (an antispasmodic) on throat and chest
  • indigo or violet on throat, chest and upper back for 15 minutes

Etc., ad nauseam. Boy, do Dummy Docs love it when their pet treatments seem to be endorsed by real medicine, especially the highest bastions of real medicine. Science, even! Is it any surprise when something like this happens? Josephine Briggs, are you reading this? If so, please look here for more discussion of that case. You also won’t want to miss the sequels to this post.

 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, Cancer, Clinical Trials, Energy Medicine, Faith Healing & Spirituality, Health Fraud, Homeopathy, Medical Academia, Medical Ethics, Naturopathy, Pharmaceuticals, Public Health, Science and Medicine, Science and the Media

Leave a Comment (53) ↓

53 thoughts on “Dummy Medicines, Dummy Doctors, and a Dummy Degree, Part 1: a Curious Editorial Choice for the New England Journal of Medicine

  1. nybgrus says:

    As I had commented over at Dr. Gorski’s post on the topic, medical anthropology is as pseudoscientific, ideologically driven, and culturally relative as just about anything else out there. I should know. I have high honors in an undergraduate degree in it. In fact, I got two A+’s in my anthro degree.

    What Moerman says does not surprise me in the slightest. It was literally screamed at me on a few occasions that medicine is a “culture bound system” and that no objective measure can be standardized – each will necessarily vary by culture. I was also informed that western reductionist scientists were evil and trying to quash “true healing” and spread dogma.

    It really isn’t surprising to me that this sort of garbage is working its way into medical schools and prestigious clinics and journals; my professors in medical anthropology were all pretty darn rabid and livid and had a very robust activist agenda.

    It isn’t surprising, but it is dangerous and does need to be stopped.

  2. qetzal says:

    Prof. Moerman claims,

    It is the subjective symptoms that brought these patients to medical care in the first place. They came because they were wheezing and felt suffocated, not because they had a reduced FEV1.

    No, what brought them in was that they had a scheduled trial visit. None of the patients in this trial were being treated because of either subjective or objective symptoms.

    Interpreting the subjective improvement is especially problematic here. These patients were told to stop using their drugs before each visit. That could easily have induced a nocebo response. “I take drugs to help with my asthma and feel better. I’ve stopped taking my drugs so I should feel worse.” The subjective response to the placebo treatments could merely have been elimination of that nocebo response.

  3. ConspicuousCarl says:

    Moerman/Jonas said:
    “Anthropologists understand cultures as complex webs of meaning, rich skeins of connected understandings, metaphors, and signs. Insofar as 1) meaning has biological consequence and 2) meanings vary across cultures, we can anticipate that biology will differ in different places, not because of genetics but because of these entangled ideas…”

    I didn’t realize that the development of Post-Modern Medicine was coming along so well. I guess Columbia will be offering doctorates any day now.

    Some other quack said:
    “(they should have the title “Diplomat of Homeopathy” after their other credentials)”

    Yes, you don’t want to end up with a bad homeopath!

    I am once again reminded of the joke about the zoophiles in the desert who don’t want to get stuck with an ugly camel (that being the punchline after T. E. Lawrence asks his second-in-command why there should be such bickering among the horny troops when there were apparently plenty of camels to go around).

  4. daedalus2u says:

    I think qetzal has the correct intrpretation for the seemingly equivalent subjective responses. There was a nocebo effect from not taking normal asthma meds.

  5. nybgrus says:

    I agree, very valid and interesting point qetzal

  6. qetzal says:

    Unfortunately, I don’t have full text access to this paper, nor do I know that much about asthma. What were the subjects’ conditions immediately before each treatment?. Based on FEV1 or other objective values, was their breathing impairment sufficient to be clinically relevant?

    I’d also like to know more about the subjective measurement. What exactly were subjects asked to rate on the visual analog scale? Were they specifically asked about their asthma symptoms? Or were they simply asked how much better they felt in general? The latter would make their subjective reports even less useful, since they could easily include feeling better because the visit was nearly over, they could resume their normal routines (at least until 48hrs before the next visit), etc.

    Also, did they only rate their perceived improvement after treatment, or did they score how they felt before and after? The wording of Figure 4 (as depicted in Dr. Gorski’s post) isn’t exactly clear, but Dr. Gorski describes the scale as ranging from 0 = no improvement to 10 = complete resolution. If so, their own rating scale was telling the subjects to expect improvement. Seems to me that would tend to maximize any placebo effects.

  7. “In other words, dummy treatments made the subjects feel better, whereas real medicine not only made them feel better but actually made them better.”

    I’ll go a little further and be more qualified than that. Dummy treatments resulted in a subjective assessment that the patients thought that they felt better. But this really begs the question of whether there isn’t a difference between the subjective assessment that the patient thinks that they feel better, and a patient actually feeling better.

    First of all there are biases and confounders in that subjective assessment that are external to the patient. Study design, methodology, statistical analysis methods, researcher bias, etc are all external to the subject, but they can affect the subjective conclusion arrived at both by the subject and by the researchers.

    Setting the external factors aside and also hypothesizing a perfectly blinded study, the question still remains, is there a difference between a patient’s subjective conclusion that they feel better and them actually feeling better?

    Have you ever answered any question differently from what you actually felt because you felt (unconscious) pressure to provide a certain answer? The old line “Now that didn’t really hurt, did it?” from a doctor after a shot comes to mind. The most accurate answer usually might be, “Yes it did hurt, but it wasn’t that bad compared to other painful experiences, and it didn’t last very long.”, but often the response is ,”No.” Does the answer of no to that question qualify as a subjective conclusion of zero pain? If with asthma or joint/muscle pain the subjective assessment of the patient is that they feel better, but their objective symptoms are not improved (FEV1 results or range of motion, etc), is that a satisfactory outcome?

    Is the goal to help make people feel better or to help make them think that they feel better, and is there a qualitative difference between the two?

    I really don’t understand the point of doing a study like this one unless the point is to demonstrate that subjective assessment is not always a good indicator of clinical effectiveness of a treatment. As designed, but with a different author/conclusion, this would be an excellent study AGAINST the use of placebos/CAM.

  8. …an excellent study, aside from the ethical and medical concerns of treating a serious condition like asthma with an inert control, that is.

  9. Jacob V says:

    Great article Dr Atwood. And apparently cigars and lemoncello wouldn’t have helped the asthmatic freak either. ;-)

  10. Mark says:

    From your post:
    “That is probably true, except for the small but possibly growing number of “integrative” aficianados out there.”

    Sad but true. Interesting timing as I just saw a posting on a listserve for internal medicine program directors asking about curriculum content for CAM rotations for IM residents. The tendrils have definitely infiltrated academic medicine. I wonder how many IM programs out there are offering such electives, and whether any professional societies have any statements about teaching methods with no scientific validity to physicians in training.

    On a positive note – this study can be put to alternate uses – I used it this week to highlight for my residents the pitfalls of poorly controlled studies that use non-objective outcomes as their “evidence.” Properly interpretedm it could serve as a warning about how to properly scrutinize CAM evidence in general.

  11. ceekay says:

    I get why you don’t like Moerman…. What’s your beef with Kaptchuk… This study lines up with what skeptics have said for years… As do most of his placebo studies….

    What’s the problem?

  12. geack says:

    So, per Moerman, it’s less important to cure the patient than to make the patient believe he has been cured? Can’t wait until that particular overextended academic theory runs into the real world. “No, Your Honor, I didn’t actually reattach that tendon. See, there was a study in Germany that showed sham arthroscopic surgery makes people feel just as good as actually fixing the damage…”

  13. pmoran says:

    I am uncomfortable with some of the commentary on this, regardless of its seeming popularity.

    Everyone seem to be alleging that, even after presenting data that clearly shows the superiority of albuterol over acknowledged placebo-type interventions, these authors are still trying to claim some kind of equivalence.

    That is inherently unlikely in the context, and it is not entirely necessitated by my reading of the quotations. They are compatible with it being taken as read that active therapeutic agents are usually the best option, while observing that under some conditions just about any kind of well-intended medical attention can perform remarkably well subjectively, possibly sometimes as well as or better than some pharmaceuticals if the potential for ill effects is taken into account.

    No good data has been presented to counter that fairly soundly evidence-based suggestion.

  14. Harriet Hall says:

    @pmoran,

    Did you miss the fact that subjective improvement may endanger lives when there is no objective improvement?

  15. hardindr says:

    Just to repeat what I wrote in a comment in another earlier post:

    I’ve read Dr. Moerman’s book on the placebo effect, and I can say that I don’t believe there is any “woo” in it. I was first made aware of it by Ben Goldacre, who cited it in his book “Bad Science,” where he recommended it highly. Not sure I see anything particularly objectionable in his editorial or his other comments quoted, either.

    I am a bit disturbed that Dr. Moerman would author a paper with a homeopath, but looking through it, I don’t see much to object to either.

  16. hardindr says:

    I apologize if this seems like I am spamming, but Moerman was interviewed on a podcast shortly after his editorial came out, and he further explains his thoughts on the placebo effect.

    http://podcasts.jwatch.org/index.php/podcast-126-placebos-and-medical-meaning/2011/07/16/

    (Note: I do not necessarily endorse all of his ideas.)

  17. Badly Shaved Monkey says:

    @Karl Withakay

    But this really begs the question of whether there isn’t a difference between the subjective assessment that the patient thinks that they feel better, and a patient actually feeling better.

    I’d like to take that a little further.

    Proponents of non-medicine are keen to criticise randomised controlled trials for being an artificial context in which to demonstrate the effectiveness of their magic. This is usually claimed after yet another RCT shows their woo to be equivalent to placebo.

    Ironically, on this occasion, the authors and editorial writer appear to require that the subjective reporting of improvement in the artificial construct of the RCT be identical with any subjective improvement that would occur outside the context of a trial. They have done this to co-opt the placebo effect to the benefit of sham therapies. In reality, the reported subjective improvement is most likely to represent the maximum subjective response that could exist. The patients’ self-assessments were reported in a context where the experimenters had optimised circumstances to enhance the reporting of benefit. I carefully use the phrase “reporting of benefit” rather than “perceiving of benefit” to allow for the potential that even in this artificial construct, as Karl Withakay suggests, patients report benefit that they do not really feel even though the environment had been optimised to create a subjective benefit.

    What would a “real” subjective response be? It would be the one that occurs when the victim does no know they are being filmed for Candid Camera. We have no idea what the size of that response would be. It would need a trial that compared subjects who knew they were enrolled in a trial and those who did not and it would require some subtle way of assessing a subjective response that can be measured without letting the “non-enrolled” subjects in on the joke.

    In the real world, patients often seem to migrate from one woo-meister to another. My guess is that, once out of the immediate vicinity of the therapist, hard, objective reality bears down again on the patient and the magic wears off, they find they have been clad in the emperor’s new clothes. The corollary of this is what we do observe- the darwinianly successful SCAMster is the one who keeps he patient coming back frequently to have their “treatment” tuned up. What must not be allowed to happen is for the patient to be left alone with their problem. If the therapist is really successful he or she can control the message so tightly that he/she can engineer the death of the patient (Cf Penelope Dingle)

  18. Badly Shaved Monkey says:

    Oops, thought I’d been careful with my proof-reading, and I’m sure my intention can be readily inferred, but when I wrote;

    Ironically, on this occasion, the authors and editorial writer appear to require that the subjective reporting of improvement in the artificial construct of the RCT be identical with any subjective improvement that would occur outside the context of a trial.

    I meant;

    Ironically, on this occasion, the authors and editorial writer appear to require that the reporting of subjective improvement in the artificial construct of the RCT be identical with any subjective improvement that would occur outside the context of a trial.

  19. nybgrus says:

    I commented on the podcast over here.

  20. nybgrus says:

    A very good point, BSM. I think that it is yet another example of shifting goalposts. No matter what the outcome, no matter what the criticism, no matter what the data shows they want their CAM so no matter what sort of gymnastics need be done, they will be in order to preserve the forgone conclusion. Not to mention the jobs of these medical anthropologists. Moerman has no real skills and needs to sell books and convince people they should learn what he teaches. That is a powerful impetus for motivated reasoning and “just so” stories.

    @pmoran: You are right – Moerman is not trying to claim equivalence. He is trying to claim superiority. Somewhat implicitly in his editorial commentary in the NEJM and outright says it in the podcast. You reading of the comments is clearly “motivated.” It would be that “They are compatible with it being taken as read that active therapeutic agents are usually the best option, while observing that under some conditions just about any kind of well-intended medical attention can perform remarkably well subjectively, possibly sometimes as well as or better than some pharmaceuticals if the potential for ill effects is taken into account.” Except that is clearly not the intent nor tone of the authors.

    Trying to claim otherwise shows a blind reading on pure face value without any other thought to why Moerman might be saying what he is and giving him a very hefty benefit of the doubt. Read my comment over at Dr. Gorski’s post on it, and (as Dr. Hall pointed out) weigh in on the concept of the silent infarct.

  21. Tell it like it is says:

    THE PHILOSOPHY OF SCIENCE?

    My strap-line is a question. Even for a professional in any specific scientific or medical field this question seems to be a difficult one to answer.

    As I see it, THE PHILOSOPHY OF SCIENCE aims at yielding knowledge which can be put to good use for the betterment of all – the planet – and all life upon it.

    How we go about this largely comprises ‘propositions’ which authors, and hence practitioners, presenters, and other ‘proponents’ wish us to accept as true; so one could say that the ‘theory of science’ is (or should be) primarily an exercise in ‘scepticism’.

    For the most part these ‘truths’ are defined as ‘laws’ that best-fit reality, but the real crux is to ask “Upon what basis can there be for these rules – and how do they aid us in our advancement?”

    As we see scientific theory after scientific theory tumble, we realise, accept, and appreciate that REALITY IS VEILED FROM US; and for the most part, we do not know what we ‘think’ we know.

    Statistics is nothing more than juggling with collected (historical) data and fails us miserably. Bayesian ‘Probability theory’ is the best we have – and we can’t even get the weather forecast right – let alone predict an earthquake or a tsunami that trashed Japan and stole thirty thousand souls off the planet.

    And so: having read and re-read the article and the comments with considerable interest, I wish to encourage everyone reading this and all other blogs – both preceding and proceeding this one – to examine what we mean by ‘UNTRUTHS’.

    As I see it, we can represent the world with four ‘untruths’, as follows:

    1 LIES
    2 BE (Bovine Excrement – or in Devon and Cornwall – HS (Horse Shi (oops) manure)
    3 DELUSION
    4 ACCEPTANCE

    LIES

    These are the ‘double whammies’. When you tell a lie you are attempting to deceive your audience with TWO false beliefs – not just one. For example, let’s say I am cheating on my husband and he asks me “Are you cheating on me?” and I answer “No”, then the situation is 1) I am deceiving him (I ‘am’ having an affair) and 2) he ‘believes’ me – he is ‘twice deceived’ – a double whammy.

    But here is the interesting thing – in order for ALL lies to work, the liar cannot ignore the ‘facts’ because the liar’s goal is to MISLEAD you about the TRUTH.

    BE

    The liar and the truth-teller have something in common – they both care about what the truth is. The bullsh!tter on the other hand, ignores FACTS and makes stuff up.

    The statistical ‘Null Hypothesis’ test used in statistics unfailingly commits ‘alpha errors’ (false positives) – the worst of the errors – so the technique is a pile of BE.
    Deliberately moving the ‘trip-point’ on a statistical ‘null-hypothesis’ scale so that the data ‘fits’ better is BE – all this does is prove the technique is seriously flawed and cannot be TRUSTED.

    Giving a placebo is BS – it serves no purpose. The treatment either ‘works’ or it doesn’t.
    Telling someone they are suffering ‘side effects’ from a medicine that is NOT addressing the problem is BS.

    Giving someone a medicine that the bullsh!tter knows is going to cause harm (the ‘side effects’ which are DELIBERATELY built-in to the concoction) is a CRIMINAL LIE!

    But here is the interesting thing – because the bullsh!tter ignores facts and makes false claims – they ‘might’ actually tell you something which is TRUE.

    DELUSION

    Delusion is more complex than lying. Here you have a ‘double deception’ – one to YOURSELF and one to your OPPONENT. In other words, you are fooling ‘yourself’ in order to fool your ‘opponent’.

    If you are applying delusion in anything other than the entertainment industry – you are a CON ARTIST and you are wasting yours and your ‘marks’ TIME on the planet. QUACK QUACK QUACK QUACK QUACK.

    Magicians delude – for entertainment! The story is engrossing and creates intrigue and the spiritual atmosphere is as tense as the ‘hot better’ at the roulette table. The ‘wow’ factor happens and everyone spontaneously applauds; and then? – the SCEPTISISM kicks in with either: the question of curiosity: “How did she do that?”; or the DELUSIONAL “I know how that is done!” when the person ‘making’ the CLAIM has NOT got a VIABLE method.

    Deliberately moving the ‘trip-point’ on a statistical ‘null-hypothesis’ scale so that the data ‘fits’ a ‘theoretical expectancy’ is DELUSIONAL. What we expect (would like to happen) and what takes place in reality is mutually exclusive.

    Deliberately adding 1.5 to a statistical ‘sigma calculation’ so that the QUALITY ‘looks’ better is DELUSIONAL – 4.5 sigma (3.4 errors per million opportunities) is NOT ‘six sigma’ – but people are deluded into believing that it is.

    Bluffing requires a very disciplined mind. Get it wrong (i.e. fail to deceive) and the bluffer will suffer HUGE losses – ask a poker player.

    Get it right (i.e. deliberately deceive) and BOTH parties will suffer HUGE losses.

    Sadly, there is plenty of evidence in these blogs that support this – both in terms of the ‘con artists’ and contributors who spew black bile, and the brave ‘marks’ who, under the thin blanket of anonymity, have the courage and decency to write about their traumatic experiences.

    ACCEPTANCE

    This is a weird one. The best way to understand ‘acceptance’ is to see how it differs from ‘belief’. When you ‘believe’ something you ‘feel’ that it is true. Because a belief is like an ‘emotional’ feeling, and so is very emotive, you cannot really ‘control’ what you believe – ask a Catholic or a Muslim.

    Acceptance is different. Acceptance is ‘accepting’ something is true – even though you ‘believe’ otherwise. The best place to see this is in the law courts, in novels, and in the performing arts.

    In the law courts a defence lawyer defending a murderer must ‘accept’ that they are there to show ‘innocence’ – and defend accordingly – ask O J Simpson.

    In novels, and in the performing arts, the entertainer is asking their audience to ‘suspend disbelief’.

    When Daniel Craig played ‘James Bond’ in the film ‘Casino Royalle’ he was playing a ‘fictional’ character; but Daniel Craig probably didn’t believe he was James Bond – LICENSED TO KILL. So why are there CHARLETON ASSASINS out there who BELIEVE they are LICENSED TO KILL?

    Here is the interesting thing – in order for ALL lies to work, the victim has to ‘believe’ the lie.

    And now: – show your love as I give you – The ‘General Custer’ puzzle.

    A man is in a dangerous country and he arrives at the entrance point of two ‘gulches’.

    Down one of the gulches the enemy await – bows and arrows, fire, and tomahawks at the ready.

    Down the other gulch is a clear path that, if taken, Custer’s men can emerge from the other side of this gulch, and enter the other gulch from the other end so as to form a ‘pincer attack’ from two fronts to defeat their foe.

    At the junction sit two Indians. One will ALWAYS LIE. The other will ALWAYS TELL THE TRUTH * see footnote

    The General is aware of this situation. He does not know who will speak false; and he does not know who will speak true. All he knows is that he may only ask ONE Indian ONE question to establish which gulch to take.

    What is the question General Custer must ask to determine the CORRECT gulch in which to lead his men?

    This question is ONE of the questions that reveal LIARS and CHEATS. Custer failed to ask it – and it cost him and his company dearly. Can you?

    You might wish to check out ‘An essay on belief and acceptance’ by Jonathon Cohen

    * The civilian Indian agents on the reservations didn’t inform the Army that large numbers of Indians had left and so Custer unknowingly faced thousands of Indians when he and his men entered the gulch. There is a delicate balance between nobility and brutality throughout ‘The battle of the Little Bighorn’ (AKA Custer’s last stand).

  22. daedalus2u says:

    I finally got around to a more careful reading the editorial and Moerman’s completely nonsensical article on “meaning”. Moerman complains that medicine has stripped the “meaning” out.

    “Moreover, as we have clarified, routinized, and rationalized our medicine, thereby relying on the salicylates and forgetting about the more meaningful birches, willows, and wintergreen from which they came—in essence, stripping away Plato’s “charms”—we have impoverished the meaning of our medicine to a degree that it simply doesn’t work as well as it might any more. Interesting ideas such as this are impossible to entertain when we discuss placebos; they spring readily to mind when we talk about meaning.”

    No, what medicine has begun to do is strip the bogus teleological magical thinking out. That is a good thing. If Moerman wants to call his personal idiosyncratic teleological magical thinking “meaning”, I suppose he is entitled to. I prefer to call it what it really is, idiosyncratic teleological magical thinking.

    I don’t find meaning in tree bark If Moerman needs to look to tree bark to find meaning in his life, I don’t really know what to say to him. I find meaning when data and facts are incorporated into a scientific schema where everything logically fits together with everything else, the way that Science does. When things don’t fit together is the only you know that your thinking is incomplete or faulty or both. Facts and data have to fit together with logic, or something is wrong or you are ignorant of how they do fit together. It is much better to be ignorant than wrong.

    It is a good thing he is not a “real” doctor trying to impose his magical thinking on any vulnerable patients. It is shameful that the NEJM allowed him to post that editorial.

    Stripping out what is wrong is the first step in replacing erroneous ideas with correct ideas. Moerman wants to maintain, increase and indefinitely perpetuate the wrong ideas of pre-scientific “healers”, witch doctors, barbers, acupuncturists, homeopaths and prescribers of bark and leaves. I am sure that when blood letting was abandoned a whole lot of “meaning” (as Moerman conceives of it) was lost. Adding nonsense back in does not increase “meaning” it increases noise and decreases the signal to noise ratio. It is unfortunate that some people (such as Moerman) are trapped in a pre-scientific mindset.

    If you want and need this kind of mumbo-jumbo, call it what it is, it is performance art, not medicine.

  23. daedalus2u says:

    qetzal They specifically state that they did not do a subjective assessment of how the patients were feeling before they did the intervention at each test.

    “Finally, we did not assess subjective symptoms before each visit’s intervention; therefore, the severity of subjective symptoms before each treatment remains unclear. Assessing subjective measurements before and after interventions could have yielded other differences.”

    Which makes Moerman’s statement that:

    “It is the subjective symptoms that brought these patients to medical care in the first place. They came because they were wheezing and felt suffocated, not because they had a reduced FEV1. The fact that they felt improved even when their FEV1 had not increased begs the question, What is the more important outcome in medicine: the objective or the subjective, the doctor’s or the patient’s perception? This distinction is important, since it should direct us as to when patient-centered versus doctor-directed care should take place.”

    even more disingenuous, and dangerous.

  24. “For an acute asthma attack try a steam inhalation (draping a towel over your head and a bowl of hot water) with a few drops of eucalyptus oil in the water…”

    So, when I’m hiking above 10,000 feet, I won’t have hauled extra water for steaming my face. Trees are scarce. I will have emergency matches, but not a camp stove on a day hike. Nor a pan. Especially not a towel. No eucalyptus oil either. Not where I hike anyway. I guess I’ll just continue to use Xopenex.

    One thing about post-modernism in Anthro. I think part of what is going on with the worship of cultural relativism is a backlash against the embarrassing history in early Anthropology of social darwinism and the concept of the noble savage. Everyone is afraid of being or being perceived as ethnocentric so they take it to the other extreme, ignoring reality somewhere in between.

  25. ““For an acute asthma attack try a steam inhalation (draping a towel over your head and a bowl of hot water) with a few drops of eucalyptus oil in the water…”

    They are right, of course, if I want to have an acute asthma attack, A steam inhalation of any strong oder is one of the best ways to trigger one, almost as effective as visiting a smokey bar.

    Did thet think to check out common asthma triggers?

  26. qetzal says:

    deadalus2u,

    Thanks for confirming that.

    The more I think about this study, the less impressed I am with its design. It’s superficially interesting that the patients reported subjective improvements after placebo, but there’s no data to suggest it’s relevant! Even if you accept Moerman’s claim that subjective responses are as or more important, this is still a pretty worthless study, because there’s no evidence that the subjective response was in any way meaningful or relevant to the patients’ disease.

    Newsflash! People can be misled into changing a number on an arbitrary scale!

  27. daedalus2u says:

    I think that by using the peak FEV1 result taken multiple times over 2 hours as the therapeutic result, they introduced a lot of bias into the results such as they are favoring the non-drug interventions due to variability in measurements.

    I don’t think the study is of any value.

    They used an unvalidated subjective test with no baseline as their main data source.

    If you know anything about asthma, the real problem in mild asthma is that long term it gets worse and causes lung damage due to the chronic inflammation. That is why people need to be treated for mild asthma, not because they can’t breathe but because if they are not treated their mild asthma will get worse and damage their lungs and shorten their life.

    Of course Moerman doesn’t know this because he is not a real doctor. I am not a real doctor either (or even a fake one ;) ) but these things are not hard to find out.

  28. pmoran says:

    In reality, the reported subjective improvement is most likely to represent the maximum subjective response that could exist.

    I agree that the unknown contribution from reporting biases biases is a significant problem for placebo influences, but disagree with what you seem to be saying here.

    Any study where the subjects are informed that they may be given an inert treatment will suppress placebo influences relative to what is possible “in the wild”. It also tells us nothng about what might be possible with a particularly charismatic healer.

  29. pmoran says:

    -
    BSM:What would a “real” subjective response be? It would be the one that occurs when the victim does no know they are being filmed for Candid Camera. We have no idea what the size of that response would be. It would need a trial that compared subjects who knew they were enrolled in a trial and those who did not and it would require some subtle way of assessing a subjective response that can be measured without letting the “non-enrolled” subjects in on the joke.
    —————————————
    We do badly need answers to such questions.

    Biases, rather than the available data, are currently the main determinant of positions adopted and there are several reasonably legitimate, not quite coincident perspectives. This is what Moerman is rather clumsily on about, exposing in the process certain limitations to his personal understanding of medicine.

    If placebo influences are powerful that at least helps us understand the appeal of CAM for its users and its grip upon its proponents.

    Patients are the most important stakeholders, but it is those paying for health care that will have the least biased approach, looking for cost-effective outcomes regardless of the underlying mechanics.

    For this reason it is the payers are likely to be most interested in pragmatic, real world, studies into cost-effectiveness. I predict some surprises for those who have an inflated perception of what the trillions spent on health care actually achieve. Health economists have no such illusions.

    OTOH such studies will likely also prove that certain CAM modalties don’t do what they claim.

    I see some possible answers to the “real”/ “not real” dilemma.

    Modern neurophysiology may already be well on the way towards providing objective evidence of placebo responses in action. Will it eventually turn up objective measures that can serve as a surrogate for “true” placebo responses, or reveal the mind of those who are simply being polite?

    There are also grades of objectivity. The emphasis of studies examining the placebo response or any form of CAM should where possible be on independently confirmable end-points, such as time off work, or pill counts, or practitioner visits.

    Smarter people than I may also come up with ingenious ways of improving present instruments, perhaps by inserting dummy questions designed to show up those too eager to please the investigators.

  30. Tell it like it is says:

    “It is a good thing he is not a “real” doctor trying to impose his magical thinking on any vulnerable patients. It is shameful that the NEJM allowed him to post that editorial.”

    Sadly, the person to whom you refer is suffering from delusion, and until either his conscience or a good whipping awakens his senses, he will be imposing his magical thinking on any vulnerable patients he can find.

    On charismatic healers.

    Lydia Estes Pinkham from Lynn in Massachusetts, concocted a herbal-alcoholic ‘tonic’ for ‘female complaints’ addressing menstrual pain, vaginal dryness, perspiration, hot flushes, mood swings, and heart palpitations, which her family mass-marketed from their factory around 1876. The tonic became one of the best known patent medicines of the 19th Century.

    Although Pinkham’s motives were largely self-serving, she used a technique later to be defined as ‘product placement’ whereby she encouraged women to write to her about ‘womens issues’ and she would reply with forthright and genuine advice – the cure for which she ‘recommended’ they try her herbal brew; and as result, she is seen as a crusader for women’s health. There is even a folk ballad written about her – ‘The ballad of Lydia Pinkham’.

    Lydia Pinkham’s daughter founded the Lydia E. Pinkham Memorial Clinic in Salem in 1922. Designated Site 9 of the ‘Salem Women’s Heritage Trail’, the clinic provides health services and advice to young mothers and their children.

    Lydia Pinkham’s original formula was an alcoholic brew containing five herbs. Without any collected evidence of ‘double-blind’ testing, it is debatable as to whether it was the alcohol that brought the ‘relief’, or the relief was genuinely due to the herbal ingredients the ‘tonic’ contained – which is claimed to contain herbal remedies that originated from the Navaho Indians.

    A modified version of the compound that satisfied the requirement of the FDA is now produced by a pharmaceutical company.

    And here is ‘Lily the pink’ performed by a band called ‘The Scaffold’ (a reference to being put to death).

    It says it all. Enjoy.

    http://www.youtube.com/watch?v=IhiyK0YBhvs

  31. Harriet Hall says:

    @TILIS,

    You have a lot to say, but this is not the place. I suggest you write your own blog instead of co-opting ours.

  32. Tell it like it is says:

    @ pmoran

    “Will it eventually turn up objective measures that can serve as a surrogate for “true” placebo responses, or reveal the mind of those who are simply being polite?”

    I love your ‘Politeness scale’ – Brilliant! Encapsulates the problems associated with placebos and ‘medicines’ we ‘think’ work – but don’t.

    Also like your comment:

    “I predict some surprises for those who have an inflated perception of what the trillions spent on health care actually achieve. Health economists have no such illusions.”

    Bang on! Anad to illustrate: aspirin is in the bark of the willow tree, tea is a diuretic, and clove oil instantly brings relief to gum ache.

  33. Tell it like it is says:

    @ Harriet Hall

    “co-opting ours”

    Thats rich! Go tell that to Facebook and Youtube.

    This is a public blog-space – you do not ‘own’ it any more than I, or anyone else does for that matter.

    What I have to say on the subject matter presented on this site is just as valid as what anyone else has to say on any said subject matter.

    What you are suggesting, i.e. sticking with frivolity that wastes time and serves no purpose, has serious ramifications for holding back progress.

    Charlie Darwin toured the world on ‘The Beagle’ and all he collected was a load of dead creatures. Having not one jot of an idea to show for the time and money invested in him, he wrote his ‘Origin of the species’.

    When Charlie Darwin published his ‘Origin of the species’ everyone laughed and burnt his books. Read the last chapter – and fall off your chair laughing – its nonsensical.

    The biggest bird that exhibits ‘fantail’ behaviour to lure its mate is the peacock. To ‘prove’ his point on ‘natural selection’, Charlie Darwin cross-bred fantail pigeons, and those that did not exhibit the ‘desired’ behaviour he KILLED.

    Out came the next generation and they displayed the sought characteristic – and he pointed to the world and said SEE – SEE – I am RIGHT!

    But two generations later – out popped birds that did not display as well – but still found mates and Charlie could NOT explain this and proposed a ‘mixing’ idea which was based upon fresh air and fun.

    Sadly, through his influence, and the influence of his offspring, he persuaded the world to accept his ‘mixing’ hypothesis – but meanwhile – an Austrian monk by the name of Gregor Mendel, armed only with a feather, through meticulous trials on sweet peas, (and later bees and cats), derived the notion of GENETICS. Mendel gave us the LAWS that ‘Charlie the bullsh!tter’ knew nothing about.

    Thanks to Darwin and his henchmen, everyone went off on the wrong track, and as a result, the discovery of DNA by the efforts of the British team Wilkins, Crick and Watson was DELAYED by nearly a CENTURY.

    Charlie the bullsh!tter’s ‘survival of the fittest’ was shot to pieces! Ask someone with cystic fibrosis.

    A prize awaits the person or persons who can crack the relationship between biology and chemistry – particularly relating to relieving the debilitating symptoms of mental illness. This prize is the NOBEL PRIZE – a prize awarded by the family of Alfred Bernhard Nobel – scientist, chemist, inventor, entrepreneur, author and pacifist – the guy who invented Dynamite.

    If what I have to say upsets you in some way and you do not like the heat, then may I politely suggest that you leave the kitchen. Either that, or avert your eyes, bury your head in the sand, or, at the very least, heed the words of Humpty Dumpty in ‘Alice through the looking glass and what she found there’ and ‘mind your temper’ for you make yourself look foolish to the world and you look a proper Charlie.

    And for your edification – I was invited to Stockholm and have applauded in the hallowed hall – covered in gold.

    http://www.keirsey.com/sorter/instruments2.aspx?partid=0

  34. @Harriet Hall-TILIS, probably lacks the focus, organizational skills and ability to writing appealing posts that it would take to maintain a successful blog.

    Writing here, he can pretend he has a following.

  35. nybgrus says:

    oh dear. I’m not touching TILIS with a 10 foot pole. But I am concerned for him/her.

  36. I read that link at the end about Megan Wilson’s death from an untreated/poorly treated asthma attack and saw this quote on the last page.

    “Warren speaks of a medical doctor who recently went through Bastyr’s naturopathy training. His “come to Jesus moment,” as she describes it, happened while operating on a 300-pound woman and realizing he was never going to be able to help her unless she did something about her obesity. That would be part of a naturopathic approach, which searches for underlying causes to illnesses.”

    I’ve seen it mentioned a number of times on here about how nutrition (in this case, weight management) is hijacked by the naturopathic crowd and claimed as “alternative” when conventional doctors who know better about the negative effects of being obese most definitely also recommend weight loss to obese people and sometimes refer them to dietitians. It is preposterous to assume nutrition is in anyway “alternative.” It’s common sense!

    More importantly, who the hell believes that naturopathic medicine seeks to find underlying causes to illnesses? Are you kidding me? This is one of those gems of the naturopathic rhetoric. They might as well have followed that sentence with a statement that all doctors are tools of the medical industrial complex and are either too stupid to help patients or would rather keep them sick to make money off of repeat business and the sale of drugs. Yadda Yadda Yadda.

    A great deal of medicine does involve suppressing symptoms, because the cause of many chronic diseases is unknown and symptoms can kill a patient whether you know what causes them or not. Action is taken based on what has been repeatedly tested to work, not based on touchy feely beliefs about what should be done. It isn’t because there is a conspiracy to keep people sick to make money by selling them drugs. It is just incredibly difficult to determine causation through research. Research often produces nothing but more questions and highlights the increasing complexity of disease. Causal factors can be difficult or even impossible to isolate, at least to the extent where you can say “Yes, we KNOW is the cause.” It takes a long time for new hypotheses to be tested enough times to yield information that can be turned into intervention. In the meantime, doctors still have an obligation to sick people to help them not suffer and not die when they come in for help.

    All of medicine, no matter the variety, not to mention all of human kind, would like to know the underlying cause of diseases. I’d assume that is THE primary objective of medical research. More often, though, when one school of thought claims to be more enlightened than the other, this accusation is made. “Well, THEY just treat symptoms. WE look for the underlying cause.” It is rhetoric and politics. It isn’t a real distinction between conventional and alternative medicine.

    Sorry for my rant. I was just upset by the story of the girl dying because it jarred my memory of some of my own terrifying experiences with NDs. How unfair it is for belief to overshadow evidence and for placebo medicine to be used in lieu of actually affecting the physical disease process in a meaningful way. How sad indeed….

  37. Scott says:

    This is a public blog-space – you do not ‘own’ it any more than I, or anyone else does for that matter.

    Blogs are run by their authors, Dr. Hall being a contributor. Drs. Gorski and Novella, as the editors, are the ultimate authorities here. They would be perfectly within their rights to ban you for spamming (or, indeed, simply on a whim – though they wouldn’t do that). Banning is rarely done here (many blogs would have banned you a LONG time ago) but you are GRAVELY confused about how blogs work.

    What I have to say on the subject matter presented on this site is just as valid as what anyone else has to say on any said subject matter.

    The overwhelming majority of the randomness you spew has no relationship to the topic at hand.

  38. @pmoran
    “Any study where the subjects are informed that they may be given an inert treatment will suppress placebo influences relative to what is possible “in the wild”.

    That’s an interesting claim; is there scientific evidence to support it? I speculate that this is not the case. I suspect that in the context of the trial, the majority of participants will be primed for the placebo factor. I suspect that participants hope to be given an effective treatment, much like people who buy lottery tickets hope to win. Their desire to be in a group receiving effective treatment causes them to believe they are probably in that group. The trial itself is a placebo factor; the researchers and subjects are both primed to expect an effect.

    Additionally, since I haven’t read the actual study, it is not clear to me whether it was clearly stated to the subjects in unambiguous words that the sham acupuncture was inert and was expected to produce no real benefit.

    It seems to me that even with careful wording, when told they are receiving a placebo or inert treatment treatment, many people don’t really understand what that means. They don’t understand that it means basically the same thing as receiving no treatment.

  39. Calli Arcale says:

    Tell It Like It Is:

    “co-opting ours”

    Thats rich! Go tell that to Facebook and Youtube.

    This is a public blog-space – you do not ‘own’ it any more than I, or anyone else does for that matter.

    It ain’t public. It’s publicly accessible; that doesn’t mean it belongs to the public, any more than, say, Mall of America belongs to the public. And Harriet Hall, while she isn’t one of the lead editors, is one of the bloggers who comprise Science Based Medicine.

    It’s not my blog, and it’s not your blog. It’s theirs. Luckily for you, they have a high tolerance for off-topic commenting. Also, not all of your posts are actually offtopic. You’re unlikely to be banned.

    Incidentally, if you think Facebook and YouTube are also public and you should be allowed to say and post whatever you like, good luck with that. They are actually both privately owned and operated, and they can and will ban people who persistently violate their terms of service. (And they can be capricious — they’re not as benevolent as you might think — though they’re more likely to simply remove offending material than to slam down the ban hammer.)

  40. nybgrus says:

    I tried reading some of his stuff again…. and gave up again

  41. pmoran says:

    Karl: @pmoran
    “Any study where the subjects are informed that they may be given an inert treatment will suppress placebo influences relative to what is possible “in the wild”.

    That’s an interesting claim; is there scientific evidence to support it?

    A bit. Kaptchuk has shown how patient reported outcomes can be manipulated as simply as through by an acupuncturist saying something like “this should help” as opposed to a neutral “it works for some but not others”. There are other studies showing correlation of reported outcomes with patient expectations.

    Again, there is the problem of knowing whether actual symptom level or merely reporting biases that are being influenced.

    Supporting what you say, an observational study of Kaptchuk’s, that I cannot locate at the moment, showed that the subjects of one such study did express considerable hope that the treatment would work, but with fewer expectations. I don’t think there was any attempt to correlate attitudes to outcomes in that study, however.

    Would hopefulness make up for not knowing whether the “treatment” was supposed to help or not? I don’t know, but I suspect the net outcome would not be optimal for placebo responses.

  42. GLaDOS says:

    When a charismatic doctor says, “this will help” as he prescribes an inert treatment, the patient may feel relieved and may enjoy strong subjective improvement. But then the patient goes home and talks to relatives and friends, some with medical training. The patient hears, “WTF?” This “WTF?” provokes a little mistrust in the physician.

  43. Artour says:

    >> He was sitting bolt upright in a chair, his hands on his knees, his mouth open, making wheezing sounds. He took short noisy breaths in, followed by what seemed to be very long breaths out, as though he was breathing through a straw. You could hear the wheezing in both directions…

    Surely, the guy was hyperventilating. Since overbreathing reduces CO2 levels in airways, they immediately go into the state of spasm (or bornchospasm) and as a result he must breathing like through a straw (CO2, as some studies claim, is the most potent relaxant of smooth muscles and most potent vasodilator as well). More about wheezing and effects of hyperventilation and appearance of bronchospasm:
    http://www.normalbreathing.com/d/bronchospasm.php

    Mouth breathing itself has additional health effects, such as
    CO2-related biochemical effects of mouth breathing (including less oxygen in body cells, advance of chronic inflammation, suppressed immune system, etc.); reduced levels of absorption of nitric oxide, absence of cleaning, humidification and warming of air flow (only for nose breathing), and more about effects of mouth breathing:
    http://www.normalbreathing.com/index-nasal.php

    Dummy doctors….

  44. Chris says:

    Artour, your clumsy attempts at spamming are always amusing.

    Unless you provide some actual real scientific literature that your special breathing is effective for asthma we will continue to ignore you. Oh, and the literature must be in the form of independent research accessible through PubMed, not your webpage.

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