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28 thoughts on “Fairy Tale Science and Placebo Medicine

  1. antiskepticalhealth says:

    bit of a dry presentation. Good for insomnia though.

  2. Badly Shaved Monkey says:

    One might call it “dry” but I thought it was a very useful bringing together of the SBM thesis. 

    I’d make just a couple of points where I think Dr Hall’s hammer just slightly missed the head of the nail in the circumstances of live speaking, and I hope she won’t mind me saying so. 

    1. Asthma/acupuncture study: Dr Hall said we don’t want patients to just feel better, we want them to be better. Actually the situation is even a bit more feeble as a ‘positive’ result. The patients saying they “feel better” are doing so under the pressure of social conventions, which she described at another point in the talk. We don’t really know whether the patients do feel better or are just prepared to say they do regardless of their actual subjective experience. 

    2. The importance of basic science and the answer to the question at the end. It is true that we don’t need to know the basic science if we know there is an effect (Penicillin). But we do need to know that basic science does not render the therapy utterly implausible. Homeopathy should be dismissed for this reason not merely because of the lack of effect in the trials that have been done.

    Could any trials rescue homeopathy? Frankly, if it worked anything like its advocates say it does then the effects would be obvious. We’d have our ‘extraordinary evidence’ to overcome our scepticism from multiple systematically documented miracle cures. What we might call ‘ordinary’ trials with ordinary p-values cannot do the job.

    A bit long-winded to give as an answer to an end of talk question, but in brief one can say, “Basic science is neither necessary nor sufficient, but basic science must not absolutely contradict the claim”. The EBM doctrine merely says basic science is not sufficient, which is true but simplistic. 

    EBM is a fine tool where the madness and complexity of SCAM hypotheses have been excluded ab initio, but hopeless for analysing a large number of the claims we meet in modern medicine. It is a Ferrari used for driving smooth roads. SBM is the Land Rover for crossing much rougher terrain. Or maybe it’s an Abrams M1 and we’re just learning to fire the damn thing. 

    I’ve also crystallised a vague thought I’ve long had about eliciting the placebo effect. As SCAMsters have retreated from their main claims to asserting they still have utility because they elicit a placebo effect, there is a tacit insistence that they can do this better than actual doctors. I think Dr Hall gave this some useful context by pointing out that the team approach of modern medicine is probably quite good at generating a placebo effect. One still has to admit this is not universal in medicine but the ground under the feet of the SCAMsters is being undermined more and more.

    1.  Their main claims are refuted so they claim action via a placebo effect. 
    2. Cumulative evidence is that the placebo effect is trivial or non-existent for objective outcomes. 
    3. Real medicine is optimising whatever placebo effect may remain by offering genuinely holistic care for difficult cases. 

    It is not sufficient for SCAMsters to show they generate placebo effects. In order to be allowed to operate, they need to show that they do so better than doctors and that the marginal gain they offer, in something whose absolute scale is small, is cost-effective. 

  3. Harriet Hall says:

    @antiskepticalhealth,

    “bit of a dry presentation.”

    Thank you for what I consider to be highest form of praise:
    1. You couldn’t find anything to criticize in the content of my presentation, so you resorted to critiquing my delivery.
    2. It’s far better to be a bit dry than to be all wet. :-)

  4. David Gorski says:

    Yep. That was indeed pretty pathetic of “antiskepticalhealth.” One would think he could come up with actual substantive criticisms. Apparently, one would be wrong.

  5. Sam Homola says:

    I loved Dr. Hall’s presentation on CAM. It was interesting, informative, factual, and appropriate for the audience she was addressing.

  6. Quill says:

    I agree with what Sam Homola wrote and would add that it would be a great presentation for almost any audience that had an interest in a concise explanation of why CAM doesn’t work as a concept, a practice or as a place to send research dollars.

  7. lilady says:

    An excellent presentation, Dr. Hall.

    Would there be room in high school curricula to teach skepticism, perhaps in math or science courses? My “nomination” for the first type of skepticism to be taught and analyzed would be homeopathic “medicine”. Surely any push backs from the naturopaths would be overcome by parents who have an education in the sciences.

    Thereafter, curricula could be expanded with some techniques to analyze bad science.

    Hey a girl can dream, can’t she?

  8. daijiyobu says:

    Aesthetics are a bitch. Male or female.

    I teach a course called “health science” a few times a year for medical assisting students.

    I’ll use this video the next time I teach it and let you know the results, Dr. H.

    Immediately it leads to ideas of a homework assignment that asks:

    ‘well, what did you think about what was talked about?’

    In that course, as part of what I usually include in terms of defining what medicine does
    in terms of science the first day, includes:
    Dawkins as pro-science, Hulda Clarke as antiscience,
    Banachek as pro-science, and such.

    I have a captive audience, of course. Yet, I’m still continually trying to find out
    what truly captivated them and not just hear from them
    what they think I should hear.

    -r.c.

  9. daijiyobu says:

    Oh, and in terms of a “bit of a dry presentation. Good for insomnia though.”

    Take it from someone who reads naturopathic web sites usually daily,

    this is quite the mixture of meanings.

    If it were boring, I don’t think one would stay up.

    And if it weren’t boring, I don’t think I would be dry.

    Ah, the nature of dumb-assed-ness.

    Something I reflect upon daily.

    -r.c.

  10. kalind says:

    Far from dull, I found the presentation rather interesting.
    In fact I owe a lot to science based medicine. Whenever in doubt about some dubious claim, I consult this site and invariably I am enlightened with the truth.
    In India we have a plethora of people practicing (s)cam and seeking the “benefits” of (s)CAM. If only they would watch this video! However, there are some sane voices here too. http://nirmukta.com/ is an example.
    Thank you and keep up the good work.

  11. fledarmus1 says:

    @Lilady – “Would there be room in high school curricula to teach skepticism, perhaps in math or science courses?”

    I think that’s an excellent idea! In fact, two companion courses would seem to be ideal – a literature course entitled “Skeptical Reading of Scientific Literature” which would focus on the many ways both scientists and pseudo-scientists hide the weaknesses in their arguments and on ways of filling in the blanks intended for liberal arts majors who are interested in scientific controversy and the use (and misues) of science to inform public policy, and a general science course entitled “Scientific Reasoning” which would focus on understanding and applying scientific method, recognizing paradigm shifts, true vs. manufactured controversy, and recognizing pseudoscience and misapplications of scientific method.

  12. tgobbi says:

    # antiskepticalhealthon 09 Sep 2012 at 4:22 am
    “bit of a dry presentation. Good for insomnia though.”

    As unofficial president of the chimerical Harriet Hall, MD fan club I must take exception to the preceding comment!

    Unlike the typical televangelist who is trained and well-versed in theatrical excesses and exuberance, Dr. Hall is a distinguished medical professional and person of science. Her claim to fame is her ability to ferret out the [expletive deleted] from the body of scientific knowledge and present it in a scholarly fashion. Indeed she performs her duties with great expertise!

  13. Robb says:

    If I may ask, what was the purpose of a presentation like this? It seems like an attempt at humour while
    preaching to the choir to do a presentation like this at a Skeptic’s Congress. I appreciate that there was some attempt to distinguish between various forms of CAM (I also hate this term but for convenience I’ll use it) but all too often it gets lumped together as though it is some homogenous entity. You lapsed into this later in your talk when you referred to “CAM people” as though they are all one particular tribe or race. The discussion on clinical trials also fell victim to this as it was rife with generalizations – as though all “CAM people” conduct clinical trials in the same way with the same flaws and only CAM clinical trials contain design flaws.

    The tone and mindset of most of the blog posts and comments on this site have a lot of in common with this.
    Being skeptical is seen as somehow “superior” or a badge of honour in itself yet skeptics can be just as stupid and religiously close minded as people who claim that their mineral supplements can cure diseases and keep you young forever. People were skeptical that the original manned Moon landing happened or that the Earth revolved around the Sun. All too often, skeptics concede rational, open mindedness for confirmation bias and preaching to the choir. For example, this constant lumping of CAM together into one mega-modality is a symptom of prejudicial thinking and it short-circuits potential for any honest, fresh, open-minded consideration of the subject. For example, any look through the research available thus far will tell you that there is a lot of good quality research available regarding herbs (generally standardized extracts) but very little to support homeopathy and reiki. Yet, they get lumped in and treated as one for some reason under this CAM banner when it comes to criticism. I find this remarkably short-sighted and narrow minded.

    I could look at a website like this and one like NaturalNews.com and make a lot of parallels about the degree of firmly convinced group-think and the general circle-jerk reinforcing of confirmation bias. Oh but we are based on science you proclaim! As you brought up, “science” can be used to show anything
    you want to show. What matters is the intent and the design, which stems from the mindset of the scientist and anyone who reviews scientific studies. All too often sites like this simply cherry pick research or examples in order to make a point that has already been decided upon beforehand. The recent one on organic food not
    having any “health benefits” over conventionally grown food being a good example. Us vs. Them is boring. The self-righteous vs. the villified other is boring, even if some people seem to derive some sort of egotistical pleasure from it.

    I understand in many ways the natural supplements industry, to whatever degree it can all be lumped together as on the same page, has brought such a reaction on itself in response to exaggerated marketing claims but the baby should not be thrown out with the bath water. The truth is that there really is value in some of these supplements and herbs and it can be found in the literature. It’s mind-boggling to me that so many people are stuck in an extremist dichotomy of either “it’s good for whatever ails ya” to “it’s all rubbish and just placebo effect”. Especially when it comes to herbal medicine and certain supplements, anyone claiming it’s all placebo effect or woo tells me they have not ever bothered to read the literature. By the same token, other elements of CAM are embarrasingly lacking.

    Back to the presentation, to me it was fairly simplified and shallow in its treatment of CAM. It provided a few self-congratulatory chuckles to audience members. As with most posts on this site, it chose to focus on the negative and the extreme rather than give any balanced view. Personally I don’t think things like vitamin D, omega 3 fatty acids, Ginkgo biloba, probiotics, CoEnzyme Q10, or St. John’s Wort for example have any relation at all to Reiki or Intercessory Prayer or Astrology and its a disservice to continue to link them.

  14. Chris says:

    Robb:

    Especially when it comes to herbal medicine and certain supplements, anyone claiming it’s all placebo effect or woo tells me they have not ever bothered to read the literature. By the same token, other elements of CAM are embarrasingly lacking.

    Actually, this statement tells me that you have not read this website very much. The issue that often comes up with herbal medicine is that it does have real active ingredients, but it is the dosing that is what is undetermined. Also, some supplements can be damaging if they are used to excess.

    It seems you are painting this website with one big broad brush.

  15. Robb says:

    @Chris
    Yes, dosage is important of course – that’s part of what is learned from doing clinical trials with different end points in different populations. Not sure what your point is about “excessive supplements can be damaging” since that’s an obvious truism for just about every substance on the planet in the right amount (the dose makes the poison, etc.). I hope you weren’t trying to make a point that vague, undetermined correct dosages of supplements leads to damaging one’s health. How would we then explain well determined exact dosages of common pharmaceuticals still causing in excess of 100,000 deaths each year?

  16. Chris says:

    The supplement being dangerous was a reference to Gary Null’s experience with his own Vitamin D product:

    There can be too much of a good thing. Gary Null inadvertently sounded a note of caution when he managed to poison himself with one of his own products.

    I am just saying that those two topics are discussed here, and not just in the form you alluded to as placebos.

  17. Narad says:

    I hope you weren’t trying to make a point that vague, undetermined correct dosages of supplements leads to damaging one’s health. How would we then explain well determined exact dosages of common pharmaceuticals still causing in excess of 100,000 deaths each year?

    What do you imagine these two sentences actually have to do with each other? And why don’t you cite your source?

  18. Harriet Hall says:

    @Robb,

    “what was the purpose of a presentation like this?”

    The purpose was to explain that the category of “CAM” is meaningless, that all treatments must be evaluated by the same standard, and that science is tricky, that you can’t automatically assume something works better than placebo just because you can find positive studies.

    “You lapsed into this later in your talk when you referred to “CAM people” as though they are all one particular tribe or race. ”

    There’s no such thing as CAM. “CAM people” are the tribe of people who believe CAM exists.

    “things like vitamin D, omega 3 fatty acids, Ginkgo biloba, probiotics, CoEnzyme Q10, or St. John’s Wort”

    This assumes there is a category of CAM to which these things belong. There isn’t and they don’t. You picked things that are being studied in scientific medicine but that have not yet gained mainstream acceptance for the indications they are being promoted for. These things fall squarely in the province of “medicine” and must be evaluated by the same standards we use to evaluate drugs.

  19. lilady says:

    Robb: About herbal medicines/supplements…if you were a regular reader of SBM, you would recall this blog by Dr. Hall:

    http://www.sciencebasedmedicine.org/index.php/red-yeast-rice-and-cholesterol/

    Now tell us, if you have been diagnosed with heterozygous familial hypercholesterolemia , why would you even consider *trying* red yeast rice supplements that contain various amounts of *natural* atorvastin (Lipitor) or no atorvastin or red yeast rice supplements that have been adulterated with Lipitor, when your doctor has prescribed measured doses of a statin drug along with a LDL-lowering medication and is monitoring their effectiveness?

    http://emedicine.medscape.com/article/121298-treatment#aw2aab6b6b4

  20. Robb says:

    @Harriet – when you say:
    “You picked things that are being studied in scientific medicine but that have not yet gained mainstream acceptance for the indications they are being promoted for.”

    What do you mean by “mainstream acceptance”? Which indications are you referring to? I’m going to assume you don’t mean the general public as the sales figures alone would testify to their acceptance, but surely this is only because they are naïve sheep easily misled by clever marketing. So we are left with medical mainstream acceptance. Is there actually such a thing as widespread mainstream medical consensus across the globe? Are you referring to just the US? Certain select countries? I know in many European countries, like Germany for example, herbs like Ginkgo biloba and St. John’s Wort are sold by prescription, reimbursed through insurance, and are “medically accepted”. I’m less familiar with their regulations though so I’ll stick to what I know best and refer to Canada where Health Canada, our equivalent of the FDA, regulates herbs and supplements with product licenses. Safety, efficacy, and manufacturing that adheres to GMP (Good Manufacturing Practices) are the major things that need to be proved before being licensed. Ginkgo biloba standardized extracts, as one example, carry a health claim of “Helps to enhance cognitive function and memory in an aging population and also supports peripheral circulation”. The omega 3 fatty acid DHA carries the health claims “Source of DHA (Omega-3 fatty acid) for the maintenance of good health; reduces serum triglycerides; when used during pregnancy and breastfeeding, DHA supports healthy neural and vision development of an infant; helps support cognitive health by improving memory and learning functions in an aging population.” Would you not agree this is “mainstream acceptance”?

    @lilady – I’m not familiar with red rice yeast as a supplement other than just hearing it is supposed to be “good” for lowering cholesterol. I’ve never used it, haven’t evaluated the claims, and don’t have cholesterol issues so I can’t really comment on it. I’m grateful I don’t have any hereditary diseases like that but if I did I would look into what diet and supplements and herbs could do first and then something like Lipitor would be a last resort – mostly due to side effects and extra cost. I’m not sure why you picked this particular example though as each herb or supplement would have to be evaluated separately – one of the points I was originally making.

  21. Narad says:

    The omega 3 fatty acid DHA carries the health claims “Source of DHA (Omega-3 fatty acid) for the maintenance of good health; reduces serum triglycerides; when used during pregnancy and breastfeeding, DHA supports healthy neural and vision development of an infant; helps support cognitive health by improving memory and learning functions in an aging population.” Would you not agree this is “mainstream acceptance”?

    These seem to be merely bland structure-function claims.

  22. Harriet Hall says:

    @Robb,

    “What do you mean by “mainstream acceptance”? Which indications are you referring to?”

    I mean acceptance by a consensus of medical scientists, not by public popularity. Vitamin D deficiency is a proven indication for supplemental vitamin D. Using it for flu prevention in lieu of vaccination is not. The claims for diet supplements must be evaluated individually, and this is not the place to do that. You missed the real point: that these things are not “CAM” but drugs that fall squarely in the province of “medicine.” They become quackery lumpable with Reiki only when they are promoted without the kind of scientific scrutiny we apply to prescription drugs.

  23. Chris says:

    Robb:

    I know in many European countries, like Germany for example, herbs like Ginkgo biloba and St. John’s Wort are sold by prescription, reimbursed through insurance, and are “medically accepted”.

    Even after evidence shows that Ginkgo Biloba does not work?

  24. Robb says:

    Chris,
    Yes. This meta-analysis below is more recent than the one you linked and was well-designed, taking into account limitations observed in previous reviews.

    http://www.biomedcentral.com/1471-2318/10/14

    With respect to Harriet’s original post, I don’t want to drag this more off-topic into a war of which review is best so I’ll leave it at this.

  25. jmcohen87 says:

    Not related, but I’m waiting for SBM to comment on this study:
    http://archinte.jamanetwork.com/article.aspx?articleid=1357513

  26. DavidRLogan says:

    Thanks for this video, Dr. Hall!

    It’s a great introduction to the SBM worldview and has some good sound-bytes/basic things to share with family and friends when they bring up these topics. I wish I would’ve found this video when I was a kid (or even last year!)

  27. Chris says:

    Robb:

    Yes. This meta-analysis below is more recent than the one you linked and was well-designed, taking into account limitations observed in previous reviews.

    Actually, it was what I found on ScienceBasedMedicine after reading Doubts on Ginkgo Biloba as a Memory Aid in the NY Times the day before.

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