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Has science-based medicine already lost to pseudoscience?

After writing Saturday’s 5,000-word magnum opus about misguided “right to try” bills that are proliferating in state legislatures like so much kudzu, I thought I’d try something a bit different—and more concise. Fear not. This doesn’t mean that I’m going to become Harriet Hall as a writer, because no one does concise and insightful as well as she does, but I do on occasion want to try my hand being less logorrheic. I’ll probably fail, but at least I can pat myself on the back for trying. If I succeed, though, it’ll only make me better. I hope. I also realize that I just made it harder by blathering on for a whole paragraph before getting to the point, a habit of mine that infuriates some readers and amuses others who find my way of winding towards the point at least somewhat entertaining.

Thus endeth the nauseatingly—but briefer than usual!—self-deprecating navel gazing and beginneth the post.

The opportunity appeared to me in the form of an article that popped up in my feed on Medscape entitled, Do Clinicians Base CAM Recommendations to Patients on Evidence of Efficacy? Since “complementary and alternative medicine” (CAM) is, by and large, mostly made up of a collection of modalities either based on prescientific thinking and possessing little, if any, plausibility on a scientific basis, my first reaction was to note that health care practitioners do recommend CAM to some patients, meaning that the answer must be, “No,” and then to move on. However, I wanted to see what Dr. Désirée A. Lie, the author, said and to see what the reasons are for whatever answer she came up with. So I read on.

The article starts with a case study:

A 50-year-old man with a body mass index in the normal range presents to your office stating that he would like to be more active in outdoor sports, but he is unable to participate because of chronic low back pain. Vertebral disc prolapse had been excluded by earlier imaging, which was notable for mild osteoarthritis of the lumbar spine. In the past, physical therapy has been of limited help, although he continues to do back stretches daily. He spends 2-4 hours commuting by car to work each day and runs or walks 2-3 times a week, 30-40 minutes at a time.

The patient is asking for your recommendation for a complementary or alternative medicine (CAM) option that would improve his functioning and ability to participate in more vigorous physical activity. He does not wish to take anti-inflammatory agents because of reflux esophagitis.

Notice how the question is framed. The patient is asking for CAM. That puts a physician in a tough spot. The patient wants something magical to make his low back pain go away, and, unfortunately, for low back pain there is nothing magical. My first recommendation would be that the man find a way not to have to drive so much, because if there’s one thing that’s hard on a person with low back pain, it’s driving for hours every day in a car. If that’s impossible, I’d ask the man if he could find a way to have better lumbar support and plenty of room. Or, I might suggest a few things but then tell the patient what he doesn’t want to hear, namely that if those interventions don’t work his desire to be more active in outdoor sports might not be feasible. Be that as it may, though, many docs would probably recommend some sort of “CAM” to this patient, although I would note that recommending more or different exercises or other lifestyle modalities represent what should be science-based medicine, not CAM. CAM has appropriated many of these modalities, such as lifestyle interventions or nutrition, as somehow being “alternative” when they are not.

Be that as it may, there are two questions in a survey form:

  1. Which of the following healthcare professionals is likely to recommend CAM for the patient’s low back pain?
  2. What modalities are healthcare professionals most likely to recommend?

The choices for the first question included physicians, nurses, and pharmacists—and, of course, “all of the above.” The choices for the second question included osteopathic or chiropractic manipulation, acupuncture, massage, and, again, “all of the above.” Disappointingly, by far the most common answer given for the second question was “all of the above” (61%), while for the first question the most common answer was “a nurse” (45%), followed by “they are all likely to recommend CAM” (40%). “All of the above” was listed as the “correct answer” for both questions, based on this explanation:

Since the 1990s, national survey data in the United States have reported a prevalence of CAM use that has risen from 1 in 3 patients to nearly one half of all patients.[1-4] A recent review of the 2007 National Health Interview Survey examined self-reported CAM use by healthcare workers (categorized as providers, such as physicians and nurses; technicians, such as sonographers and laboratory technicians; and support workers, such as nursing aides) using the National Center for Complementary and Alternative Medicine taxonomy (alternative medical systems, biologically based therapies, manipulative body therapies, mind/body therapies, and energy-healing therapies).[5]

The authors found a higher prevalence of use in the past year among all healthcare workers compared with the general population (41% vs 30%). As well, 76% of all healthcare workers reported using at least 1 modality in the prior year. Those working in the ambulatory setting were more likely than hospital workers to use CAM. Healthcare providers (such as physicians, nurses, and pharmacists) had a 2.2 times increased odds of seeking practitioner-based CAM modalities (such as acupuncture and manipulation) and 2.7 times increased odds of self-treated CAM modalities (such as botanicals or supplements) compared with support workers.

The most common reason given for CAM use by healthcare workers was “general wellness,” and the most commonly treated condition was anxiety in this study. There was also a significant increase since 2002 in use of the following modalities by healthcare workers: acupuncture, deep breathing exercise, massage therapy, meditation, naturopathy, and yoga.

I can’t help but note that the very first sentence promulgates a common myth about CAM, namely that anywhere from one-third to one-half of patients use it; i.e, that it’s so popular that it should be considered mainstream. As bloggers here at SBM, such as Steve Novella, Brennen MacKenzie, and myself, have explained, this is indeed an exaggeration, but it’s a useful exaggeration, given how it feeds CAM media myths. As Steve Novella has pointed out, for instance, that, contrary to a picture of increasing CAM use, CAM use for all categories except massage are all either static or only slightly increased. More importantly, as all of us have been pointing out again and again, these CAM numbers are inflated by including items that shouldn’t necessarily be considered outside of mainstream medicine, such as massage, biofeedback, and yoga—which, let’s not forget, is merely exercise and stretching. It’s only when pseudoscientific claims are made (as is not infrequently the case for nutrition and exercise modalities like Tai Chi and yoga) that these modalities fall outside of the mainstream and become “alternative.” Also, manipulative therapy is included. As I like to say, I have little problem with chiropractic as long as chiropractors use only manipulative therapies similar to those used by physical therapists, which is science-based medicine. I only have a problem with chiropractors when they go beyond that—which, unfortunately, all too many of them do—and become what I like to call physical therapists with delusions of grandeur, claiming to be able to treat allergies, asthma, and all manner of disease not based on the spine or the musculoskeletal system. In any case, chiropractic and osteopathic manipulation together add up to around 21%, and yoga adds nearly 10% to that.

Yes, Dr. Lie fell into that trap. She also cites a study published in 2012 claiming that CAM use is more prevalent in health care workers and providers (41% compared to 30% in the last year). If you look at the study in a bit more detail, though, you’ll soon find that it has the same issues as the 2007 NHIS had, and if you look at the numbers for individual modalities (which you can, as the study’s available at PubMed Commons for free), particularly in Table 2, you’ll see that, once again, they are dominated by manipulative therapies, 21.7% reporting having used chiropractic or osteopathic manipulation. If you look at biologically based therapies, which includes any diet-based therapy, such as vegetarian diet, macrobiotic diet, Atkins diet, Pritikin diet, Ornish diet, Zone diet, South Beach diet, as well as any use of dietary supplements, you’ll notice that 68.9% report some form of self-treatment, but only 0.3% doing “practitioner-based” therapy. One wonders whether anyone who put himself on a diet to lose weight without having a practitioner supervise it would count as having used CAM by this definition. One notes a similar issue with “mind-body” therapies. While 30.8% of health care practitioners reported using them as “self-treatment,” only 0.9% reported practitioner-based use of these therapies. One notes that yoga and Tai Chi are listed as falling under this category (supplemental information); so it’s not at all surprising that one in three people might have tried yoga or Tai Chi at some time in their lives. My wife’s done yoga. My uncle used to do yoga before it was cool to do it. I’ve thought of trying it myself to get into better shape. It’s exercise, people!

The rest of the modalities listed in Table 2 show single-digit percentages for everything else, such as energy therapies, which would include reiki, therapeutic touch, and various other forms of “energy healing” (1.5%), and alternative medical systems, which would include homeopathy and ayurveda (3.0% self-treatment, 2.6% practitioner-based treatment). Next, if you look at the odds ratios in Table 4, you’ll see that, disappointingly, health care providers have an odds ratio of having used CAM in the last year of 2.6 (95% confidence interval 1.7-4.2), leading the authors to conclude:

Even with these limitations, our results are suggestive of why CAM therapies are increasingly integrated into health care. There is evidence that personal use of CAM by health care workers is related to the provision of, referral for, or general openness to the integration of CAM therapies in health care practices. For example, Tracy et al. (2005) reported a strong correlation between personal use of specific CAM therapies among critical care nurses and the use of those same CAM therapies in practice. Thus, personal use of CAM by health care workers may be a principal determinant in the movement toward “integrative care”—the mainstreaming of CAM with allopathic medicine (Mann, Gaylord, and Norton 2004; Winnick 2005). In addition, in the context of recent federal health reform changes, in 2014 when the health insurance exchanges begin, states may be more ready to license practitioners of various CAM therapies and thus require insurance coverage for CAM.

In other words, more health care providers are using CAM, at least if you believe this study and Dr. Lie’s article. The implication (and apparent hope) among CAM advocates is that this means that CAM will increasingly become more tightly “integrated” with real medicine. True, we are left with the proverbial “chicken or egg” problem in that it’s not clear whether the reason health care practitioners are apparently using more CAM, however defined, is because of the propaganda promoting its use or whether CAM is becoming more “integrated” with medicine because more and more physicians are embracing it. It could well be a vicious cycle, in which increasing “mainstreaming” of CAM through its infiltration into academic medical centers and the medical school curriculum feeds greater acceptance among physicians and therefore greater usage. While it is true, if Dr. Lie’s article is correct, that CAM use is highest among nurses, followed by pharmacists, and then by physicians, it is noted that although the average of reported usage by physicians is the lowest, geographic variability in usage among physicians is the highest, ranging from only 24% of physicians in Denver having reported ever using CAM (I really didn’t see that one coming, given Colorado’s well-known predilection for embracing quackery) to 49% of physicians in Kentucky and up to 83% of primary care physicians at a medical school (it was the Morehouse School of Medicine, for anyone who’s interested).

It all makes me wonder whether medicine has reached a tipping point, if the CAM genie is out of the bottle and can’t be put back in. A while back, I wrote about how Andrew Weil was spearheading a plan for a board certification in “integrative medicine,” which I dubbed the “ultimate triumph of quackery,” because of how it was the next step in the legitimization of “integrating” quackery with scientific medicine. Even though CAM practitioners were very cool to the idea because of turf issues (namely, only physicians could have a board certification in “integrative medicine”), physicians are apparently flocking to this new certification, so much so that the first ever integrative medicine board exam has been postponed, as announced on the American Board of Physician Specialties website:

Since announced in mid-2013, interest in the new American Board of Integrative Medicine (ABOIM) has been overwhelmingly positive. An unprecedented number of applications were received by the December 1st deadline for the first exam administration, originally scheduled for May 2014, and this tremendous demand affected our projected timelines. In an effort to ensure the highest level of customer service to both current and future applicants, we have postponed the first administration of the examination until November 2014.

It’s times like these that I wonder whether the forces of pseudoscience have already won. But then I reassure myself by pointing out that, if you exclude exercise, diet, and manipulative therapies, vanishingly small numbers of physicians and other health care providers use anything that could in any way be considered “CAM.” Most physicians don’t use CAM themselves or prescribe it for their patients. From my anecdotal experience, most physicians appear dismissive of CAM. Unfortunately, they also don’t stand up for science-based medicine (or even evidence-based medicine) enough, either. Rather they are “shruggies,” whom Val Jones defined as “fairly inert,” unwilling to “argue the merits (or lack thereof) of complementary and alternative medicine (CAM) or pseudoscience in general,” because they just “aren’t all that interested in the discussion, and are somewhat puzzled by those who are.” That leaves it to us, the ones who are interested—such as the Society for Science-Based Medicine, which those of our readers who haven’t joined yet should totally join now (not so subtle hint, hint)—to sway them and hold our fingers in the dike protecting SBM from the ever-pummeling waves of quackademic medicine that have been pounding against it for the last 30 years ago. Stories like these remind me that we need to do more than just hold our fingers in the dike.

Posted in: Science and the Media

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286 thoughts on “Has science-based medicine already lost to pseudoscience?

  1. BillyJoe says:

    ” I have little problem with chiropractic as long as chiropractors use only manipulative therapies similar to those used by physical therapists, which is science-based medicine”

    It’s not entirely obvious, but I guess this must be tongue in cheek.
    I mean, if you excluded all practitioners who use chiropractic manipulation, treat non back conditions, use other forms of CAM like homoeopathy or herbal therapy, and who advise against vaccinations, there would not actually be a chiropractor amongst them would there?

    1. David Gorski says:

      They’re quite uncommon, but they do exist.

    2. denise says:

      I had one once. She never pushed or practiced anything except manipulation, and when I wasn’t improved after five sessions she told me she couldn’t help me and that I should see a doctor. Very rare, I think.

  2. Jann Bellamy says:

    “ . . . in the context of recent federal health reform changes, in 2014 when the health insurance exchanges begin, states may be more ready to license practitioners of various CAM therapies and thus require insurance coverage for CAM.”

    “more ready to?” All states already license chiropractors and 43 states license acupuncturists. And just because a CAM practitioner is licensed doesn’t mean “insurance coverage for CAM” is required. For example, all non-government insurance policies I’ve ever seen exclude the detection and correction of “subluxations” by chiropractors and the prescription of homeopathic remedies by naturopaths. (Unfortunately, Medicare covers subluxations.)

    When a physician recommends CAM I always wonder where else he or she is cutting the corners on evidence. And whatever happened to informed consent?

  3. The human mind seems to go fall back to a ‘quick and easy’ mentality, we’re endlessly hopeful for quick fixes and miracles. Pseudo-science fits us perfectly.

  4. Kat E says:

    It’s tough. I remember when I was in nursing school, we learned a bit about CAM, and actually had CAM practitioners come to speak to our class. While I think that it may have been beneficial to learn about how CAM practitioners (acupuncturists, chiropractors, naturopaths, reiki masters, etc) approach health and wellness issues, I think what was lacking from my education at the time was an understanding of WHY these practitioners believed the things that they did. For instance, I had no idea how chiropractic started out until a few months ago – I assumed that there was some sort of scientific basis behind it (why else would these people be able to call themselves “doctor” and why would they be able to make the claims that they make and why are they allowed to treat patients?)…. Gaining a better understanding of the history of chiropractic (the SBM series on Chiropractic was quite helpful) and the underlying philosophies as well as how CAM was regulated (or not) helped me to see how dangerous all of this could be. I think that it was valuable to learn about these therapies; however, it is important to learn about where the “knowledge” is coming from and the potential risks involved. It would be great if there were some non-..invasive, magical cure for everything! but in reality this can delay someone from accessing the medical care that they may need in a timely fashion. I think it is also important to get the message out that many of the things that CAM practitioners tout as “alternative” are not – nutrition and exercise are a huge part of the standard of care in medical interventions.

  5. goodnightirene says:

    You may well exclude things like massage from CAM, but I double dare you to find me a massage “therapist” in this city (Milwaukee) of 600,000, or its suburbs (a million and more) who does not at least dabble (most do way more) in the most outlandish claims for their modality.

    I recently spend half a day with Google looking for a simple massage. I finally thought I had found one place, but after reading further down, I found lots of anti-medical verbiage about dis-ease and the EVIL PHARMA, with vague references to the power of “healing” with “the hands”. I even tried Chicago, and found only a message board where a skeptic who was looking for the same thing as me, got about 50 replies, most of which quite abusively chastised him for not “understanding” pseudoscience.

    All of the day spas offer a wide range of pseudoscientific practices. They start out with relaxation and stress reduction, but quickly move on to claims about migraines, imply they can lower blood pressure (without saying for how long), and of course, there are the inevitable claims about the “toxins” that will be “released”. My hubby says he gets great massages in Vegas with absolutely zero woo involved, so much as I despise Vegas, I may have to tag along next time.

    1. Thor says:

      Hear hear! Massage is a major hub for all things pseudo-science, and it is rare, indeed, to find a practitioner who doesn’t subscribe to almost any and all manner of woo. While the basics of massage itself are completely legitimate (and plausible) applications based on anatomy and physiology, and which usually give the recipient several benefits including enhanced bodily comfort, relief of minor soft tissue aches and pains, overall tension/stress relief, the ancillary claims made and add-on techniques used are the epitome of CAM. There is no off-the-chart woo-modality that a massage “therapist” won’t use and make claims for. And this begins in massage school. Basic massage just doesn’t suffice and simply goes hand in hand with introducing and promoting students to all kinds of nonsense. Energy modalities, especially, have found a comfy home in the massage world.

      Interestingly, in my quarter century of massage practice (ironically, currently disabled in hand due to repetitive stress injury), part of my success was in being simply a nuts and bolts practitioner like the one you were searching for. It was exceedingly refreshing for my clients NOT to have massage “plus”. Unfortunately, my critical understanding of nutritional supplements only developed late in my career, so I recommended things like glucosamine, among others, when deemed appropriate. I look back and wince.

      1. Frederick says:

        That’s true, one of my best friend is now a massage therapist, since last year. He had taken class for that, have all diploma and everything. He is like 6 foot 1 Large and big hand, I really don’t care about getting a massage by another man, because he is good.
        He is a guy with a head and a brain, but he is not a big science geek. And he talked to me about “massage remove toxin” and other thing he learn in his class. That’s exactly the problem, they are allowed to teach thing that don’t exist. He is not a believer really, he just learn that, and like most people, he think that a teacher must know what he is talking about. Although his teacher was also going into “energy” and crap like that, that make him laughs. He told me, ” you take some, you let some slip” at least he did not fell for all the BS.

        1. Frederick says:

          oups. press send too soon.
          But i wanted to ad, that this friend will probably be the kind of person to just drop the BS he as learn, and just stick to work is real ( massage) if he Was explain in detail, by someone with credentials. ( I could do it but you know. I not a doc! :-) )

          1. Thor says:

            Yes. Encourage him to understand and see the bull. In massage, we are simply taught and exposed to these “additional” aspects, many of which are easily integrated into a massage practice. Along with basic and advanced massage, I was taught Reiki, reflexology, acu-pressure, meridians, trigger points, leg length differential assessment, pelvic stabilization, Polarity Therapy, aroma therapy, cranial-sacral therapy, etc. Most massage therapists have a large grab-bag of CAM at their disposal, permeated through and through with New Age magical world-view. Massage is so mixed in with these other aspects that someone like goodnightirene can’t even find a massage without them. It’s a shame because we all know how good it is for the body (and mind) to get a good massage.

      2. Graham says:

        That reminds me of a masseuse I met in my former job. She claimed that massage drew ‘negative energy’ from the person getting the massage into the masseuse.

        She added at the end of each day that she had to go to the ocean and wash her hands in the sea to get rid of the ‘negative energy’ otherwise it would give her arthritis…

        1. Thor says:

          Par for the course. Hands are washed, and shaken, auras are balanced, rooms are smudged, crystals strategically placed. Masseuses and masseurs are mostly coming from the vitalistic perspective anyway, so this isn’t a stretch. It is common thinking among massage therapists that negative energy gets drawn into them from the recipient. All that negative mental, emotional and physical energy gets soaked up by the act of massage and “energy interaction”. The person getting the massage is “healed”, or relieved. The massage field is saturated with “energy this and energy that”.

          On the other hand, it’s always an ironical surprise to meet a body-worker who simply focuses on what’s at hand, the reality. How about precision massage techniques, and anatomy and physiology? Imagine a massage therapist knowing exactly where the tendinous attachments of muscles begin and end, and knowing exactly how to apply manual manipulative techniques, with appropriate use of pressure. Simply that. Massage is massage, no woo needed.

          1. WilliamLawrenceUtridge says:

            Indeed, massage sells itself short when it moves beyond muscles. The mere fact of giving a massage is pretty great, it helps with sore, tight muscles, and sore, tight muscles are huge pain drivers in the body. Why do massage therapists need to make outrageous, unscientific claims, when their core business is in and of itself so beneficial? It’s a pity, and it short-changes the profession.

            1. Thor says:

              Absolutely! It’s disheartening to witness how irrational thinking poisons everything of real value and legitimacy. Everything? Yes, everything. Dr. Crislip’s famous quote about not making apple pie tastier by adding cow pie really applies. And Hitch’s subtitle for God Is Not Great doesn’t just apply to religion but to all belief not founded on solid ground. Whether it be medicine itself (doctors using acupuncture, nurses using TT), PT (chiropractic, and sometimes osteopathy), massage (Reiki, toxins, Healing Touch) and, and, and. It’s easy to understand why someone like windriven can lose hope. These poisonous mind-viruses infect everything. We need a vaccine for them, which will probably come in the form of education—teaching critical thinking as a primary subject in K-12.
              Maybe a generation or two need to die off before this is accomplished.

              1. ethan says:

                https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2565606/

                I think this editorial covers a huge swath of this discussion. IMO, does a great job of laying out the underlying reasons for the structural incoherency and “crisis of identity” at the heart of “the chiropractic profession.”

                If ethical medical practitioners keep their eye on the prize — e.g., the hippocratic oath, and creating structures and institutions that support that fundamental creed, then the best medical practices will prevail. The editorial shows how that is happening with PT — slowly and steadily, its jerky and unethical competitors are slowly becoming less and less relevant and are self-marginalizing. Not to say it’s not a threat, still. But let’s not get distracted from the actual mission here.

                It’s not about winning or losing. It’s about providing the best healthcare possible. And there are plenty of things within the supposed “science-based system” that get in the way of providing optimal healthcare.

                i think SBM.org contributors need to come to a consensus definition of “quackery” and other key terms. Half the time I see it thrown around in various forms to describe statements that have not been scientifically validated, and other times to describe statements that have been scientifically discredited.

                Also, I don’t think “legitimate” is necessary the right word to describe “Big Pharma” (can’t remember whether it was a contributor or a commentor who put those two terms together). But my underlying (and more relevant) point: Its co-optation of the US health care system has been incredibly damaging to primary care and preventative practices (regardless of any intentionality), which has boosted its bottom line by shifting the entire population away from sound public health practices and onto pill-popping dependency. Sure, it produces some drugs that work, and lots that don’t — do we really want those flooding the market even more than they do now???

                That said, medicine is so much broader than drugs. For example, we have a system that opposes rather than uses the placebo affect to its benefit. Do we have anyone asking the question of whether and how placebo can be a sound part of SBM practices? And how patient experience needs to be a contributing factor to new and innovative research? (scientific innovation stems from curiosity about individual experiences, after all!). For example, all “non-alternative” medical practitioners I have EVER consulted with ignored the possibility that dietary factors were contributing to my personal misery. And these are successful, well-educated, intelligent and caring practitioners. It’s just that no one wanted to believe that my body was reacting to a standard food item as a poison (in my case, nightshades). But it does. Why? Nobody knows. IMO, clearly there are structural issues at play. Doctors are not scientists, and there is often a large, frustrating gap between the two (and even more frustration when doctors try to play scientist without adequate training in statistical analysis). I’m not sure it’s reasonable to expect doctors to become amateur scientists, but there are probably ways to coordinate anonymous patient profile data to determine priority research trends and respect patient experience a bit more, because the “professional / lay” objectification of patients is also a factor as to why “CAM” maintains viability — because it actually does some things really well. Like provide empowerment, respect and sensitivity to patients. It shouldn’t have a monopoly on those things, though — they are important. Are they not “science-based” for some reason?

                Medical practitioners need to be holistic. I think that’s a huge part of the battle — SBM self-defines so narrowly in such unnecessary ways that it self-alienates from being able to provide the type of multi-disciplinary care that people need. PT, acupuncture, meditation and diets that reduce vs contribute to chronic, system inflammation to help manage or even cure chronic pain, for example — not just drugs. Making it “either/or” is a losing battle.

          2. brewandferment says:

            if one doesn’t have an ocean in which to transfer all the negativity, where pray tell does it go? should someone call the EPA or whoever for a violation of clean water acts by a masseuse who is poisoning the ocean with negative energy?

            Wonder if any of the classes address the matter of proper disposal of negative energy, is there a special way to cordon off the place where it is shaken so some innocent bystander doesn’t get vaporized? it’d be amusing to find out how the instructors handle that line of questioning. I (not a medical person) once asked a proponent of “healing” touch those questions, and he was not amused.

            1. Thor says:

              Haha! Didn’t you know that “the Universe” transmogrifies negative energy into harmless quantum components? It’s all taken care of by the natural order.

  6. Andrey Pavlov says:

    It seems to me that most of it is a combination of ignorance and shrugginess. There is obviously no real data but my own experience plus that of others I have spoken to as well as a common theme of experience running with the contributors and commenters of this and other blogs seems to support that idea. Yes, experience can be dangerous, but in the lack of better evidence and considering the context it doesn’t seem unreasonable to me to draw at least tentative conclusions from it.

    Obviously the PR machine of CAM is well documented here and explains the inward thrust, but why the acceptance of it? Sure in some cases we can point to avarice (Oz, Weil) and some outright gullibility (Ornish, Guarnieri) but most of it is really just pure ignorance as to what is really being proposed.

    Think about it. As physicians we know that there is much that we don’t know. We consult our colleagues, typically from other specialties but often within our own to pick their brains about what we may be missing. And unless we are damned sure our colleague is wrong (or that it will harm our patient) we defer to professional humility and simply chalk it up to us not knowing or understanding some nuance. It is considered poor form to directly contradict and/or lambaste a colleague. Heck, I’ve seen it happen with actual science based treatments in the ICU where unnecessary tests are ordered because the problem simply wasn’t thought through well enough. I am often unable to speak up strongly because of my low status on the totem pole (though I am definitely more outspoken than most of my classmates and colleagues, I’ll admit it is difficult for me to do and extremely anxiety provoking the handful of times I’ve directly contradicted an attending and I have only ever done it when I am 110% certain of myself and in a particularly deferential manner) but I have seen plenty of examples of fellow attendings obviously biting their tongues. My impression is that this is usually because they assess the risk as low, that there exist possible benefits, and that it ultimately isn’t worth the argument. Sometimes it is because they don’t actually have a good argument handy and later on it simply isn’t worth following up directly for myriad reasons.

    And that is when it is well established scientific medicine in question. Now imagine when it is something like CAM which is even well less explored and understood. Go ahead – casually ask as many colleagues as you can over lunch or coffee if they can even define CAM modalities that they know the name of – acupuncture, Reiki, TT, reflexology, homeopathy, etc – let alone what “CAM” actually is. (BTW if they do define CAM itself, tell them to let the NCCAM know because even they flat out admit they cannot define it and don’t even bother with it, after I badgered Dr. Killen about it and he wrote an entire blog post in response, utterly dodging my challenges).

    Every single time – bar none – I have had a conversation with someone about CAM and its modalities, they are absolutely astonished when I explain to them what the modality really is. One story I love telling comes from my friend in the year behind me. His parents are professional chemists and he came home one day and saw his mother had a bottle of homeopathic medicine. He asked why and she gave the typical non-committal response of “well, I thought it may help and I saw it on the shelf at the pharmacy.” He explained what homeopathy actually is and they were absolutely dumbfounded. They are well aware of Avogadro’s number, after all. People generally don’t study what the CAM in question actually is – merely the fluff PR garbage that gets touted around and without direct and clear demonstration of harm, give it a pass as a result. After all, the business of real medicine is time consuming and difficult enough.

    And that blends in to the shruggie side of things. I’ve also had experiences where once explained, astonishment and all, they then literally shrug their shoulders and basically say “who cares?” It is admittedly low in harm directly and they are busy enough doing real medicine that they could care less if some shaman is paid to come in to cast magic spells over their patients (so long as the shaman doesn’t yank out a central line in the process of waving hands over the patient, of course). In essence, the threshold is “don’t harm my patient in any meaningful and direct manner” rather than “don’t waste time and money not helping my patient.” I’ve also seen a bit of the “well, whatever they believe… it is not my place to judge if they want to believe in magical spells” which is likely heightened by the cultural sensitivity aspects of medical training (necessary, but gone too far).

    Throw in those who consider the “art of medicine” to be “random stuff happens that you can’t explain so I can do whatever I feel makes sense” and you’ve got trouble like we see. Which is why I am unbending and active in my stance on the topic. I challenge people to explain to me what and why for everything, particularly CAM. I challenge anything that needs challenging, particularly CAM. And I take the time to explain the details of whatever is relevant to blow their minds in incredulity that such ridiculousness exists and prompt them to look more actively into it.

    It is a slow process, but an important one that I think will eventually prevail. A really good tack is to point out how expensive medicine is and how we should not waste resources on things that simply “won’t harm” but also probably won’t help. It is easier to argue against doing something if it is coming from a resource availability standpoint, particularly in the current medicopolitical climate.

    1. WilliamLawrenceUtridge says:

      Given particularly your final point, I wonder how a comment like this, regards a test used unnecessarily, would fare? Probably phrased more tactfully though.

      “You don’t need to run that test because of [reason]”
      “I wan’t it anyway, what’s the harm?”
      “You running that test means [hypothetical patient without insurance] with [condition that actually requires test] would not be able to be teseted. The hospital has limited resources, particularly for patients without insurance.”

      But even here, I can see flaws. Testing isn’t really a zero sum game, and I doubt most tests run for patients with insurance are charged purely on a cost-recovery basis. All those expensive, unnecessary tests might actually pay for someone else’s actually necessary but not covered tests.

      I’m glad I have public health care.

      1. Harriet Hall says:

        There’s also the non-financial argument, that we have reason to believe doing the test is more likely to harm than help.

        1. Andrey Pavlov says:

          Absolutely correct Dr. Hall. There are, indeed, myriad reasons. But I have found from my own experience that the financial/resource argument seems to work the best. I believe this is at least in part because of the serious crisis we are in regarding the use and allocation of resources and the huge push by the ACGME to require QI and efficiency improvements, research, and work by all residents.

          In fact, starting in middle/late of last year during the daily morning reports we began doing exercises where the “game” was to accurately diagnose a patient for the least amount of money spent possible. The team that “won” was the one the got the “cheapest diagnosis.” While people may have various ideological bents or varying proclivities for magical thinking (or lack of thinking) when you can tie in your argument to something that is blatantly in front of us it makes it more compelling. In the same way that I can argue a d-dimer on a patient with Well’s score of 8+ is a complete waste of money and we should just go straight for the spiral CT, I can argue that doing Reiki or offering reflexology is also a waste of money.

    2. David Gorski says:

      Every single time – bar none – I have had a conversation with someone about CAM and its modalities, they are absolutely astonished when I explain to them what the modality really is. One story I love telling comes from my friend in the year behind me. His parents are professional chemists and he came home one day and saw his mother had a bottle of homeopathic medicine. He asked why and she gave the typical non-committal response of “well, I thought it may help and I saw it on the shelf at the pharmacy.” He explained what homeopathy actually is and they were absolutely dumbfounded.

      Yup. I’ve had this experience many times, not just with homeopathy, although it is the most common one that flabbergasts my colleagues when they learn what it really is. Most of them think homeopathy is herbs and supplements and have no idea of the two major laws of homeopathy, particularly the concept that diluting something beyond Avogadro’s number makes it stronger. That’s why I make it a point to educate medical students and residents about this whenever the opportunity presents itself.

      The same is true of reiki. When I explain that reiki practitioners believe they can channel “life energy” from the “universal source” and then describe how this is basically the same concept as faith healing in Christian traditions in which the faith healer channels the “healing power of God” into the recipient (substituting Eastern mysticism for Christian beliefs, of course), they can’t believe it.

      Doctors just don’t know the real ideas behind various CAM modalities that they “shrug” about. Steve Novella has described how he managed to put the kibosh on a credulously taught “integrative medicine” module by simply getting a hold of the actual curriculum and showing it to a dean. After that, the module underwent major modifications. It is up to us to educate our colleagues and trainees.

      1. Andrey Pavlov says:

        It is up to us to educate our colleagues and trainees.

        Agreed. I also find that they can and do become very engaged in the conversation when the opportunity arises. I frame it more from a questioning their understanding rather than lecturing them perspective. So far it has worked extremely well. I also do not mince words and there have been a few occasions when we were extremely busy and pressed for time and the topic tangentially comes up, so I give a very blunt answer. I was once asked, rather incredulously, “So you are saying you don’t think there is anything worthwhile in CAM?” And I responded flatly and matter-of-factly, “No. By definition it can’t since if it were there and we knew about it, it would be medicine.” Sometimes that get’s their ire up which makes them come back and try to challenge me. That’s the opportunity for the good discussion. Sometimes nothing comes of it, but nothing would have come of it regardless (in those instances).

      2. Birdy says:

        I’ve also noticed that. Lots of people think ‘homeopathic’ and ‘herbal’ are interchangeable (a misconception the homeopaths seem perfectly fine to base their marketing on.) Herbal preparations have at least some possibility of having an actual effect, however uncommon the useful ones really are. It’s nice to see the lightbulb moment when they realize what a crock it really is.

        My own husband – subjected many times to my rants about quackery – even once bought a homeopathic preparation. It was in tiny, tiny letters on the side of the box. He’d not have bought it if he saw that, but he had a terrible sinus infection and went for what was on sale.

        My septic system is now somewhere around 100C homeopathic nose spray. If I could bottle it, I’d be rich.

        “It is up to us to educate our colleagues and trainees.”

        Some trainees-to-be are taking steps to educate themselves, fortunately. Our Students for Science-Based Medicine group has had a strong uptake right out of the gate, and we’ve had some fantastic discussions already, with many to come.

        It’s nice to have more established professionals looking out for the integrity of our educations, though. It is nice to have people who are willing to challenge bad education on the behalf of students who, very often, are cautious about possible consequences for challenging the higher-ups.

    3. Dr Robert Peers MBBS [UniMelb] says:

      Andrey, Excuse my ignorance, but what makes Dr Dean Ornish “gullible”? What is he gullible about? If he’s not, then he would presumably feel hurt by your remark.

      All I know of him is that he runs this Preventive Medicine Research Institute, in beautiful downtown Sausalito, that he once did a pretty good study on a Pritikin-type diet and vascular prevention [that was poo-pooed by Dr Hall], and that his paper Statins and the Soul of Medicine is an inspiring call to use scientific diet, as well as–or in place of–statins.

      What’s gullible about that?

      More recently, he has called large preventive trials into question–for good reason, I suspect–but got into hot water for challenging their scientific basis. Perhaps he will get over that, with some gentle feedback.–or funding for his own big trial!

      I once asked, on SBM, for some evidence that he might do a sideline in selling vitamins or similar woo, that I am not aware of–I don’t think I got a response.

      I will be sorely disappointed if this rare medical-turned-nutritionist, who has done valuable work on the low-fat, high grain and bean diet [like Dr R James Barnard, at UCLA], now believes in toxins or something.

      Can you please clarify? And what do you make of his Statin paper, above–particularly the last paragraph, which I regard as totally inspiring to GPs?

      1. Andrey Pavlov says:

        Andrey, Excuse my ignorance, but what makes Dr Dean Ornish “gullible”? What is he gullible about? If he’s not, then he would presumably feel hurt by your remark.

        He is gullible in the sense that he is a true believer of his diet ideas to the point where he has written a rather execrable piece about how RCT’s should be abandoned, because they did not support his pre-conceived as true conclusion that his diet works. While not as bad as Guarnieri, he is also gullible in that he is (at least seemingly) swayed by CAM thinking.

      2. WilliamLawrenceUtridge says:

        One doesn’t need to be making money from an idea to be biased, one can also be an ardent proponent for intellectual reasons, or merely because one has endorsed an opinion in the past and cognitive dissonance prevents one from admitting they are wrong. Particularly if you’ve dedicated not only your professional life, but your personal life and gustatory pleasures towards a specific, less than tasty diet, for decades.

  7. stanmrak says:

    I can tell you that there IS magic for low-back pain – based on my own “miracle” recovery from 15 years of lower back discomfort, without drugs, surgery or even physical therapy. But no one here would believe me.

    1. WilliamLawrenceUtridge says:

      No stan, we wouldn’t. But mostly we would ask “How do you know it wouldn’t have gotten better anyway? Most back pain gets better without treatment over the course of several weeks no matter what you do. Even chronic back pain gets better over time.”

      1. stanmrak says:

        Apparently you missed the part about the 15 year time-span. You want to know why the public is losing trust in the medical profession? It’s because doctors often insist that the patient doesn’t know as much about their own body as the doctor does.

        1. Andrey Pavlov says:

          It’s because doctors often insist that the patient doesn’t know as much about their own body as the doctor does.

          I hate to break this to you Stan… but we do. I had this exact argument with someone over drinks. The claim was that he knew more about his body than I possibly could because he’d lived in it for 35 years. I agreed that he knows more about how he is subjectively feeling, whether what he feels is new or he has experienced it before, etc… basically everything I ask during a good history. But in terms of the body yeah, I definitely knew more. He said I was stupid and arrogant. I put my finger on his chest and said, “OK if you know more about your body than I do, tell me every single tissue layer – in order – between my finger and the skin on your back, what sort of histology it has, what molecular receptors there are, what kinds of diseases and pathologies can happen there, and what drugs will affect it in which ways.”

          Sorry Stan, but yes, we really do actually know more about the human body – your human body – than you do. That’s kind of why we go to school for so damned long.

          1. windriven says:

            Well done. Was he able to get any deeper than epidermis?

            1. Andrey Pavlov says:

              @windriven:

              It was actually sadly more futile than that. He thought my rhetorical question was fatuous and was able to list of things like “lung, heart, rib, muscle” and felt that was sufficient. He then proceeded to try and argue that the decision making process for a cardiothoracic surgeon is “do I cut or not” and if so, you do and if not you don’t. He literally reduced the entirety of it to a single sentence binary decision and felt that it was ludicrous to spend more time, effort, and resources fancying it up so that we could get paid more.

              By this point in the conversation I was somewhat tipsy (as was he) and my fiance was glaring at me. It was almost a real life reenactment of Tim Minchin’s Storm. We were out at a local place called the Rum House with our two very good friends and it was their friend that they brought along (which is why it was the first – and last – time I ever met him). I’d apparently spent upwards of 40 minutes engrossed in the argument with the 3 others trying to ignore us until they could not any longer and my fiance was about to kill me with the daggers in her eyes when we finally decided to call it a night.

              Luckily the friends were a very good and extremely science based (though not activist/skeptic type) classmate of mine from medical school and his wife, so there were no ill feelings from them. It was about time for us to all call it a night anyways.

              1. windriven says:

                Jesus Andrey, what a night!

                I’m always amused by people who assume that the fragment of nothing that they know about some subject must amount to 90% of everything known about it by anyone.

                There is nothing like a bit of serious education about something to convince one just how little they know about anything.

              2. Andrey Pavlov says:

                @windriven:

                Yeah, it was quite a night. I was quite baffled that someone would pose the arguments he did. Those situation always leave me wondering whether my interlocutor really believes what (s)he is saying to that extent or is merely arguing whatever they can for the sake of arguing since their position is being dismantled.

                And yes, you said it well – and that is the heart of Dunning-Kruger. They feel as if they are indeed more educated and “smart” than the average bipedal primate and thus think there just can’t be that much more to be known.

              3. WilliamLawrenceUtridge says:

                Heh, once someone tried to convince me that the likelihood of life after death was 50/50, either it existed or it did not. I was…less than impressed. I questioned whether the chance of getting a bulls-eye in darts was 50/50, because you either get a bulls-eye or you didn’t.*

                In situations like those, where the complexity is unappreciated, I try to think of an example relevant to the other person’s experience. If they’re a mechanic, insist their job is easy because they just have to make the engine work when it doesn’t. If they’re an accountant, taxes are easy because you just have to figure out how much money you owe. The flaw in this strategy is that you actually have to know a fair bit about the profession in order to understand yourself the complexities of their job :(

                *That’s actually a lie, this line of “reasoning” came to me after the argument was over. Which is too bad, because it’s killer.

              4. windriven says:

                @WLU

                ” this line of “reasoning” came to me after the argument was over. ”

                Don’t you hate when that happens. I always come up with a brilliant come-back. Sadly, it is often the next day.

              5. Andrey Pavlov says:

                The French call it L’esprit de l’escalier or “staircase wit” – meaning you though of it as you were headed down the stairs and out of the place.

              6. WilliamLawrenceUtridge says:

                See also the almost-related, but always-fun TV Tropes page on Fridge Logic.

          2. Frederick says:

            Amen to that! I just a science curious geek and skeptic, And I want to learn, i already know more about my body than average ( and my wife best is a science bases doctor! always like when she explain stuff).
            Never will a said i know more my body than a doctor.
            It will be like saying a know more my car because i Love driving it for 7 years ( and I’M a enthusiast driver and car geek) than the engineer how build it.

          3. stanmrak says:

            My doctor admits that what we know about the human body is the tip of the iceberg, and all the scientific tests that can be done on a patient doesn’t change that. Sometimes, the patient does know more. A doctor who refuses to admit that is one to avoid.

            1. windriven says:

              How the hell do you get from doctors not knowing e dry thing about the human body to the patient knowing more than the doctor? That is fatuous.

              Think about it like this: My mechanic admits the he doesn’t know everything about my 2014 one-of-a-kind Dussel Elektra automobile. It just goes to show, sometimes I know more about what’s wrong with my car than he does.

              Sorry Stan but it is the doctor who should be avoiding you.

            2. WilliamLawrenceUtridge says:

              YOU HAVE A DOCTOR?!?!?!?

              My gaster is flabbered.

              1. windriven says:

                He never said it was a medical doctor.

        2. WilliamLawrenceUtridge says:

          Apparently you missed the “Even chronic back pain gets better over time”.

    2. Chris says:

      Why? Because you are selling it?

      My back pain was solved by doing some simple exercises suggested by my family doctor. Then to be careful on bending, twisting and lifting. Plus regular exercise helps to strengthen the back muscles.

      Nothing mysterious, just plain common sense.

      1. Frederick says:

        I also have back pain that fade in and out
        I do exactly the same, exercise, when i stop dong them, the pain come back, it is not super intense pain, but just enough to be annoying I have a minor scoliosis, it does not help. Anyway no need to invented a new religion or energy, or pseudo-science, just common sense and reality, the reality of how the body work, demonstrate by all the knowledge of SCIENCE. not old belief that have been demonstrate to be non-existent.

    3. Harriet Hall says:

      “I can tell you that there IS magic for low-back pain – based on my own “miracle” recovery from 15 years of lower back discomfort”

      I can tell you about another magic for low-back pain: my friend’s miracle recovery from back pain in 24 hours. On a Friday he phoned to make an appointment with a chiropractor. The appointment was for Monday. His back pain vanished on Saturday, never to return. If you claim that whatever you did caused your miracle, I could equally claim that not seeing a chiropractor also caused a miracle.

      “But no one here would believe me.”

      Do you understand, and can you articulate, exactly WHY no one here would believe you? You’ve been reading this blog long enough that you ought to have understood our reasoning well enough to state our position as if you were defending our side in a debate. Can you do that?

      1. Andrey Pavlov says:

        On a Friday he phoned to make an appointment with a chiropractor. The appointment was for Monday. His back pain vanished on Saturday, never to return.

        I’m sorry Dr. Hall, but you are clearly wrong and the answer is obvious: the chiropractor works so well that merely calling for an appointment works for mild-to-moderate acute back pain :-P

        1. Harriet Hall says:

          I stand corrected. And I even have another anecdote to support your conclusion. I had shoulder pain with restricted motion for almost a year, and it mysteriously vanished. I suddenly realized that my cure must have been due to driving past the several chiropractic offices located on the main road that we travel regularly. So you don’t even have to make that phone call! :-)

          1. Andrey Pavlov says:

            I suddenly realized that my cure must have been due to driving past the several chiropractic offices located on the main road that we travel regularly.

            The aura they emit is truly powerful! If only we blinkered Western Biomedicine reductionist physicians would be more open minded we could learn to do the same. I would love to sit at home and just have patients drive past me to get healed. Now if we could find a way to apply that to the ICU I would be all set! But of course, that should be trivial for the Universal Life Force….

      2. mousethatroared says:

        I always think of this as the hair appointment effect. No matter how terrible your hair has gotten, it will look fabulous the morning that you have an appointment to get it cut.

    4. Thor says:

      Of course we wouldn’t believe you. By using words like magic and miracle, you lose credibility. “Magic” tells us you are easily fooled (duped), as there is no such thing. “Miracle” proclaims your belief in the supernatural, which most rational people don’t subscribe to. You wear your mind on your sleeve. Kudos for not even pretending.

      1. stanmrak says:

        Do you think I care for one second if my cure was due to unproven therapies and I have fooled myself into thinking that my back no longer hurts after 15 years?

        1. MadisonMD says:

          I think you meant:
          “Do you think I care if my cure was spontaneous, yet I have fooled myself by attributing it to unproven therapy?”*
          and, if so, the answer is:
          Yes! Otherwise how to explain your post here claiming such?

          —————————-
          *It is clear from the posts above that everyone accepts that your back only hurt one time 15 years ago.

        2. Denise says:

          I had pain in my legs whenever I walked more than about half a block, for six years. No one could find a cause. I had no treatment other than in the beginning NSAIDS and ice, and then varying amounts of rest – a day, a week, a month, two months. No matter what I did, it never improved. I couldn’t walk a block without having severe pain. Six years.

          Then it suddenly went away. It’s been about five years now and it’s never recurred. Whatever it was, it healed itself, and pretty abruptly.

        3. Harriet Hall says:

          “Do you think I care for one second if my cure was due to unproven therapies and I have fooled myself into thinking that my back no longer hurts after 15 years?”

          No. Do you think we care whether the therapies we offer patients are science-based? Yes. Do you think we want to deliberately fool patients? No.

        4. WilliamLawrenceUtridge says:

          Do you think I care for one second if my cure was due to unproven therapies and I have fooled myself into thinking that my back no longer hurts after 15 years?

          No, I don’t think you care or not. And that’s why you get no respect here and that’s why your approach to patient treatment would set medicine back two centuries.

        5. Marion says:

          Stan.. stan… stan…
          I can’t list (because there are too many to remember) all the times I have had conditions: rheumatoid arthritis, colitis (diarrhea), eczema go on for years and years at a time, then spontaneously disappear, only to reappear a decade later. Back and forth.

    5. @stanmrak, It is unbelievable that intelligent people would not believe that your back pain can be treated without a scalpel or fusion or dismantling surgery.

      In a case as this I would have to disqualified from further research of the inter personal or clinical type.

      All back pain that is not caused by cancer, tumors, infections or aneurysms can be simply treated with therapy. (NO high-tech needed)

      1. weing says:

        “All back pain that is not caused by cancer, tumors, infections or aneurysms can be simply treated with therapy. ”
        I would add, with physical therapy and a lot of times without any therapy.

        1. mousethatroared says:

          ““All back pain that is not caused by cancer, tumors, infections or aneurysms can be simply treated with therapy.”

          Well I’m confused by that, how about ankylosing spondylitis?…and then there was my niece that got a fracture of the lumbar spine – what do you call them, the bits that stick out – diving. She had back pain for quite awhile before seeing the doctor, then she had to wear a shell. (okay, I didn’t sleep much of last night, so I can’t remember many words, but I bet you know what I mean). And then there was my sister who had osteoarthritis of the lumbar spine. She was in pain for years (had therapy didn’t improve), had a fusion surgery and she regained a lot of function, much much less pain.

          I mean, I guess these things can be treated with simple therapy. But does it work? Does it work as well as medication, surgery and the like? I know that it depends. But I know a lot of people who have tried pretty intensive surgery for back pain and tried to wait it out, but then got surgery and said the had excellent results. (Even to the point of feeling an improvement after waking up from surgery).

          1. “how about ankylosing spondylitis?”
            If the diagnosis is accurate, then the patient has a relatively normal life.
            If the diagnosis is not accurate or incomplete then the patient may have a dual diagnosis. One is the classic AS the other is the masquerader which is likely Myofascial Pain and Dysfunction as per Travell/Simons. Myofasical pain and dysfx is like a Grim Reaper or masquerader who will torture the patient until they want death. So if traditional therapy is not completely effective these patient will always requires therapy.

            If you only use traditional options and the patient is ok, great. But if the traditional options are not effective then The Grim Reaper has to be treated. IMO, these patients should be treated or you can let the patient suffer from neglect. That is the standard of care today, so no one will get reprimanded or sued because no one can prove the patient was ever in pain. This is what Chronic pain patients have to contend with, no one believes them, so no one cares.

            “my niece that got a fracture of the lumbar spine … She had back pain for quite awhile before seeing the doctor, then she had to wear a shell.”
            All fractures will heal within a couple months, so the pain should slowly dissipate — if the bones are not weight bearing. So if pain persists, the “fracture” may be an artifact or the diagnosis is incomplete. In these cases, the Grim Reaper is the issue and must be addressed.

            “And then there was my sister who had osteoarthritis of the lumbar spine.”
            Most if not all OA cased are simply treated with pills and should not cause incapacitating amounts of pain unless there is a dual diagnoses The Grim Reaper! In these cases, she still need ongoing therapy for weeks to years. If no therapy, then the “surgery” will be corrupted by the powerful forces of the sick muscles of the myofascial disease that originally caused the DJD.

            “ excellent results. (Even to the point of feeling an improvement after waking up from surgery).”
            There are some place in the word where they will put chronic pain patient under anesthesia which will help their pain, Valid? Only if MFR therapy is not helping. Laughing gas helps and Ketamine too.

            1. mousethatroared says:

              Once again, SSR making claims that are comple unsupported by reality. My sister had incapacitating pain (even after PT) until she had the fusion surgery and then the pain was gone. That was over 11 years ago and the pain is still gone and no, she didn’t have ongoing therapy for weeks to years. Lucky she didn’t see you*, sounds like you would have tried to convince her she had to have a bunch of “therapy” she didn’t need.

              *Actually this is not true, my sister does not suffer fools gladly…in fact it’s more like she gladly makes fools suffer. It might be quite a show.

              1. As always … everyone is assuming and blaming which is not a good environment for learning.

                An assessment is a GUESS!!!

                Ask youe sister how she is really doing. NOT of me but for her. I can’t do anything for you or her except give you real time/real life accounts from the past 100 yrs and not from the past 20.

              2. WilliamLawrenceUtridge says:

                A blood test isn’t a guess, there’s a pretty specific genotype for 90% of AS patients.

                Why you assume MTR’s sister is lying or mistaken merely because her experience doesn’t fit into your straightjacket of “all problems are caused by myofascial pain” is a mystery to me.

                Actually, it’s not. When all you have is a hammer…

                Steve, not everything is caused by myofascial pain and trigger points.

              3. mousethatroared says:

                SSR – “An assessment is a GUESS!!!”

                There’s these words called modifiers. “Sometimes, occasionally, approximately”…etc. If you are not certain of something, I suggest you communicate that with a modifier. No one can tell if you are understand you are guesstimating if you speak as if you are certain.

                The doctor whom I trust do not need to be told this sort of thing.

                SSR “Ask youe sister how she is really doing. NOT of me but for her. ”

                LOL – Sure, but it’s hard to get ahold of her between the black diamond skiing, climbing, mountaineering, intense mountain biking, race car driving*, etc

                SSR again “I can’t do anything for you or her except give you real time/real life accounts from the past 100 yrs and not from the past 20.”

                This makes no sense, How do you get real time accounts from the past 100 years? Are you like 120 Years old?

                I’d prefer the science from the past 20s, anyway. But you are right on one point. You can’t do anything for her.

                *she’s had to slow down because of her age.

              4. Your sister is fortunate, many others are not.

            2. mousethatroared says:

              SSR “how about ankylosing spondylitis?”
              If the diagnosis is accurate, then the patient has a relatively normal life.
              If the diagnosis is not accurate or incomplete then the patient may have a dual diagnosis. One is the classic AS the other is the masquerader which is likely Myofascial Pain and Dysfunction”

              For folks that might be fooled by this misinformation.

              http://www.niams.nih.gov/Health_Info/Ankylosing_Spondylitis/ankylosing_spondylitis_ff.asp#f

              Does it sound like a relatively normal life to you?

              1. That site is a basic info site that is incomplete and leaves a lot of people in the cold suffering in pain.

                When high tech science medicine fails … what are patient’s to do?

              2. WilliamLawrenceUtridge says:

                When a quack claims he can solve all problems, what’s a patient to do? Stop seeing the quack, obviously.

                That you think you know better than the National Institute of Health is rank arrogance. And note that some of the recommendations are rather far from high tech; exercise is a primary recommendation, and it’s rather low tech.

                Further, your assumption that because high-tech medicine has failed, low-tech medicine must be the solution, is a logical fallacy – false dilemma.

              3. mousethatroared says:

                @SSR – the point was you said

                “All back pain that is not caused by cancer, tumors, infections or aneurysms can be simply treated with therapy. ”

                If you “simply treat” AS (or other types of inflammatory arthritis) with therapy the patient may end up with joint damage, pain and other complications that could have been prevented with the appropriate medications.

                This is something I’d expect a doctor to know.

      2. MadisonMD says:

        Why is it so difficult for you to understand that the body can heal itself? I don’t think Stan needed surgery (who said that!?). Nor do I think his back was cured by magic. All it took was the body’s natural healing and tincture of time.

        Why oh why is the power of natural healing such a foreign concept to SSR and Stan?

        N.A.T.U.R.A.L. H.E.A.L.I.N.G.
        (NO high-tech needed, NO magic needed, NO needles needed)

        1. WilliamLawrenceUtridge says:

          Stan’s back pain could have been cured by whatever approach he took. Back pain and muscle pain in general is fairly poorly understood, particularly by front-line MDs. We have no idea if it was time or something else that cured his back pain (or even if it’s still there, or if it ever existed – there’s no guarantee that stan is even a person rather than a trope-generating machine). Back pain is a beast for which there is no really good, guaranteed treatment. What is truly unwarranted is his absolute certainty that he knows what fixed his back (and it happens to be what he is selling).

          Medicine needs more research on and information about back pain. It needs less certainty and more research (and more specialists, and better diagnoses, and more treatment possibilities, etc.)

  8. I don’t understand the constant head-scratching and indignation among the regular posters here who keep declaring, “It’s not CAM – it’s just medicine” when referring to appropriate diet and exercise modalities. The simple answer is, it’s *not* “just medicine” as practiced by the high proportion of pill-pushing, push-you-out-the-door-in-five-minutes MD’s encountered by so many of us.

    1. Chris says:

      “The simple answer is, it’s *not* “just medicine” as practiced by the high proportion of pill-pushing, push-you-out-the-door-in-five-minutes MD’s encountered by so many of us.”

      Citation needed. Do provide the documentation showing us this statistic: “high proportion.”

    2. Harriet Hall says:

      Sure, a lot of doctors neglect those areas and are pressed for time due to the “system”, but that’s a reason to improve conventional medical practice, not to abandon it for another system based on nonsense like the memory of water or imaginary subluxations or qi.

      1. False statement, a lot of the past treatment worked very well or did nothing.

        How we want to fix and medicate and use chemicals with is also a failure.

        To add overall value we should use what work and jettison what does not.

        Back, hip, knee surgery fail miserable.

    3. Andrey Pavlov says:

      Funny that. Besides all the other correct comments, perhaps you would like to take some practice medical board questions and see what they ask? Many of them will give you a vignette akin to:

      “Pt has high blood pressure, no current comorbidities, no other risk factors, what is the appropriate intervention?”

      And they list things like:

      “Diet, exercise, lifestyle modification; ARB; beta-blocker; ace-inhibitor”

      And if you pick the medication as the answer, you get the answer wrong.

      There are in fact decision algorithms for risk stratifying patients into whether lifestyle modification plus watchful waiting (or as my ID attending used to say “masterful inactivity”) is appropriate or whether a medication is needed.

      I kid you not – this is in our board exams!

      So yes, diet and exercise is “just medicine.” The fact that some (but certainly not the majority or even a significant minority*) physicians don’t practice what is established medicine – so much established that it is on every single board exam you will ever take – doesn’t make it not medicine.

      *unless you have some citation to demonstrate otherwise. But that still wouldn’t make it “not just medicine” it would mean that we have more of our colleagues to chastise.

      Here is one example from the American Board of Internal Medicine board exam practice questions (scroll down to question #9 of the embedded PPT):

      The best recommendation to convey to this patient is diet and exercise as he has a high body mass index, making Choice E (Encourage lifestyle modifications) the best answer. Additionally, he should be told that if he doesn’t control his prediabetes now, this can lead to diabetes mellitus and will likely require medical treatment in the future

      Isn’t it weird that our own medical board exams would require us to know something that is “not medicine”?

    4. WilliamLawrenceUtridge says:

      Bruce, what you are describing is a problem of the economics and politics of medicine in the United States, not “medicine” as an approach. I don’t live in the US, and my doctor does not shove a pill on me with every appointment.

      Further, there is ample information from many mainstream organizations regarding what constitutes a healthy diet, emphasizing whole grains, fresh fruits and vegetables, minimal fats and oils and lean protein. Many Americans don’t follow that advice – but it’s there, it’s easy to find, and it’s obvious. Ditto for exercise – advice to undertake at least low-impact aerobic activity most days of the week is very, very standard.

      I wonder if you could ever find a doctor that recommends a sedentary lifestyle with lots of McDonalds. I wonder if you could ever find a doctor who recommends a morbidly obese change their diet, lifestyle and lose weight.

      One cannot blame doctors when patients refuse to take the conventional advice for a healthy lifestyle. That’s a cop-out.

  9. windriven says:

    “I reassure myself by pointing out that, if you exclude exercise, diet, and manipulative therapies, vanishingly small numbers of physicians and other health care providers use anything that could in any way be considered “CAM.” ”

    With all due respect Dr. Gorski, your own words above discredit this reassurance.

    ” these CAM numbers are inflated by including items that shouldn’t necessarily be considered outside of mainstream medicine, such as massage, biofeedback, and yoga—which, let’s not forget, is merely exercise and stretching. It’s only when pseudoscientific claims are made (as is not infrequently the case for nutrition and exercise modalities like Tai Chi and yoga) that these modalities fall outside of the mainstream and become “alternative.” ”

    It does not much matter how you or I define CAM. What matters is how the public at large (and the state legislatures that license and regulate them) defines CAM and the fact is clear that CAM proponents have done a masterful job of constructing a large tent. If the average person believes that chiropractic is both CAM and perfectly acceptable for, say, LBP we are asking an awful lot of the great unwashed to assume that it is not appropriate for something else when that very chiropractic practitioner is telling them otherwise.

    CAM has won not just the battle but the larger war. Yes, there are still battles to be fought but as Jann Bellamy pointed out above, every state now licenses chiros and almost all license acupuncture and a bunch license naturopaths. She goes on to say that it doesn’t mean that insurance will pay but ACA is well on the way to solving that little problem. The tide is against us and not by just a little.

    As I have pointed out ad nauseum in these pages, the pinnacles of mainstream medicine have clasped CAM to their collective breast.

    Board certification in Delusionology might well be a fait accompli but where is board certification in SBM? Doesn’t exist. I’m guessing it never will. And at some point it just becomes too easy for PCPs to go with the flow; the Sisyphean becomes the stupid. I’m not sure that hasn’t already happened. And it will become increasingly easy for insurers to just pay for it and move on.

    So tell me, what are the forces that are marshalled to push the pendulum in the other direction?

    (chirp, chirp …)

    1. WilliamLawrenceUtridge says:

      So tell me, what are the forces that are marshalled to push the pendulum in the other direction?

      The Darwin Awards?

  10. Pedro says:

    Would you or one of the other physicians at SBM be willing to get certified in “integrative medicine” in order to critique it from the inside?

    I imagine it would produce a lot of worthy blog fodder.

    1. David Gorski says:

      I’ve thought of that. However, it would require doing an “integrative medicine” fellowship and/or doing a crapload of “study” just to be eligible able to sit for the test. In other words, as cool as it would be to do, it’s just not practical for those of us with demanding day jobs.

      1. Andrey Pavlov says:

        Haha, slightly more succinct than my answer. But I was curious as to what it really entailed and I was both surprised and entertained (and appalled, I suppose). I really am curious about the apparent contradiction that you are eligible if you are a quack but must also have an ABMS or ABPS board certification. I don’t know about the governing body of the ABPS but the ACGME and AOA don’t, to my knowledge, accept NDs/DCs/LAcs into their residencies which means it would be impossible to have that degree and get a residency. Unless you have both an MD and a quack degree and got through a real residency… but I imagine that would be an exceedingly small population of individuals.

      2. Pedro says:

        That’s entirely fair enough.

        It would obviously be bad to take talented researchers, surgeons/physicians and other clinicians away from doing potentially life-saving work.

        It would still be good to get someone with a skeptical bent on the inside – perhaps a semi-retired pysician who’s into skeptical blogging.

        1. weing says:

          @Pedro,
          It would have to be someone like Mark Wahlberg’s character in The Other Guys, who learned ballet and art appreciation just so he could make fun of them.

      3. irenegoodnight says:

        Ha! I doubt it takes much study time to pass their “test”. I bet they are very lenient in the scoring. I further bet that anyone who has read SBM’s little eBooks could could get a passing grade. The only trick would be to not keep laughing out loud during the whole thing.

        It’s a Tooth Fairy test of made up stuff, so just make up answers. How are they going to argue if you recommend homeopathy over acupuncture for “pain”?

    2. Andrey Pavlov says:

      @pedro:

      I think that would be a resounding no, unfortunately. I would probably have been the most willing except that I can’t do it for another 3 years anyways (they require board certification in any ABPS or ABMS specialty (and I have yet to go through residency since I just graduated a few months ago). But the really big clincher that will effectively preclude pretty much any science based physician from doing it is this:

      All applicants must qualify under one (1) of the following:

      a. Have completed an ABOIM approved Fellowship in Integrative Medicine OR

      b. Have graduated from an accredited 4-year naturopathic college OR

      c. Have graduated from an accredited Accredidation Commission on Acupuncture and Oriental Medicine (ACAOM) college OR

      d. Have graduated from an accredited Council on Chiropractic Education (CCE) college OR

      ….

      The board will consider physicians with a minimum of 500 points of documented training and experience in integrative medicine subject areas, as demonstrated by alignment with domains listed in the exam description.

      Since none of us graduated from quack schools the only two options are to do the fellowship or to have 500 CME credits that meet the criteria, I think it is a no-go. None of us here would go and apply for a fellowship to go leave our jobs and do a ridiculous training program for a year just for blog fodder.

      The CME credits is also only for a limited time and you must have them complete prior to Dec 1, 2016. That is more feasible but the description is rather onerous. It is something that would actually require a significant time commitment to do.

      The part that I find confusing is that an ND/DC/LAc can qualify, except that you must also be boarded in something from the ABPS, ABMS, AOA, RCPSC, CFPC (osteopaths and Canadians for the last 3) and I do not think that those degrees are eligible for residency and boarding. Perhaps the ABPS allows it, but I am pretty darned sure the AOA and ABMS don’t. I’m not certain about the RCPSC or CFPC, but I doubt it. It seems conflicting to me.

      Dr. Gorski has explained in his post about Weil’s proposed IM boards and how the ABMS rejected the proposal so he went to the ABPS. The ABPS is basically a pretty small and not well respected board certification entity. The vast, vast majority of actual physicians who are boarded are so through the ABMS.

      If you look through the rest of the descriptions it is a hoot:

      Integrative Medicine is the practice of medicine that seeks to achieve optimal health and healing by:

      Reaffirming the importance of the relationship between the practitioner and the patient
      Focusing on the whole person
      Basing conclusions on evidence
      Making use of all appropriate therapeutic approaches, healthcare professionals, and disciplines

      How that differs from “medicine” is beyond me. That is what I was taught to do in medical school and I did not learn “integrative” medicine.

      They even admit it themselves:

      According to the NIH, Integrative Medicine “combines mainstream medical therapies and CAM therapies for which there is some high-quality scientific evidence of safety and effectiveness.” Some practitioners of Integrative Medicine like to simplify the definition even further. Integrative Medicine, they say, is medicine – plain and simple.

      The rest of the page is full of howlers too.

      The exam seems fairly straightforward with a little added emphasis on “religion and spirituality” until you get to the part about CAM where you are tested on:

      Manipulative and Body-Based Medicine (e.g. osteopathic, cranial-sacral, chiropractic,
      massage)
      Energy Medicine (e.g. therapeutic touch, Reiki, Healing Touch, tai chi, qi gong, light) Movement Therapies (e.g. yoga, Feldenkrais, Alexander technique, Trager)
      Expressive Arts (e.g. art, music, dance, sound)

      In other words, pure quackery. Which kind of goes against the whole “has an evidence base to support it” part. Oh yeah, they also test on homeopathy.

      They have a section with texts that are recommended to use for study for the board exam. It may be interesting to know what the heck they actually say. There is a text on “Integrative” versions of most common medical specialties listed. I have no idea what “integrative cardiology” would be.

      Anyways, it was a good idea. And I would have done it if it were as simple as just taking the exam. But perhaps deconstructing the topics and recommended resources will suffice anyways.

      1. Pedro says:

        That’s actually quite frightening. If that info were included in the article it would probably have a different tone altogether.

        Perhaps the logorrhea is important after all!

      2. denise says:

        One good thing, board certification would make it clear that certain doctors should be avoided.

    3. Harriet Hall says:

      There’s no way I could undergo that training and keep a straight face while I offered patients a treatment I knew was not only useless but silly. It would require a dishonesty and lack of ethics that most of us simply do not have.

  11. Arrogance that modern science is better or more valid the old science.
    So all the research that was done in the past to you guys is invalid?

    Pseudoscience can be valid science if it is reliable and reproducible.

    The only CAMs, I practice are Acupuncture, needles(prolo bio steroid injections) and manipulations for pain and dysfunctions. I advise a lot of what helped folk for milinal and they are; Tai Chi, Yoga, exercise, Hot baths, Meditation, Biofeedback Prayer, CBT, Active tissue release. Some of the other CAMs, colonics, touch therapy, chelation and Homeopathy, I would not recommend.

    1. Pedro says:

      Chiropractor?

      1. WilliamLawrenceUtridge says:

        Naturopath.

      2. mousethatroared says:

        No, it appears he’s board certified in Family Medicine. Scary, eh?

        Although I still wonder if it’s just some person that has a grudge against the real Stephen S. Rodrigues MD and is trying ruin his good name. Weirder things have happened on the internet.

    2. squirrelelite says:

      How old do you mean by old science?

      Modern science is better than old science (pre-1500) because lots of people hae been working and learning a lot. As a result, we know of effects and have measurement techniques that were unheard of in ancient times.

      What interpretation would a Han dynasty Chinese healer give of an MRI scan, for instance?

      But, a key feature of science is reproducibility. Someone else has to be able to do it and get the same results. That doesn’t invalidate the research of ancients like Eratosthenes, Archimedes and Ptolemy. We just can do it better and more accurately now.

      But, reproducibility is where acupuncture fails. The results are small and hard to distinguish from the normal progress of the condition.

      And, the acupuncture researchers seem reluctant to learn from their own research. If the research shows it doesn’t matter where you stick the needles or even if they penetrate the skin, why risk infection by sticking the needles in?

    3. windriven says:

      Ah Steve, I wonder if you’re really a physician. I wonder if you went to university. In my heart of hearts I wonder if you graduated high school.

      “Arrogance that modern science is better or more valid the old science.”

      There isn’t modern science and old science, there is science. Now it is certainly true to say that modern science is more valid than science as it existed 100 or 200 or 500 years ago. That is part of the majesty of science: the constant process of refinement and improvement, always looking just a little deeper, learning just a little more.

      “Pseudoscience can be valid science if it is reliable and reproducible.”

      Pseudoscience by definition is not science. If it was reliable and reproducable it would be science, not pseudoscience. Steve, you are so full of sh!t, I don’t know how you breathe.

      ” I advise a lot of what helped folk for milinal …”

      I have a really, really good dictionary. The darned thing must weigh 25 pounds. When I get really stumped, I turn to it. And dagnabit, it has no definition for milinal. If you get a chance tell us what it means. I love learning new words.

    4. windriven says:

      @Pedro

      “Chiropractor?”

      No. Douche. Apparently with an MD – or so he claims. I simply cannot believe that anyone as disconnected from reality as SSR could have actually gotten through medical school and been licensed somewhere.

      1. I did what was required as a good soldier to get my the degrees and certifications. Then I saw all the collateral damage that I could not ignore, so instead of acquiescing, I grew in my knowledge and experiences. I have ~12 hats now: MD, Chiropractor, Physical Therapist, CBT, Counselor, Psychologist, Breathing Coach, Hypnotist, Spiritual Adviser, Career adviser, Marriage Counselor, Financial adviser, studying Metaphysical and writing etc. Is there anything wrong with that?

        1. windriven says:

          ” Is there anything wrong with that?”

          Ummm … what is says to me is that you couldn’t make it as a physician. Would you use a CPA who also ran a karate dojo, a candle store, a coffee shop and a bicycle repair shop out of his accounting office?

          But Steve, “Financial adviser”? Really? Should I hedge my index funds with DXD on the chance that the historically high sovereign debt load will lead to another financial collapse? You can tell me while you stick needles in my shoulder to cure my athlete’s foot.

          1. Asinine. You have no idea what we do in the clinic. Go and learn basic clinical medicine.

            1. WilliamLawrenceUtridge says:

              Asinine. You have no idea what scientific medicine is. Go and learn basic epistemology, critical thinking and controlled testing.

              1. You have just put the nail in this sites coffin!

                Scientist do not ignore data points no matter how old or disbelievable. Ignoring data points, especially the ones that have been tried, practiced, vetted and still a major part of health and wellness is ignorant. Applying these warped ideas on the public and doing harm is sadistic.

                Then to think that your site is the greatest since sliced bread and oppress alternatives that work is the definition of a despot. NO data point is negated — NONE. Please change the name of this site to “Illegitimate and Asine Based Medicine”

              2. MadisonMD says:

                Show us the data.

              3. windriven says:

                “Scientist do not ignore data points no matter how old or disbelievable”

                Your fantasies do not equal data points.

      2. Hey this is not about me this is about alternatives that work!! You guys can’t see it yet, but some will be a part of general medicine as they once were.

        1. WilliamLawrenceUtridge says:

          If they “work”, why do they consistently fail well-controlled tests? If acupuncture “works”, why does it not matter where you needle, if you even penetrate the skin, and why does practitioner enthusiasm matter more than anything else?

    5. WilliamLawrenceUtridge says:

      Pseudoscience can be valid science if it is reliable and reproducible.

      Um, no. Pseudoscience is pseudoscience because it adopts the trappings of science without the substance. Pseudoscience that undergoes testing and responds to the results is no longer pseudoscience. Of course, in many cases “responding” consists of admitting it is worthless and abandoning it – because much of what is pseudoscientific is predicated on nonsense. CAM is pseudoscience because it will avoid doing conclusive tests (i.e. it would be trivial to conduct a placebo-controlled trial of homeopathy, but homeopaths generally never do so because of incompetence or fear of the results), avoid doing relevant trials (i.e. conducting a survey of patient satisfaction rather than patient improvement), ignores the results of testing, or insists on a mechanism that is patently absurd (i.e. “memory of water”, qi).

      Also, science is not arrogant, it is humbling. It asks “how do you know?”, then asks repeatedly, “how do you know it’s not actually ____?” Arrogance is insisting that personal experience is sufficient to overturn and abandon all contradictory research and what is known about the body. Naturopaths, homeopaths, acupuncturists and all other CAMsters are basically only interested in science if it supports what they do, otherwise they simply ignore it as it would inconveniently require them to change how they practice. As opposed to doctors who are expected, even required, to change their practice in the face of new evidence.

      So tell me – who is arrogant again?

  12. David Gorski says:

    Pseudoscience can be valid science if it is reliable and reproducible.

    In which case, it almost certainly wouldn’t be pseudoscience. Lack of reliability and reproducibility are part of the definition of pseudoscience.

    You’re not making any sense.

    1. @David. How does one go from an epiphany, an idea, deep logical thinking and imaginative idea to the final scientific truths? You have to take those ideas through the rigors of the scientific methods. During that process you would call the ideas pseudo-science. I thought Acupuncture was a complete pseudo-science, that I wanted to learn if it could help patients. But time after time the results were reliable and reproducible. Now I’m certain that Acupuncture is NOT what you read in books. It is much more profound set of stainless steel needling options. That process took 3-5 yrs that begun in ‘97.

      1. WilliamLawrenceUtridge says:

        How does one go from an epiphany, an idea, deep logical thinking and imaginative idea to the final scientific truths?

        1) There is no such thing as “final scientific truths”, only ever-more-supported-tentative conclusions.

        2) Through rigorous testing and the continuous efforts to prove one’s self wrong

        3) Epiphanies, logical thought and imagination can propose a myriad ideas, but that doesn’t mean they accurately reflect reality and a real scientist will abandon an idea that is not supported by empirical testing no matter how compelling it seemed at first glance.

        I thought Acupuncture was a complete pseudo-science, that I wanted to learn if it could help patients

        Wow, you sound like an idiot then.

        But time after time the results were reliable and reproducible. Now I’m certain that Acupuncture is NOT what you read in books.

        What is acupuncture then? Why does it consistently fail upon testing? What is wrong with the methodologies of all of the studies that come up null?

    2. MadisonMD says:

      Making sense is not Stephen’s strongest point. For example, here is a lovely suggestion he made to Thor:

      Shake your testosterone and become enlightened and master the art of medicine or lap is the luxury of your stupidly.

      1. Shake your personal attacks, I’m an easy target we know that! It is more difficult and time consuming to read, practice and learn or go get the textbook.

        YOU do not have the expertise to know what the hell I’m referring to as it relates to needles and pain therapy. For the sake of your patients -ask or study.

        it is the corruption of science by dogmatist, I am after. “Wallow in your blissful ignorance, but don’t use you stupid to make policy that can harm others” is a good one too

        1. MadisonMD says:

          Look, dude. This is SBM. You need to put up some data or drop it. You’ve written hundreds of posts. Many of them are incomprehensible drivel. Once, you cited a paper. Once. It said this:
          1. Acupuncture has a specific needle-dependent effect on pain 7.5% of the time;
          2. Acupuncture has a placebo effect 12.5% of the time
          3. Acupuncture has no effect
          80% of the time, although pain improves anyway 30% of the time.

          So if you want to talk about these findings, go for it. In fact they are interesting when compared with your ridiculous claims. It also explains why your experience is not accepted to mean that needles work.

          If you want to put up another scientific article, then please do. But if you continue to just put up garbage; if you continue to write ridiculous nonsense; if you go on endlessly about our ‘dogma;’ if you continue to tell us how Travell and Gunn saved the universe without actually publishing any replicated scientific studies; if you continue to tell us that you are infalliable:

          Sorry to disappoint you but I can’t be wrong.

          . Well, then, friend, it isn’t compatible with science. You have entered a place where you don’t belong. And if you stick around, you are likely to get hassled. What other response can possibly be expected to an incorrigible–and often incomprehensible–unscientific practitioner on a blog called Science-Based-Medicine?

          1. “Look, dude. This is SBM.”

            “You have entered a place where you don’t belong.”

            “Acupuncture”

            The science of the past 100 yrs shows us that needles are effective. By your definition I would assume your definition of SBM is cherry picked from the last 20yrs. Please change the name to fit your belief of science. Cherry Picked from the past 20 yrs material mechanical, narrow view Science from dogmatist Medicine.

            I have to be here to warn readers of your false ideology.

            1. Harriet Hall says:

              “I have to be here to warn readers of your false ideology.”

              Haven’t you noticed that no-one has been convinced by your “warnings”? Haven’t you realized by now that your efforts are wasted? Can’t you see that you are being ridiculed here? Even more, your efforts are counterproductive: by setting such a bad example you are dissuading even more people from trying your kind of treatments. Why not use the time you spend writing these posts to better advantage plying one of your manifold trades? You could earn more money, invest it following your own financial advice, become filthy rich, and use your profits to fund proper controlled trials to test your beliefs and convince the world that you are right.

            2. MadisonMD says:

              The science of the past 100 yrs shows us that needles are effective.

              Don’t tell us, SHOW US DUDE! Link to a scientific article published sometime over the past 100 years that shows it!

              1. What is your background. If you have not read and practiced Travell/Simons, Rachlin, Devin J. Starlanyl, Pybus, Gokavi, Chaitow, Baldry, Wyburn-Mason. or Gunn … shut the hell up.

              2. Harriet Hall says:

                ” If you have not read and practiced Travell/Simons, Rachlin, Devin J. Starlanyl, Pybus, Gokavi, Chaitow, Baldry, Wyburn-Mason. or Gunn … shut the hell up.”

                If you have not read everything in the archives of this blog and have not understood the point of science based medicine and the fact that you, too, are susceptible to human error, you are the one who should shut up.

                By the way, the appeal to the authority is a logical fallacy. We require data, not the opinions of those you claim are experts.

              3. @hall
                You have just put the nail in this sites coffin!

                Scientist do not ignore data points no matter how old or disbelievable. Ignoring data points, especially the ones that have been tried, practiced, vetted and still a major part of health and wellness is ignorant. Applying these warped ideas on the public and doing harm is sadistic.

                Then to think that your site is the greatest since sliced bread and oppress alternatives that work is the definition of a despot. NO data point is negated — NONE. Please change the name of this site to “Illegitimate and Asine Based Medicine”

              4. Harriet Hall says:

                “Scientist do not ignore data points no matter how old or disbelievable.”

                SSR likes to make up his own definitions. Apparently for him “data points” = anything some guy said in a book about how he treated a patient and claimed that the patient got better. SBM calls that anecdotal evidence, or at the best, case histories that must be confirmed with controlled studies to find out whether that guy might have misinterpreted what he observed and whether the patients would have done just as well or better without treatment or with a different treatment. There are any number of “data points” from the era of bloodletting. We ignore them because they are old (prescientific era), disbelievable, and have been superseded by scientific studies showing more harm than good.

                “oppress alternatives that work”

                This site doesn’t “oppress” anything. It critiques misleading information. And if any alternative were proven to work, we would all gladly embrace it. The reason it is called “alternative medicine” is precisely that it is not supported by the kind of evidence that would justify incorporating it into mainstream medical practice.

              5. Harriet Hall says:

                To SSR: You have failed to understand what this blog is all about. You have repeatedly demonstrated that you don’t understand the need for scientific evaluation of claims, and you don’t understand that you, too, are susceptible to the kind of human errors that can only be corrected by the scientific method. Until you do, you can have nothing of value to contribute here (except as a bad example). We have been very patient, but we do occasionally ban commenters who offer insults instead of citing scientific studies, and who disrupt the conversation. Our patience is not inexhaustible, and we are getting exhausted. Consider yourself warned.

              6. WilliamLawrenceUtridge says:

                What is your background. If you have not read and practiced Travell/Simons, Rachlin, Devin J. Starlanyl, Pybus, Gokavi, Chaitow, Baldry, Wyburn-Mason. or Gunn … shut the hell up.

                So I looked up some of these books:
                - Rachlin is from 1993. A second edition is from 2002. No pubmed-indexed publications.
                - Starlanyl has at least published a new book, in 2013. It’s published by North Atlantic Books, which also publishes such delights as “Quantum Touch 2.0”, “Macrobiotics for All Seasons”, “Applied Kinesiology” and “Archetypal Acupuncture”. No pubmed results for this author.
                - Pybus I assume is Paul Pybus, who in 1984 wrote Intraneural Injections for Rheumatoid Arthritis and Osteoarthritis with Control of Pain in Arthritis in the Knee . 1984. 30 years ago. If it is so effective, why haven’t we eliminated arthritis of the knee? Why hasn’t he published anything since 1988 (a letter to the editor)?
                - Gokavi is actually Cynthia Gakavi ? Who self-published a single book Gokavi transverse technique the treatment and management of Chronic Myofascial pain Release? Who also has no pubmed publications, I note.
                - Leon Chaitow does have a variety of pubmed-indexed publications. Most of which are from the Journal of Bodywork and Movement Therapies. Of which he is the editor. Judging by the contents of the journal (a lot of case studies, pragmatic trials and a lot of chiropractic attention, I don’t hold out much hope for the quality of the editorial and peer review board. He also apparently thinks Candida is a big deal. Oh, and he’s a British osteopath. They’re lunatics, aren’t they?
                - Baldry is Peter E. Baldry I assume? Nothing on pubmed (unless he was a practicing pulmonologist in the 60s), two books on Amazon, one oddly published by Churcill-Livingstone, which seems to sell a variety of text that range the gamut from hard-core biochemistry to nonsense like Traditional Chinese Medicine and naturopathy.
                - Wyburn-Mason must be Roger Wyburn-Mason, simply because he looks like a loony-tune. “Everyone else is wrong!”, “All arthritis is caused by one thing!”, “Candida causes all your problems!”, “Alcoholism is caused by allergy to alcohol (???)!”, “Remove your mercury fillings!”, and of course, “BIG PHARMA!” I wonder if there is a single trope in the “natural is better” playbook that he doesn’t use.
                - Gunn at least has some publications, but as has been dealt with elsewhere, you are citing the books, which are old, and even within the “trigger point community” his explanations (and in particular his needling technique, which I will give him credit for, abandons much of the nonsense that is problematic with acupuncture) are considered simplistic and questionable. You are pointing to his opinion as if it were proof when it is really just speculation that hasn’t been validated in controlled clinical trials.

                Merely because something is published in a book you have read, doesn’t make it true. The Protocols of the Elders of Zion and Mein Kampf (GODWIN FTW!) were books that many people read, that didn’t make them true.

                See, the thing is – all of these authors appear to have one thing in common, which they share with you. They appear to base their conclusions on how impressed they were with the clinical effectiveness of their pet interventions. Thus, all have the same flaw – how do they know they were effective due to their intervention? How do they know that it wasn’t simply the passage of time? Or anything else the patient was doing? Or simple reassurance from the care provider? Pain is centrally-mediated, after all, so simple reassurance could be a factor in at least some cases in “dialing down” the urgency, intensity or emotional burden of the raw sensory stimuli.

                And that is why we don’t take your anecdotes seriously. This is a complex area, you are treating it as if it were simple. You are being naïve and arrogant in assuming you have the answer, rather than recognizing that you might, at best, have only a portion. Mechanical stimulation probably does help, for some patients, for some types of pain. But not necessarily all, and above all this one frail truth you may have does not invalidate all of medicine. That is rank, dogmatic arrogance.

              7. MadisonMD says:

                Scientist do not ignore data points no matter how old or disbelievable. Ignoring data points, especially the ones that have been tried, practiced, vetted and still a major part of health and wellness is ignorant.

                You keep talking about all this great data. Talk is cheap. SHOW US THE DATA WE ARE IGNORING!

              8. windriven says:

                @Silly Rodrigues

                “Scientist do not ignore data points no matter how old or disbelievable.”

                I have yet to see you offer actual data. Anecdotes? Yes. Wishes? Yes. Fantasies? Yes. Data? No.

                Further, scientists certainly do ignore data that is not believable. That is part of how science works. We might think something is true, we test it, perhaps find that it isn’t true, and then we change our position based on the new information. What a concept. You might give it a try.

              9. @WilliamLawrenceUtridge.
                Then change the name of this site to “pubmed publications is all the science we believe in” based medicine. You are not scientists but research article analyst and have no clues as to how a therapy will act in the real world.

                There are a many others
                http://www.ncbi.nlm.nih.gov/pubmed/23629597
                http://www.ncbi.nlm.nih.gov/pubmed/23593553
                http://www.ncbi.nlm.nih.gov/pubmed/24352752
                http://www.ncbi.nlm.nih.gov/pubmed/24597999

                I will ping in to counter any statements that falsely malign the alternatives that work.

              10. WilliamLawrenceUtridge says:

                You are not scientists but research article analyst and have no clues as to how a therapy will act in the real world.

                Hi Steve,

                Nope, not a scientist, just a critical consumer.

                See, there are always two explanations to not finding an effect. First, you did it wrong. Second, there is no effect. When thousands of studies have been performed, and you still don’t know if there’s an effect, perhaps there is no effect.

                One of your studies is a case study of what is really TENS. We know TENS works. Sticking in a needle then electrifying it is not acupuncture or trigger point therapy. It’s TENS. And case studies are shit, the very starting point of hypothesis generation.

                One of your studies is a small-n comparison of dry needling versus physiotherapy. First off, is acupuncture dry needling? An interesting question. Second – the two groups were indistinguishable. Physiotherapy has the advantage of not penetrating the skin.

                Another study is of the use of CAM with anxiety and mood disorders. There’s a significant placebo component here, and a lot of “CAM” is actually exercise and relaxation – both of which are helpful mainstream modalities. However as a literature review I can’t really analyze it without going into its primary sources, which I’m not going to do – but garbage in, garbage out.

                The last one I’ll talk about actually looks decent – control groups (though what is the “placebo-sham” group actually getting?) and reasonable numbers. Congratulations! You’ve got a starting point for a program of study that could eventually lead to the validation of myofascial pain treatment through deep needling stimulation! Hopefully the authors continue their work and eventually if found consistent and the active, effective treatment identified, this can be adopted widely and spare a bunch of people pain! You’ve finally provided something worth talking about!

                Why did it take you so long?

              11. MadisonMD says:

                Agree with WLU mostly. I also had a look at SSR’s citations. Let’s start with #2-4 which as pointed out by WLU clearly don’t support his assertions:

                1. (Couto et al.) Unfortunately this is behind paywall and I do not have access to this journal through university library. Looks like a positive study supporting the use of dry needling–so far so good. But there are some issues. First, there is no discussion of blinding, only “placebo-sham,” leaving open that some or all of the observed possibility was due to placebo effect. There was no primary endpoint specified and multiple comparisons are made, so multiple hypothesis testing could be an issue. Yet, these might not be major problems. Incidentally the article was reviewed by Paul Ingraham here Paul noted that the abstract neglected to say how much better the pain was with dry needling– and it turned out to be an improvement of 2 on a 10-point scale.
                2. (Rainey) is a case report of TENS as pointed out by WLU.
                3. (Rayegani et al.) is a small RCT of dry needling versus physiothearpy for myofascial pain syndrome. There was no difference in outcomes for either group. So, SSR is showing us that patients would be just as well off with physiotherapy… but really doesn’t demonstrate that either is effective.
                4. (Bazzan et al.) is a CAM review about treatment of mood and anxiety disorders. Not sure why he linked this b/c it is devoid of primary data and is not about treating pain. ???

                —–
                So congrats, SSR, one of your 4 cited articles actually provides some limited data to support use of dry needling for one pain syndrome… although unsurprisingly the effect is much more modest than you claims. Also, it is not clear how much was placebo effect without knowing about blinding.

              12. MadisonMD says:

                I got access to Cauto article after all. It is a study demonstrating the effect of electrical stimulation through needles (not clear from abstract).

                It is registered at clinicaltrials.gov here.

                It turns out that the control group was needled without stimulation whereas the intervention group had electrical stimulation. So this shows effect of electrical stimulation– which is unclear from the abstract. There was a good attempt to blind subjects, which might not have worked:

                The electrical connection between the stimulator and the patient was broken at the output jack plug of the stimulator so that no current could pass to the patient. The patients were informed that this was a high-frequency, low-intensity stimulation and that they would most likely feel no sensation from it.

                Subjects received treatment 2x/week x 4 weeks. Pain scores started at avg 65/100 for all groups, and declined to mean of 40/100 in control and 15/100 for electrical muscle stimulation, meeting the primary endpoint of the study. There is no assessment of durability of the improvement.

                So, aside from the understandable difficulty in blinding, a fairly decent study which shows a modest effect of electrical stimulation of muscle in reducing pain.

                This obviously does not support Rodrigues’ claims. So actually the score is 0/4.

              13. Cherry picking in the science world is a personal choice which invalidates your conclusions. I knew additional information was not going to be integrated into your thought processes. Scientist do not stand firm on any conclusion and is alway ready to update, reevaluate and reconsider a position as more information is presented.

                Yall are stuck, by choice or by mandate. At least if it is my mandate you are doing a good job. By choice, gee no one can help you, You will remain lost in space until you get medication or seek counseling.

              14. MadisonMD says:

                Your citations don’t support your conclusions. because the studies don’t test your intervention.

                If I claim that pigs can fly and offer this and this as proof, you would find it compelling? Similarly, you are linking to studies that have no bearing on your claims.

                You might do better if you read the studies you link to. It’s clear that you didn’t. WLU and I did.

                SSR, I am truly embarrassed for you. Your patients can search your name and read these blogs. I really think it is in your best interest to stop displaying your ignorance.

            3. WilliamLawrenceUtridge says:

              The other thing to think about is whether any are better than usual care, or no intervention whatsoever. A “no treatment” arm would be very informative. While the relief of acute pain is a good thing, if all groups are identical three months out then you’ve got yourself a conundrum. Is it worth it in terms of economics, time spent, training investment, quality of life, etc?

              And before Steve claims that this is some sort of special pleading to wave away the first positive study he’s ever been able to produce – this is what science is. It is endlessly critical. That’s why it is a group exercise – to poke holes, to find flaws, to force improvements. You don’t get to cherry pick results that support your assumptions and ignore the rest, and you don’t get to whine when someone suggests an alternative explanation. Reality is complicated and papering over that complication with an aversion to criticism isn’t helping anyone. Science grinds slowly, but it grinds finely and over the long term, produces conclusions that can be trusted. Even well-established knowledge is expected to be questioned, and if you are the lucky dog who manages to prove it’s wrong, even in some minor detail, the community celebrates at an improvement in knowledge.

              1. WilliamLawrenceUtridge says:

                Oops, replied at wrong level, meant to arrive just after these comments.

            4. WilliamLawrenceUtridge says:

              Cherry picking in the science world is a personal choice which invalidates your conclusions.

              Cherry-picking is indeed a problem, which is why meta-analyses have rules and protocols in place to determine which studies are included and which are excluded.

              Cherry picking (and special pleading, and false dilemmas, and arguments from personal incredulity and arguments from personal experience, and the use of anecdotal data, and a host of other fallacies) is mostly a problem among quacks and proponents more interested in promoting than debate. If an effect is real, it shows up in the data and you don’t need to ignore the rules of logic and evidence to support a position.

              I knew additional information was not going to be integrated into your thought processes.

              You gave us additional information. We pointed out how one of the studies you presented was a reasonable early clinical trial (and followed-up with why it wasn’t necessarily a miracle cure). The rest of your studies and sources we also evaluated and found them wanting. It’s not our fault you support your points with shitty data. You need to either get better data, or stop even pretending science matters to you.

              Scientist do not stand firm on any conclusion and is alway ready to update, reevaluate and reconsider a position as more information is presented.

              You say this as if it were a bad thing. Or as if it weren’t something we have been saying repeatedly. Or as if you’ve presented enough information that should make us reconsider our position. In any case – no duh, this is a feature, not a bug.

        2. WilliamLawrenceUtridge says:

          Again, “dogma” is someone who insists upon an idea’s correctness despite ample evidence to the contrary. Pointing out that acupuncture is not supported by our knowledge of anatomy, phyisology, microbiology, chemistry and physics is not “dogma”. Pointing out that acupuncture is indistinguishable from placebo in well-controlled tests is not “dogma”. Pointing out that it doesn’t matter where you put the needles, whether you penetrate the skin, and that qi does not exist (and further, that practitioner enthusiasm is more important than anything else) is not dogma. It is inconvenient reality smacking you repeatedly in the face.

          If what you are doing is better than simply a nice conversation over a cup of tea, then test it. Find out what part is useful, what can be discarded, and how to apply it so it is reliable and teachable. Stop insisting that you’re right because you see patient improvement. Bloodletters and priests saw patient improvement as well (except for all the patients that died and were forgotten). It’s very, very easy for memory to be self-serving, to skip over the patients that didn’t improve, to minimalize or brush off the ones who got worse.

          Insisting you are right in the face of contradictory evidence is what makes you dogmatic, and means you expect us to believe that you are somehow the sole infallible human being on the planet, despite nigh-7 billion who are not.

        3. PMoran says:

          SSR: “Some of the other CAMs, colonics, touch therapy, chelation and Homeopathy, I would not recommend”

          Why not, SSR? People report feeling better from these, and their practitioners are often just as convinced as you are about the benefits of their methods and its rationale. Is this not all that you offer?

          This is one of the matters making it difficult for the mainstream to endorse methods that might “work” (in subjective and psychosomatic states), but mainly via placebo and non-specific influences.

          Where do we draw the line? We can be cautiously sympathetic towards people having access to CAM methods should they wish to try them, especially when the mainstream has no entirely satisfactorily answers, but still support the mainstream in not endorsing them for routine medical care.

  13. Edward C. Holmes, DC says:

    No. Keep up the good work at SBM.

    1. I am totally disappointed in this site. What good does a strict narrow dogmatic view if it does not help patients. I see a large percent of the failures of SBM and it’s a travesty of justice and medicine.

      1. WilliamLawrenceUtridge says:

        Nobody keeps you here.

        Nobody makes you post repetitive comments.

        Nobody prevents you from engaging with the scientific literature.

        Nobody forces you to claim all of medicine is wrong because it doesn’t address one symptom you have a fetish for.

        You are the only one that can acknowledge your personal and clinical judgment are in error.

    1. Short sighted … yes even NPR!

  14. Alex says:

    I find it funny you state Gerson doesn’t work, and Charlotte Gerson is apparently in it for the money….Wait whats this I see at the top right of your page to “donate” or burn money away to medical science. We already have cures idiot.

    1. Chris says:

      “We already have cures idiot.”

      Citation needed.

      1. Josh Berndt says:

        My BS meter always goes up when the words “worked” or “works” are used. Most of the time it is referring to pain. Which according to the IASP definition is 100% an output from the brain. This is where the waters become muddied. When you claim an intervention “works” because pain decreased, all you know for sure is that your brain is perceiving less threat today than it was yesterday. That could be from the weather, more sleep, meds, a hug from a kid, we don’t know for sure. However a common error in CAM is attributing the decrease in pain to fixing energy, CSF flow, subluxations, hitting the right meridian with a needle. The larger error is using this faulty logic to explain the existence of said CAM target when it is completely falsified under scientific scrutiny.

        Medicine is guilty of having a poor understanding of pain as well, but the research in real peer reviewed scientific journals is mounting and helping us understand the neurobiology of pain. We are trying to do a better job on the front end in regards to acute pain to stave off the chronic pain states many people are in, but still fall short.

        In my opinion once the patient is given accurate science based explanations and treatments in the primary care settings across the country with appropriate follow-up, we will see fewer patients seeking CAM and magic cures that “work”

    2. WilliamLawrenceUtridge says:

      The “donate” tab supports only this website, not medical research in general.

      Charlotte Gerson is providing, and charging desperate cancer patients for, treatments that have not been shown to work. She may be doing it with the best of intentions, but that doesn’t mean it cures cancer. In fact, tests of Gerson’s successor, the Gonzalez protocol, was tested and it turns out that patients die faster, in more pain, compared to conventional treatment. A pious fraud is still a fraud, and an ignorant fraud is still a fraud.

  15. Marion says:

    This subhuman moron Stephen Rodrigues can’t even name one serious condition that accupuncture can cure or make better which cannot be made better faster cheaper & provably so by actual medicine or surgery.

    1. What is your background. If you have not read and practiced Travell/Simons, Rachlin, Devin J. Starlanyl, Pybus, Gokavi, Chaitow, Baldry, Wyburn-Mason. or Gunn … shut the hell up.

      1. WilliamLawrenceUtridge says:

        Hi Steve,

        See my comment here.

    2. windriven says:

      Well said, Marion. Subhuman might be extreme – I do believe Steve to be human. But I won’t quibble with moron.

      And darn it Marion, until you’ve been to Hogwarts you should just STFU and accept it on faith that pigs fly and Justin Bieber is a moosical genius.

      1. Ignoring data points from any legitimate scientist with altruistic intentions is not scientific that is just stupid.

        1. WilliamLawrenceUtridge says:

          “Altruism” is irrelevant. It can even be a form of bias, when someone is filled with the self-righteous conviction that their cause is noble and too important to wait for something as trivial as evidence. One could call it the “think of the children” effect.

          You keep coming up with alternatives to and rationalizations for why your particular pseudoscientific fetish doesn’t have, or doesn’t need, evidence that it works. I will point out the obvious fact that this is a distraction from the fact that this does not replace the missing evidence, it is merely a distraction. If acupuncture, needling, whatever actually worked this should be see in the scientific literature, after there being thousands of trials on the topic.

          Just admit that you don’t have any evidence sufficient to convincingly demonstrate your case. Just admit that you are basing this on a hunch and hopeful wishes. You’ll get much more respect (assuming you also stop dogmatically asserting that you are right and everyone else is wrong).

          And also, of course, even if you are right about The Cause Of All Pain, that doesn’t mean all the rest of medicine is wrong.

          1. @WilliamLawrenceUtridge:
            “Altruism” is irrelevant.” Without a nobel motivation it would be difficult to believe any human being who has the ability to bend the truth. Inanimate science does not need a noble intent because it can be verified easily by anyone. The Science of medicine has to be done without bias, financial incentive, egos, power or any gain for it to be as reliable as possible. Why? Trust and how difficult it is to duplicate or replicate a trial. Remember (not sure of the counts) but most trials are not replicated. I don’t trust you — don’t take it personal because you have not shown any respect for another scientist indicative of your insecurity with your ability to determine what is truth.
            “It can even be a form of bias, when someone is filled with the self-righteous conviction” Gee just because I have done 10 yrs studying alternative therapeutic options and have actually used some of the modalities, YOU think my observations are bias and self-righteous not just different or more informed. An ignorant fool will blame the messenger and not truly do the necessary leg work to verify the message. Hey guess what, I am here to expose some of your scientific methods faults, so take them and used to increase your credibility.
            missing evidence” You and your buddies have chose to dismiss the evidence, I keep posting the authors and I wonder if anyone has actually looked into the leads? http://jama.jamanetwork.com/article.aspx?articleID=1835483&utm_source=Silverchair%20Information%20Systems&utm_medium=email&utm_campaign=MASTER%3AJAMALatestIssueTOCNotification03%2F04%2F2014
            “You’ll get much more respect” Please you do not have to worry about me, my importants is irrelevant compared to the prior authors and all of their diligent work. I would want you to respect yourselves, the art of medicine, patients who fail traditional medicine without other viable options and become better scientist.

            “even if you are right about The Cause Of All Pain, that doesn’t mean all the rest of medicine is wrong.” You have misunderstood my posts, related to pain. Travell’s quote “Chronic pain is myofascial until proven otherwise by myofascial release therapy with hands-on and with needles”

            1. WilliamLawrenceUtridge says:

              Without a nobel motivation it would be difficult to believe any human being who has the ability to bend the truth.

              Yeah…ever heard of a pious fraud? You think people haven’t lied with good intentions? Science can’t be done without motivations, bias and whatnot – it’s done by people. That’s why evidence and consensus, public consensus, must be the touchstone and turning point. It’s amazing to me that you still don’t know enough about science, after all these comments, to realize where you go wrong about it.

              Also – your statement about how few studies are replicated? What does it say about the study you posted today? Has that been replicated? Should we trust it more merely because you believe it to be true and it plays to your prejudices?

              Yes, there is a letter to the editor about acupuncture being supported, by Vickers and Linde, presumably based on their 2012 meta-analysis. There are also numerous other letters to the editor, discussions and meta-analyses that conclude acupuncture is useless, or an elaborate placebo. It’s a complicated question, one that’s not settled, but one that is still answerable with “placebo effect”.

              Gee just because I have done 10 yrs studying alternative therapeutic options and have actually used some of the modalities, YOU think my observations are bias and self-righteous not just different or more informed.

              No, I think you are uninformed because you consistently, until today, have only cited old books and shoddy sources to support your point, how you ignore the large number of sources that contradict your opinion, and how you have consistently failed to recognize how your clinical experience can deceive. I’ve said this repeatedly. You haven’t done any leg work until today, just cited old and poor-quality books, as if we were going to read them all.

            2. MadisonMD says:

              So you link to Vickers and Linde review of acupuncture meta-analysis again? Here is the bottom line of what you linked to:

              Acupuncture is associated with improved pain outcomes compared with sham-acupuncture and no-acupuncture control, with response rates of approximately 30% for no acupuncture, 42.5% for sham acupuncture, and 50% for acupuncture.

              i.e.
              acupuncture works 7.5% of the time (acupuncture-sham)
              sham acupuncture works 12.5% of the time (sham-no treatment)
              and no treatment works 30% of the time

              Ergo, this does not support SSR’s assertions.

            3. MadisonMD says:

              @SSR

              I keep posting the authors and I wonder if anyone has actually looked into the leads

              Funny you should ask. Your article is a clinical summary of a meta-analysis covered on SBM…. twice… here and here.

              You really need to read more.

  16. What is your background. If you have not read and practiced Travell/Simons, Rachlin, Devin J. Starlanyl, Pybus, Gokavi, Chaitow, Baldry, Wyburn-Mason. or Gunn … shut the hell up.

    1. WilliamLawrenceUtridge says:

      Hi Steve,

      My comment here addresses this claim that you have posted repeatedly.

    2. David Gorski says:

      Stephen S. Rodrigues:

      Chill man. You’re getting a bit too—shall we say?—frisky. (Obnoxious, actually.)

      Tone down the insults. That goes for everyone. For you, there won’t be a second warning.

      In other words, if you feel the urge to tell someone here to “shut the hell up,” it’s time for you to shut the hell up.

      1. @David have you heard the vitriol in this place, why are you singling me out?

        Why not have some type of decorum? Personal attack should not be allowed.

        Attack the data by doing due diligence from the past > 100 yrs not the past 20. The last few decades of research has been funded by business and has in my opinion and others to be tainted. Modern researchers dismiss all the work done by our predecessors.

        Remember discounting a data point is a personal choice and thus is not part of any aspect of science.

        1. windriven says:

          “Why not have some type of decorum? Personal attack should not be allowed.”

          Because you are batsh!t crazy – or at least you talk as if you are. People didn’t start jumping on you the moment you arrived here. But Stephen, you have written countless comments, none of them backed with anything like meaningful scientific evidence, all proclaiming the power and majesty of acupuncture.

          This site is called Science Based Medicine for a reason. I recognize that you believe that your clinical observations constitute scientific evidence. many commenters here have tried unsuccessfully to explain to you why they are not. But their explanations flow off you like water from a duck.

          For a while I posted the same response to everything you wrote. I did that for a reason: because each of your comments, though they may use different words, say the same darned thing. Repeating something that isn’t correct doesn’t make it correcter (!). It makes it tiresome.

          Science has moved a long way in the past 100 years. 100 years ago Einstein had just published special relativity. Germ theory was only a couple of decades old. Evolution was still controversial. The structure of DNA was still far in the future.

          “Remember discounting a data point is a personal choice and thus is not part of any aspect of science.”

          Explain the data point that is being discounted and back it with accepted scientific evidence.

          1. I don’t think data points are relevant to you or some on this blog. You have corrupted the word science and I would like someone here to defend that use of that word. I really do not think you understand science. Sorry to tell you this.

            Here goes again. http://jama.jamanetwork.com/article.aspx?articleID=1835483&utm_source=Silverchair%20Information%20Systems&utm_medium=email&utm_campaign=MASTER%3AJAMALatestIssueTOCNotification03%2F04%2F2014

            1. @ windriven. You have to belief that science is 100% and that is your error.

              @windriven or any one of you who are research hawks and not on the frontline.
              What are providers to do when an appendectomy does not relieve abdominal pain? (Oh the CT was positive and the path report was “normal” and all the other test are normal)

              Hint: You will not be able to figure it out unless you use the age old scientific methods of trials and errors or try and see.

              What are the unlikely causes?

              1. windriven says:

                “You have to belief that science is 100% and that is your error.”

                What do you imagine science to be, Steve? Science is nothing more than a carefully organized methodology for understanding reality.

                Your objection, if I can paraphrase you, is that science does not recognize your observations as evidence. many of us have tried to explain why your anecdotes do not rise to the level of evidence but it is quite clear that you do not understand. I, for one, have concluded that this does not owe to poorly structured explanations.

                “What are providers to do when an appendectomy does not relieve abdominal pain?”

                I am not a surgeon nor a physician, but I have observed a number of appendectomies. Appendicitis can, of course, be misdiagnosed. But once you get into the abdominal cavity there is no mistaking a ‘hot’ appendix – even for someone untrained.

                But returning to your point, it is important to understand – at least to try to understand – why there is abdominal pain. Diverticulitis? Intestinal torsion? Ectopic pregnancy? Gastroenteritis? That is why medical schools spend lots of time on differential diagnoses.

                Importantly, the appropriate treatment regardless of Dx is not going to be acupuncture.

              2. MadisonMD says:

                The funny thing, Windriven, is that he has linked to Linde and Vickers without actually reading/understanding the abstract which clearly says that pain gets better 30% of the time without any intervention.

                Right there *boom* goes the anecdotes.

              3. WilliamLawrenceUtridge says:

                Windriven clearly doesn’t think science is infallible. I would venture that none of us do. Our consistent criticism of you has been your belief that your personal experience is sufficient to overturn science. That and your willingness to cherry-pick science when it supports your point, and to forgive the flaws of those items that reinforce your existing beliefs.

                For you, science is a tool to avoid changing your mind, to prop up whatever you happen to currently believe. For you, your conclusion dictates your premises, evidence, etc. Reinforcing one’s existing beliefs is easy, humans do it pretty much automatically.

                For actual scientists, science is a tool to discover what is real and understand reality. Reality dictates premise and conclusion. Illuminating reality is hard, and it took tens of thousands of years of development to arrive at a state where people stopped assuming they knew and started asking if and how they knew. But since that set of questions began to guide research, the progress has been dizzying.

                Humanity and medicine has lived short lives and suffered because of the kinds of comforting delusions you currently hold. You should abandon them, and start to ask if you’re right rather than assuming you are.

            2. windriven says:

              “You have to belief that science is 100% and that is your error.”

              What do you imagine science to be, Steve? Science is nothing more than a carefully organized methodology for understanding reality.

              Your objection, if I can paraphrase you, is that science does not recognize your observations as evidence. many of us have tried to explain why your anecdotes do not rise to the level of evidence but it is quite clear that you do not understand. I, for one, have concluded that this does not owe to poorly structured explanations.

              “What are providers to do when an appendectomy does not relieve abdominal pain?”

              I am not a surgeon nor a physician, but I have observed a number of appendectomies. Appendicitis can, of course, be misdiagnosed. But once you get into the abdominal cavity there is no mistaking a ‘hot’ appendix – even for someone untrained.

              But returning to your point, it is important to understand – at least to try to understand – why there is abdominal pain. Diverticulitis? Intestinal torsion? Ectopic pregnancy? Gastroenteritis? That is why medical schools spend lots of time on differential diagnoses.

              Importantly, the appropriate treatment regardless of Dx is not going to be acupuncture.

              1. Hmmm. That was to show that all of high-technology as well as modern medicine is fallible. Why? Humans are fallible.

                Observations and imagination are at the core of biologic and physical gee ALL science. Whether you believe me, it or not.

                Do you believe the researcher who interviews the patients in a trial? You have to believe somebody to accept conclusion.

                Why believe them and not my finding? What if it was published?

                Science bias is causing our present healthcare crisis and the number of failed and miserable people. Hmmm easy to lambast me but harder to have empathy for all those suffering souls. Continue to hide behind your absolutist science for the sake of saving money.

              2. WilliamLawrenceUtridge says:

                Hmmm. That was to show that all of high-technology as well as modern medicine is fallible. Why? Humans are fallible.

                Duh. This is known, that is why research continues to try to discover the basic underpinnings of disease and suffering, and iteratively attempts to reach consensus on diagnostics and treatment.

                Observations and imagination are at the core of biologic and physical gee ALL science. Whether you believe me, it or not.

                Um, wrong. Prediction is at the core of all science. Imagination suggests ideas, observations test them, specific predictions is what allows science to advance – that and the abandonment of ideas that fail testing.

                People had lots of imagination and observation. It has always existed. People have come up with many imaginative reasons to explain their observations, and many observations that appeared to explain their imaginations. Prediction and testing is what tore away the wrong ones, and illuminated the true ones.

                Do you believe the researcher who interviews the patients in a trial? You have to believe somebody to accept conclusion.

                Yeah, that’s why clincial trials tend to have strict inclusion criteria, to remove some of the unpredictabilities that accompany clinical judgment. That’s why objective measures are given pride of place for many medical situations. Removing wiggle-room removes some of the ability to self-deceive.

                Why believe them and not my finding? What if it was published?

                If your findings were published, I would point out that they were conducted in an uncontrolled case series that completely precludes any conclusion on causality. All you could say was “I did this, and this changed”. How do you know that change is due to the intervention, and not merely the passage of time? Even more specifically – how would you know what part of your intervention caused the change, assuming it was causal? How do you know it was mechanical pressure, versus compassionate listening, versus practitioner confidence, versus the chairs in your waiting room?

                Publication is one aspect of the scientific enterprise. What you have here is the charicature of science, that is to say – pseduoscience. You’re like the antivaccination nutters who point to Medical Hypotheses articles and say “look! It’s published, so I’m right!”

                No, you’re not. Publications are great, they are a necessary step, but they are still only a single step.

                You are still showing that you don’t understand science.

                Science bias is causing our present healthcare crisis and the number of failed and miserable people.

                Are you sure that economics doesn’t play a part? Most other countries in the world, particularly the first world, have publicly-funded health care systems that produce better care for less money. Most have some sort of quality control or best practices bodies that help guide the standard of care.

                Continue to hide behind your absolutist science for the sake of saving money.

                Have you evern seen any of the comparisons of US health care versus other countries? The current system doesn’t save money. The science is irrelevant. In fact, the science is pretty clear, and if people followed the science (vaccines, clean drinking water, exercise, sleep, fresh food, low stress, no smoking), health care would save a lot of money. Science isn’t the problem, people who don’t follow the science contribute far more.

            3. windriven says:

              “Here goes again.

              Sorry, but I do not subscribe to JAMA and don’t have access. The abstract provided with the link is not even useless. But without knowing anything about the study design or number of subjects I must say that acupuncture doesn’t look materially better than placebo.

              1. Just as I suspected you all need to change the title of this blog!

                http://www.ncbi.nlm.nih.gov/pubmed/24595780

              2. WilliamLawrenceUtridge says:

                Yeah…that’s a letter to the editor.

              3. MadisonMD says:

                Actually, its a clinical discussion of the old Vickers et al. meta-analysis covered on SBM by Dr. Novella here and by Dr. Gorski here.

                It also says that chronic pain improves 30% of the time without any intervention which explains why SSR is so mislead by his anecdotes into believing his intervention works.

              4. A bean counter without full access to all the beans?

              5. WilliamLawrenceUtridge says:

                So…details aren’t important when they don’t support what you already believe?

            4. WilliamLawrenceUtridge says:

              Steve, every comment you have made shows every indication that you don’t understand what science is. You seem to be saying “science is whatever supports what I already believe in”. Well, that’s wrong. You waving about a single reference as if it obviated all other criticisms of acupuncture is not science, and the fact that you do it repeatedly is proof of your faulty understanding.

              Science is about challenging and testing what you already believe. It is iconoclastic. It is self-critical. It asks “Why? Why not?” It encourages new, better data. Science knows it is not 100%, that’s why it keeps on trucking. If science knew everything, it’d stop.

              1. The material science of modern medicine is not self-critical.

                Once a product get on the market it stays until it kill or mames and the cost-benefits dictates it’s removal.

                Have yall done reviews of present protocols as knee arthroscopy? Where is the article that states “it does not work”?

              2. WilliamLawrenceUtridge says:

                The material science of modern medicine is not self-critical.

                Yes, you’re right. That’s why medical practice never changes. That’s why a saying in medical school isn’t “50% of what you learn will be worthless by the time you retire, but you don’t know what 50% it will be”.

                Once a product get on the market it stays until it kill or mames and the cost-benefits dictates it’s removal.

                Yes, but a) it does happen (natalizumab, recoxifeb) and b) how else would that happen? We can’t know in advance all rare adverse effects – that’s why we need postmarketing surveillance. What’s the alternative? The FDA already gets grief for being too slow in the approval of new drugs, further restrictions would make it worse. Sick people really, really want to get better, and myofascial release will only help a tiny minority.

                Have yall done reviews of present protocols as knee arthroscopy? Where is the article that states “it does not work”?

                Please note the first sentence. I could probably find a better article, but this is sufficient to note that knee arthroscopy is not considered settled science.

                http://link.springer.com/article/10.1007/s00264-013-1896-3#close

              3. MadisonMD says:

                Have yall done reviews of present protocols as knee arthroscopy? Where is the article that states “it does not work”?

                Wow, just wow. Stephen, we already discussed this NEJM article that states that knee arthroscopy doesn’t work. How could you forget– an article that actually supports some of your notions?

                You even said it was a good article! Perhaps you forgot because you didn’t actually read it and were too busy bloviating about needles? And then you later and falsely claimed that everyone here supported surgery without evaluating the science. Way to advance the discussion, Stephen.

                You need to read, think, understand, and thereby retain more.

        2. David Gorski says:

          This is not an argument, and you do not have a say regarding moderation policy. You are flooding/hijakcing threads. Settle down. I will not warn you again.

          1. @David, Is that aimed at me? Because I debating, arguing discussion with information that is from every aspect of basic observation, imagination, creativity, deduction, without denying what history has worked so diligently to uncover. If want to have a doctor to doctor consultation we had do so my phone or skype.

            1. WilliamLawrenceUtridge says:

              Question – is this part of some “poke the bear” routine so you can get banned and thus claim “censorship”, saving face at the same time?

              Just wondering what your planning horizon is.

              1. mousethatroared says:

                He’s playing a game. The object of the game – the person making the most comments making the least sense wins.

                I’m pretty certain that I could beat him – but I understand how nonsense hurts the sensibilities of the skeptical crowd, so I won’t compete.

              2. windriven says:

                @WLU

                “Just wondering what your planning horizon is.”

                This made me laugh out loud! I’m still chuckling as I write this.

            2. I seem to be poking all of you bears. It nice have everyone in this cult are on the same page. But when you realize the earth is round you what to kill the messenger so you flat world ideology will be safe.

              Which is your prerogative!

              BUT when your idea, concepts or theories has the potential to do harm to innocent people who are not scientist, that is WRONG plain and simple. I’m also on this journey of what is true and equitable and it is my responsibility as a Physician to expose these discrepancies so that people can have full disclosure to all the information to make the best decision for themselves.

              Kill me and other round earthers will find you and exposure your hypocrisy.

              1. windriven says:

                “I seem to be poking all of you bears.”

                Hah! Poking irritates bears. You amuse us, Steve. You are sort of the poster child for delusional reasoning – an object lesson, if you will.

                I believe it would astound you to know how many views this site gets. Only a teeny-tiny fraction ever write comments and fewer still write regularly. But there are thousands who read and learn. And it is for them that you serve a purpose – yours is the face of CAM in all of its wild-eyed, delusional glory! It really makes the task of marking the difference between science based medicine and nuttiness almost too easy.

                You repeat the same things over and over and do it without coherent structure and generally inarticulately. Will the reader on the fence be drawn to your nonsensical, spittle-spewing delerium or to the reasoned arguments of Madison, Andrey Pavlov, WLU, and many others? Do you think they spend their time responding to you in the belief that you will come to your senses??? They write to put the difference between science and Steve-ism in sharp relief, as a learning opportunity for inquisitive readers.

                It has been raised before but it bears repeating – your argument – your one and only argument – is like a paraphrase of the old Chico Marx quote – Who are you going to believe, Steve Rodrigues’ opinions or the weight and evidence of a medical science that has transformed the human condition?

                So keep writing, Steve. Poke the bear if that is how you like to think of it. We’ll mock you, of course; it is just too much fun. But it does serve a valuable purpose for the readership. You’re sort of the pinata at the science party – we hit you with sticks and all sorts of good things come out :-)

              2. mousethatroared says:

                You know how they figured out that the earth was spherical and traveled around the sun? science, evidence – you know all that stuff people keep asking you to provide.

                I’m pretty sure that if Galileo’s inquisition was a bunch of people on a blog asking for evidence that the earth was spherical and traveled around the sun, then his persecution wouldn’t be as famous as it is today.

              3. WilliamLawrenceUtridge says:

                It nice have everyone in this cult are on the same page

                Yeah…cults rely on personality. You know, like acupuncturists rely on personality and charisma to generate placebo effects.

                We merely ask for evidence. You finally provided some. Most of it was shit, what wasn’t was decent, but preliminary and limited. So get off your high horse and stop pretending we’re unreasonable merely because we aren’t willing to take your word for anything.

                BUT when your idea, concepts or theories has the potential to do harm to innocent people who are not scientist, that is WRONG plain and simple.

                What, you mean like a collapsed lung due to acupuncture being portrayed as risk-free? Or the corrosive belief that diseases can be prevented and treated through manipulations of a “life force”?

                I’m also on this journey of what is true and equitable and it is my responsibility as a Physician to expose these discrepancies so that people can have full disclosure to all the information to make the best decision for themselves.

                Yeah, if you want equitable, why not advocate for a public health care option rather than offering boutique treatments to the worried well?

                Also, your efforts mostly consist of asserting real medicine is worthless, occassionally pointing to studies that show real medicine is continually self-critical (then basically pretending you get credit for this, rather than acknowledging the tentative nature of scientific and medical knowledge), and from the sound of things not telling your patients that the evidence for one of your most substantive treatment measures is an area of considerable controversy and research with not-insignificant risks.

                You’re not “promoting truth and fixing medicine”, you’re competing for resources by disparaging your competitors and misrepresenting the few tools you have that other doctors don’t use.

                Kill me and other round earthers will find you and exposure your hypocrisy.

                Um…melodramatic much? Are you having a psychotic break or something? How did “your ideas and resources are terrible” become “BLARG WE WANT TO MURDER YOU!!!!!”? Is your life so sad and empty that you need to fill it with illusory dramas about people tracking down where you live and attempting violence? ‘Cause dude, not hard.

                Nobody’s coming to get you. You’re still free to post on this website. We’re just pointing out how stupid your ideas, assumptions and arguments are, how does that become “murder”?

                Also, as Mouse points out – your metaphors are incredibly inapt.

  17. PMoran says:

    The findings are consistent with the emergent paradox — that perhaps the more information people are exposed to regarding dubious methods the more inclined they are to try them out, and, moreover, whether the information is positive or negative. .

    Also, it seems, those who know most about medical matters, nurse, pharmacists and MDs, are not immune to this influence. Perhaps the medically educated are more aware of the limitations to medical treatments for common minor ailments such as anxiety, depression, tiredness, insomnia, musculoskeletal problems etc.

    They can also hardly be unaware of the mainstream’s rejection of such methods, even if they are “astonished” at some of the details of the methods when Andrey and others point them out.

    I have been suggesting for some years, that the use of CAM is rarely a mature scientific judgement in the sense that medical sceptics think of medical decision-making. It is typically a matter of trying something out, with minimal intellectual commitment, often on little more than the recommendation of another, when there is (crucially) an unmet medical need and no obviously superior medical option and at least the perception that there is nothing much to lose if it doesn’t work..

    The hope of relief can presumably also inhibit some degrees of doubt so that there may never be a sound substrate upon which “critical thinking” can do whatever it is supposed to do. .

    Trying to inhibit such instinctive, evolutionarily ingrained human tendencies with negative information and persuasion is presumably a good thing when there is serious medical or financial risk involved. That will surely help some to think twice so long as we already have their trust as an unbiased, solid source of information..

    What about when there is little downside to the methods, even when they don’t work, but they may help some via palcebo and non-specific influences, and through satisfying the deeply ingrained urge to be “doing something” about bothersome problems? This is the question some of the so-called “shruggies” may be unsure of the answer to.

    I state for the umpteenth time that there remain are sound reasons why the mainstream should not endorse such methods for routine patient care. This is about having rational and realistic objectives and how best to achieve them — (beyond our simple duty to portray the scientific position in as accurate and unbiased a manner as we can.)

    1. Andrey Pavlov says:

      Hi Peter. Time for me to “find something to disagree with you” again.

      But I am very pressed for time this am, so it will necessarily need to be somewhat brief. I’ll also try and balance it with points I agree on :-D

      that perhaps the more information people are exposed to regarding dubious methods the more inclined they are to try them out, and, moreover, whether the information is positive or negative

      Possibly indeed. Whether the balance lays with that facet of spreading information or not is where I’d disagree. Not vehemently, but it seems that while many people would the majority wouldn’t and so the overall balance seems to be in the “not keeping your mouth shut” camp.

      it seems, those who know most about medical matters, nurse, pharmacists and MDs, are not immune to this influence

      Sadly true.

      Perhaps the medically educated are more aware of the limitations to medical treatments for common minor ailments such as anxiety, depression, tiredness, insomnia, musculoskeletal problems etc

      I don’t think this is the driver. This argues that the rationalization used is “well, I’m educated and I know where treatments for [x] are limited so I will try [zzzz]” This is discordant with the data we do have and my own experience. It is the type of personality that drives it independent of the knowledge.

      They can also hardly be unaware of the mainstream’s rejection of such methods, even if they are “astonished” at some of the details of the methods when Andrey and others point them out.

      You’ve misread me. They are indeed unaware of the outright rejection. They have simply not looked at it at all and merely have heard the name. They are aware it is outside the mainstream, but do not know the details nor that it is outright rejected by science. They are prey to the same PR campaigns as everyone else. They become astonished that they did not know it was outright and vehemently rejected by the mainstream upon learning the details.

      I have been suggesting for some years, that the use of CAM is rarely a mature scientific judgement in the sense that medical sceptics think of medical decision-making.

      100% agree.

      It is typically a matter of trying something out, with minimal intellectual commitment, often on little more than the recommendation of another,

      Also agree.

      when there is (crucially) an unmet medical need and no obviously superior medical option and at least the perception that there is nothing much to lose if it doesn’t work..

      And disagree. Completely. Yes, that is certainly a facet in some cases. It is not at all the driver. And the data very clearly show this, as does the entire PR strategy of the CAM camp. It is most oftenly used by people who concurrently use actual medicine and most oftenly for nebulous ideas of “improved wellness.” To “boost immune systems” and make you “healthier.” And in many, but not all, cases where it is actually used in lieu of actual medicine it is used primarily rather than after exhausting all possible avenues. So yes, while you describe a valid facet it is most certainly not a crucial facet. And not at all the primary driver of use.

      (I’ve provided you with numerous sources of data to demonstrate this and I don’t have time to do so again at this point)

      Trying to inhibit such instinctive, evolutionarily ingrained human tendencies

      Now you are treading a bit more in my bailiwick and overstating your premise. This is a feature of the mind which is much more plastic than our physiology in general. Don’t make the mistake of thinking that this is akin to trying to change evolutionarily ingrained molecular pathways.

      I do agree that there is an evolutionary predisposition towards belief over skepticism. In some, but not all, of the population (probably a very large minority or perhaps a small majority). But like all things to do with consciousness and cognition it is a tool of the mind, not a fixed thing the mind does. Meaning that depending on the sociocultural milieu that tendency for “belief” can be redirected at just about anything. In the past (and currently to a large degree) it was religion of various kinds. Today it is often new-agey crap. But if you give the right context – as you correctly comment “so long as we already have their trust as an unbiased, solid source of information” – that is where that will go.

      I do agree that the deeper question is how do we position ourselves as such is important. That is a deeper discussion than I have time to get into today. But suffice it to say my point is that it is incorrect to frame this as some massively entrenched thing and combatting it is like moving mountains.

      What about when there is little downside to the methods, even when they don’t work, but they may help some via palcebo and non-specific influences, and through satisfying the deeply ingrained urge to be “doing something” about bothersome problems? This is the question some of the so-called “shruggies” may be unsure of the answer to.

      We’ve discussed this many times before and can be summed up easily by saying that one can – and should – unbendingly denounce the CAM in question but not be so cruel as to slap the homeopathic pills out of grandma’s hand in your office.

      And no, those are not what shruggies are in our parlance. Your comment implies that they know the details of it and know it is utter BS but shrug it away. Yes those exist, but (and correct me here if I am wrong Dr. Gorski and others) my use of “shurggie” is someone who knows only very, very superficially what these CAMs are and the concept of CAM and go off of the general PR to shrug away cares about the details.

      The former would maintain his or her stance when confronted with the details (and I’ve met one such person) the latter will be those astonished and often spurred to action upon actually learning the details (as per the story of Dr. Novella and the IM module at his institution).

      This is about having rational and realistic objectives and how best to achieve them

      Agreed. And you still have yet to provide any semblance of a cogent answer as to do that. The only thing you’ve got is sniping at us for doing it wrong, for various reasons, without ever offering your own suggestion as to an alternative, let alone what may be better.

      1. WilliamLawrenceUtridge says:

        And that was brief? :P

        1. David Gorski says:

          Andrey’s been training under my tutelage. :-)

          1. WilliamLawrenceUtridge says:

            You’re patient zero :P

          2. Andrey Pavlov says:

            Haha, that was brief! It was a lot of blockquoted stuff, written in prose, without references! I also said somewhat brief. ;-)

            I also type very quickly. That took me less than 10 minutes to write.

            1. mousethatroared says:

              Andrey – SHUT UP!* – my typical one to four paragraphs often take me 1/2 hour and up to write. They only have a fraction of the valuable information and they are not nearly as well written.

              Really, that was just gratuitous.

              *I’m trying to get banned so that I will be forced to concentrate on this ridiculous slide presentation I’m compiling.

              1. David Gorski says:

                You’ll have to do better (or should I say “worse”) than that. :-)

              2. Andrey Pavlov says:

                @mouse:

                Sorry Mouse. But it was actually not particularly well written either.

                But thank you for the compliment.

              3. mousethatroared says:

                @AP – Don’t apologize. I hope it was clear I was joking, about the gratuitous part, not about the compliment part.

      2. PMoran says:

        The ten minutes shows, Andrey, and has always shown in your writings.

        Your straining to make a case leads to the internal contradictions e.g.–

        “— And disagree. Completely. ( — but — PJM) Yes, that is certainly a facet in some cases.”.

        –and various hasty misreadings of my position. There are other examples in the above. See if you can find them for yourself. My pointing them out merely provokes another torrent of words in self-justification.

        My words may stand (eventually) but only to the degree that they reflect the truth about medicine as it exists today. I am pretty sure they are part of the truth in an immensely complicated arena.

        What I have said would suggest that recent trends don’t mean an ascendancy of pseudoscience, because neither science nor pseudoscience play a critical role in decisions to use CAM ( the science to do with placebo and non-specific aspects of medical interactions probably helps explain its durability).

        Thinking about how things really are might help prevent us looking foolish or biased or simply not understanding when we talk about CAM.

        A simple example of this is the stance of some sceptics that all of CAM is a conscious scam. Their clients “know”, often rightly, that they are not. SSR and his ilk should have shown us by now that they often have honest belief in what they do. (Yes, I know there are some true charlatans)

        That generalisation leads some medical sceptics to explicitly ask for the total banning of CAM, or to create the strong impression that this is their ultimate aim. Most CAM users already believe that this is our aim simply by reading between the lines. Why would we not want to ban homeopathy, when we think it is a useless scam, and stupid, and belief in it is liable to start us down the road to extinction?.

        There are many ways in which subtle misunderstandings about CAM and its use can make us look as though we either don’t know what we are talking about, or have deeper agenda. That is not a good look if we want to be perceived as an authority on CAM matters.

        .

        1. Harriet Hall says:

          “the stance of some sceptics that all of CAM is a conscious scam”
          ” some medical sceptics to explicitly ask for the total banning of CAM”

          Just who might those skeptics be?

          “Thinking about how things really are ”
          Do you think we are not thinking about how things really are? Are you the only one who is? What makes you so sure?

          1. PMoran says:

            -”- Just who might those skeptics be?”

            Not you, I know. Do you want me to name names?

            Admittedly few are “explicitly asking” for a total ban on CAM, but I am sure many more would if they thought it was at all politically feasible, such is the (largely understandable) depth of feeling of many about some aspects of CAM. Many more ” create the strong impression that this is their ultimate aim”, as per the alternative I stated in the same sentence.

            The perception that CAM is predominantly conscious fraud is conveyed in many ways. The descriptors sCAM and $CAM send that message. Or should they be seen as a propagandist tactic?

            Steve (Novella) used to hint that the insinuation of CAM into hospitals and academia stems from underhand objectives. I cannot recall him ever acknowledging that the proponents might sincerely believe that it may have something to offer (somehow).

            How am I to know what others are thinking? I can only go on what is said, and what is allowed to pass without objection or discussion.

            1. Harriet Hall says:

              @PMoran
              “How am I to know what others are thinking?”
              You can’t. And yet you presume to when you say you are sure many more would call for a ban if they thought it was politically feasible.

              “The descriptors sCAM and $CAM send that message.”
              Not necessarily. I think they also send the message that the belief systems have scammed the providers, not that the CAM providers are deliberately scamming the patients. When Rose Shapiro titled her book “Suckers” she made it clear that she was not just referring to patients; she was talking about how CAM practitioners had been suckered into believing in useless treatments.

              1. PMoran says:

                H: “How am I to know what others are thinking?”
                You can’t. And yet you presume to when you say you are sure many more would call for a ban if they thought it was politically feasible.”

                Not quite touché, because that is a not unreasonable deduction from much that is said here. I cannot know that people are thinking as critically as I am about common SBM presumptions if they don’t say so.

                “– that the belief systems have scammed the providers, not that the CAM providers are deliberately scamming the patients.”

                It’s not the belief systems so much as the illusions and quirky influences within daily medical practice that misleads everyone (IF they are totally misled in what can be an extremely complicated human interaction).

                And we shouldn’t feel too superior about this — mainstream doctors and its esteemed professors have shown that they can be just as misled about pet treatments, moreover also continuing to believe in them even after studies suggest not intrinsic worth to them. Such is the power of such influences. They leak through our best attempts to eliminate them in extremely elaborate and expensive clinical studies.

                Also, as with politics, we are often dealing with perceptions, and there is little doubt whatsoever how most people will interpret terms such as “sCAM” and “$CAM”.

              2. Harriet Hall says:

                “that is a not unreasonable deduction from much that is said here. I cannot know that people are thinking as critically as I am about common SBM presumptions”

                Some of us disagree and think that you ARE making unreasonable deductions. And no one else is chastising us the way you are, and we think we are thinking more critically and more clearly than you are about these issues. We are still waiting for that guest post we asked you to write. If you are right, and can explain it to us in a way that we can understand, you should be able to persuade us; but so far we are only confused about exactly what you would have us do differently and why.

            2. windriven says:

              “The perception that CAM is predominantly conscious fraud is conveyed in many ways. The descriptors sCAM and $CAM send that message. Or should they be seen as a propagandist tactic?”

              The perception that CAM is predominantly a fraud owes to the way it is often marketed: what THEY don’t want you to know; the miracle weight loss formula; mainstream medicine has it all wrong (but this modality has it all right), and the simple reality that sCAMs are neither developed nor investigated in a way intended to improve medical science. We’re it not for the political idiocy known as NCCAM most of these methods couldn’t attract the interest of a fourth tier journal editor with a lot of pages to fill.

              Our own Stephen S Rodrigues is the poster child for this sort of thinking. Special pleadings and appeals to popularity underscore his every utterance. There is no interest in exploring the underlying physiology, no interest in demonstrating the existence of qi, meridians, or anything else – it is all to be embraced on faith supported only in a web of anecdotes. Pfahh.

              I for one have no wish to ban sCAMs. I hold that arguably sane adults should have very broad latitude in choosing what to do and what to ingest. But I also hold that any marketing that is fraudulent or deceptive should feel the hobnailed boots of the regulatory authorities.

              There is only one field of medical science. There is a place for research in even the wildest ideas that are intended to expand the horizons of medical science. Those efforts that stand in opposition to medical science rather than to its furtherance define themselves as bulltwaddle and in my estimation there is no invective too vile to heap on them.

            3. Andrey Pavlov says:

              but I am sure many more would if they thought it was at all politically feasible

              I am glad you are holding the utmost scientific rigor by assuming what others may be thinking and then using that as a basis for your arguments.

              The descriptors sCAM and $CAM send that message. Or should they be seen as a propagandist tactic?

              Thanks to some handy knowledge on how to “power search” via Google, I checked and found that there were precisely 7 times the term “$CAM” has ever been used on SBM. All 7 were in the comments. 2 came from you (including this most recent time), 1 from user lizditz, 3 from user elburto, and 1 from Dr. Hall in quoting you just now.

              But besides that, Dr. Hall addressed it well – the sCAM is the overarching concept, which practitioners themselves are scammed by. While not always made explicitly clear, in the context of the rest of our writings that should be obvious to anyone actually reading without a conclusion as to our motivations already in mind (ahem). We have actually oft discussed here – myself included – that the practitioners who are honest believers have been hoodwinked and how we actually genuinely feel sorry for them as well. Most often this has come up in the context of chiropractic, but in other areas as well.

              And yes, it also serves to correctly label those practitioners who actually are con men and scam artists.

              Steve (Novella) used to hint that the insinuation of CAM into hospitals and academia stems from underhand objectives

              Yes, we have indeed discussed and documented how groups like the Bravewell collaborative is indeed using sneaky “trojan horse” tactics to get CAM into academia and medical institutions. I myself have documented how this is done in specific medical school lectures (my own). They re-brand science based methods such as diet and exercise “CAM” and then begin to “sneak” in the actual woo. My “integrative medicine” professor in medical school did exactly this – first talking about diet and exercise, then probiotics, then acupuncture and then finally in the Year 2 lectures talking about how personality influences both the types of cancer that you get and outcomes of treatment. He also happens to sell $300 saliva tests to determine the status of his anti-aging woo, and offers weekend courses for physicians to get certified in doing the test as well (for which he charges a couple of thousand bucks).

              So no, you’ve once again misread us by inserting your own assumptions and going well beyond what we’ve said. We do not think that there is some evil cabal of people who know that the nostrums they peddle are pure bunk and are trying to hoodwink everyone for a profit. And we have never said or even intimated that. They do, however, know that their nostrums have very little scientific evidence and thus seek the imprimatur of legitimacy from science and academia. They are true believers and that is why they argue to change the standards of evidence, claim trials are more positive than they are, cherry pick data to support their belief, and work politics to gain the aura of legitimacy by any means possible. If it was actually the “evil cabal” scenario the tactics would be rather different and much less arduous with better results. If one (or a group) is intentionally trying to game the system for nefarious personal gains, there are much easier ways to go about it.

              The fact that you still don’t seem to get this is demonstrating to me quite clearly that it is you who has a belief about us and are cherry picking and retro fitting everything to fit that narrative. But you are simply incorrect and you can only manage to argue your point by blatantly assuming what we all must be really thinking.

        2. Andrey Pavlov says:

          The ten minutes shows, Andrey,

          Oh yes it does. And the example you provided I noticed myself before your post. And a couple of others. I did say it was very rushed.

          and has always shown in your writings.

          I actually often spend a fair bit more time. Kind of like that time I took apart the article on acupuncture you referenced to support your point and demonstrated how bad it was. Which you then just blithely hand waved away by saying that well maybe that article wasn’t exactly right but there were others… which you never referenced.

          But I digress. It isn’t too hard for me to dismiss your dig at me considering that while I may make a gaff or two my point is usually reasonably well understood whereas after countless posts of yours not a single person here can ever understand yours.

          I am pretty sure they are part of the truth in an immensely complicated arena

          We already know you think very highly of your own opinions Peter.

          because neither science nor pseudoscience play a critical role in decisions to use CAM

          Hmm. Except, perhaps, for the fact that the pseudoscience gets play in the media, notably from one Dr. Oz amongst many others, plastered all over magazines, the internet, TV shows, news channels, etc. So when someone makes that decision that for themselves is not based in pseudoscience nor science, where do you think they may get the specific and particular ideas from?

          But no, clearly pseudoscience can’t be on the rise because the average Joe and Jane don’t look at and use scientific principles in decision making.

          Thinking about how things really are might help prevent us looking foolish or biased or simply not understanding when we talk about CAM.

          Still waiting for you to tell us how they really are. I won’t hold my breath though. You’ve been thoroughly incapable for some 4 years now.

          A simple example of this is the stance of some sceptics that all of CAM is a conscious scam

          As Dr. Hall said – which skeptics? I challenge you to find anywhere I have ever written or even implied that all of CAM is a conscious scam. Some of it is and you cannot deny that. But the fact that it is honest believers rather than con men does not change the facts of CAM. And I personally have said that innumerable times, as have the rest of the contributors here at SBM.

          SSR and his ilk should have shown us by now that they often have honest belief in what they do.

          And…..? So what? The Muslims have a very genuine, honest, and deeply felt belief in martyrdom, the Catholics in the sin and depravity of homosexuality, the Hindus in the Untouchable caste. I suppose we should just let anything that is done from an honest belief have a pass?

          That generalisation leads some medical sceptics to explicitly ask for the total banning of CAM, or to create the strong impression that this is their ultimate aim.

          Once again, I challenge you to find where I have ever said that. Or any other contributor here. Your warming me up with all those burning straw men.

          Why would we not want to ban homeopathy, when we think it is a useless scam, and stupid, and belief in it is liable to start us down the road to extinction?

          Wow. Hyperbole much?

          And who here as ever even intimated we should ban homeopathy (or any CAM)? We certainly want it out of academia, we want public policy to reflect the scientific realities of it and not allow it license to practice or insurance to reimburse (mostly public insurances), but to ban it? We don’t demand a ban for people who run psychic and Tarot card reading shops, but we would certainly be up in arms if a credulous class on it were taught at universities or if public funds were used to pay them to help solve crimes (funny, that has happened and that has been decried).

          My computer may melt with all these straw men bursting into flames.

          There are many ways in which subtle misunderstandings about CAM and its use can make us look as though we either don’t know what we are talking about, or have deeper agenda.

          Oh do tell us those subtleties! 4 years of suspense is killing me Peter.

          Your only stance is that you have a very high opinion of your own opinions, that you can dismiss me as a novice physician (previously as a medical student), that you understand some secret deep and profound subtleties that are so profound they should change everything about how we do things and yet are so subtle you can’t articulate them, and your only real commentary is to just say we are doing things wrong (without ever being able to say how to do things right), usually by hyperbolic caricature that leads to much combustion of hay.

          Forgive me if I am unimpressed, particularly since you once again resort to an ad hominem attack on me.

          1. WilliamLawrenceUtridge says:

            SBM doesn’t want CAM banned, it wants all of the social capital it accumulates through association with science to be stripped away. That means removing it from medical schools unless properly studied and found to be safe and effective. That means removing legislative protection or outright promotion. That means homeopathy no longer has an exception within the Act that created the FDA that exempts it from testing. That means no NCCAM to divert funds from promising areas of research. That means no federal funding for research unless it follows the path that all other research must follow – bench work, animal trials, phase I, II and III trials. That means no religious exemptions from vaccination requirements to get into public schools.

            SBM wants an even playing field, not one in which a specific approach is privileged merely because it is old, or imported, or people’s feelings might get hurt.

          2. MadisonMD says:

            Well said, WLU. This is it precisely.

            Perhaps we could even add:
            *no funding in CMS or VA (US) or NHS (UK) for practice of homeopathy, acupuncture, etc.
            *more oversight of supplements/repeal DHSEA
            *strengthening state medical boards ability to reprimand or revoke license of MD or other providers who deviate markedly from standard of care (including but not limited to those practicing quackery).
            *limiting or eliminating licensing for quackery

            Many of these these items have been covered in this blog.

            1. Andrey Pavlov says:

              Both WLU and you are absolutely correct. And WLU did indeed say it very well – CAM needn’t (and shouldn’t be banned). But it should be relegated to the appropriate level of social capital. In the same way that an average person will scoff at the idea of a manhunt for Elvis because he is still alive, so should we scoff at the idea of doing research on homeopathy.

              I also had a thought come to me as I re-read some of the previous comments (including my own). I may be wrong here, but would love your take. It strikes me that Peter may, at least in part, be committing an ecological fallacy. He is taking the actions and motivations of the individual and attributing them to the population. Many times he and I have been at odds and he has stated I am inconsistent in my thinking because my hard-line stance on SBM is incongruent with my much softer stance when my patient is in front of me. I’ve tried to explain that it is possible to be consistent and yet still act differently in different social and professional contexts. But perhaps his inability to grasp that is based on this ecological fallacy I am now beginning to see.

              Thoughts?

              1. WilliamLawrenceUtridge says:

                Yeah, there’s a distinct difference of a principle that can be espoused by organizations and governments, versus the principles that are practiced while dealing with a patient. A firm and rational line with the former reduces the need to apply the latter. It would seem that many patients want CAM because it is framed in such a way that it seems effective.

                Also, let me again venture my disappointment in the Pete Moran who maintains an anti-cancer quackery site, and the one who shows up here to argue minutea and sophistry.

        3. Self Skeptic says:

          PMoran,

          I think CAM’s function at SBM, is to provide an all-purpose scapegoat. For scapegoating to work, there has to be a bright line between Us, the good people (in this case the “Science-Based”), and the Other, the bad people. Actually trying to understand the others, by finding similarities between us and them, threatens to break down the wall, and allowing the bad that has been projected onto the scapegoat, to bounce back into our tribe, and contaminate our sense of our own essential Goodness. (I’ve capitalized some words to indicate that they are parts of this thought system that can’t be questioned without freaking people out, here at SBM.)

          As part of this mechanism, all the good qualities we can think of, automatically get assigned to Us (mainstream medicine) and all the bad qualities get assigned to Them (CAM). So we are smart, sincere, reality-based, etc, and the other has to be, almost by definition, stupid, deceptive, deluded, etc.

          It looks to me as if, by suggesting that CAM practioners are mostly sincere rather than cynically exploitive, and otherwise suggesting that people look at CAM with curiosity rather than contempt, you’re fouling up this mechanism, which denies mainstream medicine’s exploitive qualities (in this example), by projecting them “away,” over the wall, onto the Other. If we were to take an anthropological approach, and even temporarily suspend judgment in order to understand CAM, its function as a scapegoat would be compromised, and moral complexity would be introduced. From the SBM standpoint, that’s not desirable. The bright line, or wall, between good Us and bad Them, really needs to stay intact.

          It’s good old-fashioned tribal thinking, very human. During election years especially, I catch myself doing it, with regard to the political party I favor, versus their opposition. So I’ve got a laboratory in my own head, to see how these things work. ;)

          1. Andrey Pavlov says:

            Between you and Peter my computer is about to burst into flames with all the straw men set ablaze.

            1. Dave says:

              I could rephrase this as follows:

              “There has to be a bright line between Us, the good people (in this case the “holistic” cam practitioners)and the Other, the bad people (SBM providers). Actually trying to understand the others, by finding similarities between us and them, threatens to break down the wall, and allowing the bad that has been projected onto the scapegoat, to bounce back into our tribe, and contaminate our sense of our own essential Goodness.

              As part of this mechanism, all the good qualities we can think of, automatically get assigned to Us (CAM practitioners) and all the bad qualities get assigned to Them (SBM). So we are sincere,holistic, etc, and the other has to be, almost by definition, deceptive, deluded, uncaring, greedy etc.

              It looks to me as if, by suggesting that SBM practioners are mostly sincere rather than greedily exploitive, and otherwise suggesting that people look at SBM with curiosity rather than contempt, you’re fouling up this mechanism, which denies CAM’s exploitive qualities (in this example), by projecting them “away,” over the wall, onto the Other. If we were to take an anthropological approach, and even temporarily suspend judgment in order to understand SBM, its function as a scapegoat would be compromised, and moral complexity would be introduced. From the CAM standpoint, that’s not desirable. The bright line, or wall, between good Us and bad Them, really needs to stay intact.

              The reality is of course much more nuanced. It has been stated here on numerous occasions here that some (probably most) CAM practitioners are sincere and believe in what they do, as are some (I believe most) SBM practitioners. Some CAM practitioners are charlatans and expliotative, and some SBM practioners are greedy. The issue in this blog is what works and what does not. The motives of certain practitioners (Dr Oz for example) has on occasion been brought up when there are egregious reasons to suspect the motives but that’s certainly not the focus of the site.

              I would be very careful about projecting your own suspicions onto the motives of others.

              1. Self Skeptic says:

                Yes, Dave, I think your parody is a reasonable portrayal of how that subgroup of CAM practitioners that demonize mainstream medicine, are thinking. It’s that extreme subgroup that is the “other side’s” counterpart to SBM.

                Remember, I’m not a user or apologist of CAM, nor are the people close to me. Consequently, it hasn’t hurt me or mine, personally. Wrong mainstream medical guidelines, however, …

                I gather that there are many CAM practitioners that respect mainstream medical treatments that work, as far as they can see; conversely, there are many mainstream medical practitioners who don’t hate CAM, even if they don’t use it. But tolerant and/or discerning moderates aren’t very relevant here. I suppose the extremes on both sides despise them as shruggies.

                Anyway, thanks for showing how this kind of scapegoating works, in reverse. It’s a good point.

          2. Sawyer says:

            @SS

            “It looks to me as if, by suggesting that CAM practioners are mostly sincere rather than cynically exploitive, and otherwise suggesting that people look at CAM with curiosity rather than contempt, you’re fouling up this mechanism, ”

            Name one contributor to this website that has not acknowledged that most CAM practitioners are sincere in their beliefs, or claimed that everything mainstream doctors offer is good. Surely you can locate a few people that espouse this philosophy if it’s so common, right? Does Dr. Gorski? Dr. Novella? Hall? Crislip? Bellamy? Anyone?

            Okay I’ll make it easier. Name even a single commenter here that doesn’t believe most CAM fans are sincere in their beliefs. There are dozens of us that leave feedback here on a regular basis. Clearly the most vitriolic among us must believe that the majority of CAM fans are con artists, yes? Can you produce evidence of this?

            The fact is no one here believes the strawman position you invented. And you have spent enough time here to know it. Stop falsely attributing beliefs to other people. This is the THIRD time I have made this exact request. I may still believe most CAM proponents are sincere, but I’m increasingly suspicious that you are NOT sincere in the desire to communicate with people here in an honest manner.

          3. weing says:

            “During election years especially, I catch myself doing it, with regard to the political party I favor, versus their opposition.”
            Sorry to break it to you, but it’s not just during election years and with regard to political parties. You just did it with your comment.

          4. PMoran says:

            Very eloquent, but I disagree strongly with the scapegoat aspect, SS.

            There is much to be rightfully concerned about from CAM and I am sure you know that.

            Sceptics are also definitely not trying to project medicine’s own failings onto CAM, though many do seem reluctant to observe the degree to which various limitations to mainstream medical care help create a fertile environment for CAM use. Medical needs are rarely mentioned when the question “why do people resort to CAM” crops up.

            1. MadisonMD says:

              many do seem reluctant to observe the degree to which various limitations to mainstream medical care help create a fertile environment for CAM use. Medical needs are rarely mentioned when the question “why do people resort to CAM” crops up.

              Not really. It is an obvious observation. Quacks sweep in where there are unmet needs precisely because this is where they can find patients who are vulnerable to the wishful thinking that there is something better. Who is that surprising to?

              I think the points made here are:
              (a) CAM should not be dishonestly portrayed as effective
              (b) limited research resources should be invested in plausible and truly effective treatments to actually meet the need of these patients.

  18. Laurenac says:

    As a long time reader first time commenter I first just wanted to say thank you to the authors/contributors and wonderful people who comment on this blog as I have learnt so much reading these articles :)

    I just wanted to contribute something I saw on TV last night about CAM in the veterinary world too. I was watching a life style show (Better Homes and Gardens for any fellow Aussies out there) and they had a whole segment on ‘complimentary medicine for animals’ including acupuncture for cats and a chiropractor for horses. So it’s looks like our poor animals are getting stabbed pointlessly with needles too :(

    1. Dang those animals are enjoying the placebo effects of the ancient voodoo. Thank God that some of us will not give into the bias and “new” impersonal science methods.

      Blame the patient or their imagination if they feel better or worse … wow sceptics, oops, cynics have it both ways to stay in the dark pit of ignorance.

    2. MadisonMD says:

      Hi Steve,
      Since you aren’t posting scientific publications, after your brief and futile attempt to demonstrate that you are right, I thought you might enjoy this:

      Schools of acupuncture are common in the United States where many people cannot afford real healthcare. At many of these schools, students are required to bring their own practice dummy. If a student arrives with an inflatable dummy it means that they are even more confused than their classmates and therefore qualified to study chiropractic medicine.

      and, of course, The Ghosts of Woo.

      1. windriven says:

        Great stuff, Madison. But wasted on Steve. The pictures are good but there are way too many words.

        I most liked the ‘roofing nail’ series of panels. Their reproduction of the graph from Wechsler et al in NEJM summarizes much of what I don’t understand about sCAMettes*. Albuterol demonstrated substantial clinical benefit versus placebo, sham placebo, and delusional placebo. Why are people attrated to sCAM when there are highly effective medical interventions available?

        *sCAMettes being the squealing groupies who keep sCAMers in business.

        1. PMoran says:

          “Why are people attrated to sCAM when there are highly effective medical interventions available?”

          Asthmatics are in fact amongst the highest users of CAM.

          Being “highly effective” does not always or even often translate into clinical perfection. Many or most patients, depending upon the condition, will have residual disability even from optimally applied mainstream care..

          This is just one study suggesting that those with poor control over their asthma are twice as likely to use CAM (mainly supplements, homeopathy and acupuncture). Unmet or poorly met medical needs lie behind most use of CAM, uncomfortable as this news may be for us mainstream supporters.

          http://www.ncbi.nlm.nih.gov/pubmed/20808977

          1. mousethatroared says:

            @pmoran – I just took a look at that study, since I have asthma I was curious.

            “The prevalence of reported CAM use among Quebec children with asthma remained modest (13%), with vitamins, homeopathy and acupuncture being the most popular modalities. CAM use was associated with preschool age, Asian ethnicity, episodic asthma and poor asthma control.”

            One could interpret that to mean parents of children with poor asthma control are seeking out CAM. But it could also suggest that when parent have a tendency to rely on CAM the result is children with more poorly controlled of their asthma, yes? Or a mixture of the two, or something else.

            It doesn’t look like they determined causation.

            1. Andrey Pavlov says:

              Good read on it Mouse. That is part of what my critique of the study would be.

              They also explicitly state that they could not and did not determine causation and also that previous data has shown that 44% of people use CAM before conventional treatments which does not support Peter’s assertion that CAM use is driven by a lack of good conventional medical options. Also the fact that ethnicity – specifically Asian – was a stronger predictor of CAM use than asthma phenotype further suggests that it is driven by preconceived ideas about CAM rather than a move of desperation. This is bolstered by the fact that other ethnicities were associated with less likelihood of CAM use. Other studies also identify Chinese ethnicity as being a much stronger predictor of CAM use in asthma than just about anything else, further adding confidence to the idea that it is the cultural bias that most strongly influences CAM use rather than unmet medical needs.

              Though admittedly the fact that being younger is also a strong predictor may well indicate that parents want to “do everything” they can for their children, the data in this study don’t (and can’t) indicate that this is because they feel they have run out of conventional options. Taken strictly, we must remain agnostic on this issue, but in context I would assert it is likely that it has to do with new parents “doing everything” for their young children. The fact that there is a significant reduction in use in older children may indicate that parents figured out it adds nothing to their usual care and are thus dropping the added expense.

              Additionally, the survey very specifically asked only about CAM us at the time of initial assessment. It did not ask for frequency of use nor did it assess continuation of use. So if a parent tried a CAM just once and never again it would still count as use.

              So overall, this study is not at all inconsistent with my own stance nor the literature at large as per my understanding. It does indeed show that unmet medical needs are a part of CAM use, which I (nor anyone here) has ever denied is indeed a component. My argument has always been that it is not the main driver, however. And this study does not support Peter’s assertion that it is.

              Additionally, the reference in the article he linked to which specifically addresses the idea of dissatisfaction correlating with CAM use (which can be found here, full text free) and finds that while the correlation does exist, the most common “CAM” was “breathing techniques” which is not at all ridiculous considering we are talking about asthma here. But more to the point, the way the survey data was attained was by correlating whether people felt “concern” over their medications and their side effects. Those that did were more likely to use CAM. So rather than unmet need driving usage, it seems that much of it was driven by a desire to reduce medication usage to minimize side effects, whether perceived or actual.

              It also noted that:

              Unsurprisingly, the alternatives of which those with asthma were aware were those having a high media profile at the time….

              So Peter’s claim that the question of science vs pseudoscience and scientific integrity matter not is not supported and indeed contradicted. It matters because that is what makes it into the media, what gets false legitimacy, and what patients base their ideas on by proxy, even though the decision to use CAM on the individual level is not typically a scientific one.

              And despite writing so little, he gets his two major points wrong:

              Asthmatics are in fact amongst the highest users of CAM.

              Not according to the references cited in his own article (which I linked directly above):

              In conclusion, whilst a previous study…suggested high use of [CAM]… study of a more “typical” population… revealed low rates of usage, with a bias towards use by those expressing concerns regarding conventional medication

              and

              Unmet or poorly met medical needs lie behind most use of CAM, uncomfortable as this news may be for us mainstream supporters.

              Is not actually supported by the very study he linked to try and prove his point, assuming you read past the abstract, of course.

              1. PMoran says:

                “So rather than unmet need driving usage, it seems that much of it was driven by a desire to reduce medication usage to minimize side effects, whether perceived or actual.”

                And this is supposed to refute my argument that CAM use is very often driven by the limitations of mainstream care?

                You were obviously rather upset by what you regarded as an “ad hominem” attack upon your patently sloppy discourse. Be advised that that was a mere shot across your bows. You are not compelled to dispute everything I say.

            2. PMoran says:

              Yes, that could well be an element, I suppose, Hard-core CAM users might be poorly compliant with mainstream care.
              There will still be a group who have proved difficult to control through normal variation.

              Reinforcing my interpretation, other studies show an association of CAM use with ongoing poor health of any kind, and this despite the fact that the vast majority of CAM use is complementary to mainstream care.

              No “association” constitutes final proof, of course, but surely this supports what you would expect, if the promoters of CAM are not often observed seizing healthy people off the street and forcing them to consume asthmatic medicine, or arthritis cures, or cancer treatments.

              Admittedly, a substantial proportion of overall CAM use derives from “wellness” and longevity interests, where the “medical need” is arguable. Nevertheless a very large and perhaps more important remainder is for the relief of symptoms or the treatment of illnesses which for one reason or another mainstream treatment is inadequate or unsuitable or perceived to be so.

              One reason this viewpoint may not be heard much within medical scepticism is that, as I have pointed out before, most data on CAM usage, including that in the one discussed by David above, involves asking a whole population or population sub-section about their use of CAM over a given period. Most of those asked will never have been sick over that period. The data is then used mainly to make CAM use look paltry.

              Such studies necessarily slant data towards these “softer” uses of CAM. Ask the same question of patients with any given illness, especially serious ones, and you will get much higher rates of CAM use.

              MTR, I recall that you also were a doubter when I suggested that SSR had genuine belief in what he is doing. Do you still think that and why?

              1. MadisonMD says:

                Ask the same question of patients with any given illness, especially serious ones, and you will get much higher rates of CAM use.

                Maybe. But your citation only showed 13%, and that included a big chunk of kids who were taking vitamins…. so maybe not all that high.

                I took vitamins occasionally as a kid, and my kids have (very occasionally) received chewable vitamins. Does this make us CAM users?

                Anyway, I don’t really understand what you are getting at. Why does it matter if people are using unproven and probably ineffective therapies at 5%, 20%, or 40%? Why does it matter if people with illness take them at a higher rate than those without?

              2. mousethatroared says:

                pmoran “MTR, I recall that you also were a doubter when I suggested that SSR had genuine belief in what he is doing. Do you still think that and why?”

                I don’t recall actually caring about how genuine his beliefs were, but my memory is not alway great. I did say I think he’s a predator…is that what you are referring too? I do think that people can be genuine in their beliefs and still predatory.

                By predator, I mean someone who manipulates or exploits people to fulfill their own personal needs for money, attention, power, etc with a disregard for the impact that manipulation or exploitation might have on the recipient. The way SSR attempted to use misinformation and scare tactics on me suggested that is a habitual pattern. The way he plays the victim and deflects criticism on to other targets, all recall manipulative behavior I’ve seen.

                That doesn’t mean he’s not sincere in his beliefs, but I care very little about how genuine someone’s belief is, because I haven’t experienced a reliable correlation between genuine beliefs and trustworthiness.

                What I care about is trustworthiness and I don’t generally trust someone unless they’ve earned it. How has SSR earned my trust?

                As a side note, I think this is irrelevant to Skeptic’s comment about sincerity and CAM practitioners. I have no reason to believe that SSR is representative of CAM practitioners in general. I am making an individual judgement based on the comments he’s made on this site.

                I am tired and rambling, so I’ll just stop there.

              3. Andrey Pavlov says:

                Slamming us for not being scientifically rigorous enough for your tastes and yet basing an argument in what you assume the data would be if it were something that it isn’t. Which happens to conveniently support your narrative. And is contrary to the data I actually linked for people who were already sick gathered over a rather long period of time.

                You’ve certainly got some gall to lecture us about being strictly adherent to the evidence. And you continue to make assumption after assumption. What seems obvious to you is patently false. I was not at all upset by your ad hom. I don’t take yours – or any writings on the internet – personally. But when someone touts the superiority of his position ad nauseum, I’m quite happy to point out how abject your arguments actually are. And you continue to make some equally bad assumptions about what Mouse thinks and feels. You really should stop doing that, though you seem to not be embarrassed by being continually corrected by her.

                And yes, I did actually refute your argument that unmet needs were the main driver of CAM use.

                Feel free to keep “firing shots across my bow.” The evidence around these parts seems to rather clearly support that it isn’t my discourse that is sloppy.

                In any event, I’m done for now. Feel free to continue your assumptions.

        2. mousethatroared says:

          windriven – “Albuterol demonstrated substantial clinical benefit versus placebo, sham placebo, and delusional placebo. Why are people attrated to sCAM when there are highly effective medical interventions available?”

          I hope this isn’t a rhetorical question. Albuterol makes my hands shake and my chest feel strange and because I have more drawn out mild episodes of asthma (rather than asthma attacks) it’s hard to tell if it’s working. Often it’s not enough and I need to use Flonase as well. Which seems to give me reflux like symptoms.

          Sometimes that’s not enough and I need to use a steroid inhaler, $135 for a months supply (high deductible insurance) and as far as I can tell that the cheapest type available. I don’t get to many side effects with, but it a nuisance to remember and you have to brush your teeth right after or risk a yeast infection.

          Some people have to take oral steroids instead, which have side effects and can have long term consequences if they need to be taken for long period of time.

          Even with all that, some people still have to make hard decisions to control their asthma. I’ve know two people, who had to rehome beloved pets due to allergic asthma.

          So, medications downsides, side effects, cost, incomplete control – perfectly understandable why folks might look for something else. The fact that, for many people (like me) the symptoms of airway narrowing or opening are confusing and unclear and come and go, makes it easy to mistake effectiveness of remedies or lifestyle interventions.

        3. windriven says:

          Thanks to pmoran and mouse. I had no idea that asthma was so difficult to manage.

      2. MadisonMD says:

        Great stuff, Madison. But wasted on Steve.

        That’s OK. It’s not for him. He’s just playing the role of stooge in the comedy act.

      3. This is what I have discovered about you guys and this website;
        You believe that modern medicine is the same as what you’ve seen in a Sci-Fi movie ie All wishful and imaginary!
        Scientific medicine is as precise as rocket science.
        Scientific Medicine is as durable and reproducible as the law of gravity.
        That people or patients are gullible and unaware of their own feeling-and as such have to factored out of the equation and therapy.
        Science can fix people like you can a car.
        Science have a treal-all pill for every ailment.
        Medical Science does not failure and if there are failures, it is the patient’s fault so they should be punished and left to suffer for not complying with the plan.
        Everyone lives happily ever after.

        LOL I fear you guys that you are harming people with your free speech which is your prerogative even in the US where you are free to lie and deceive if you have no responsibility to a patient. Yall are like politicians who are voted in to lie, cheat and deceive to a degree as long as you do these acts under the rules of the game. You know that no one can sue you for a failure, conflict of interest, abuse, neglect or mis-informed consent.

        1. Dave says:

          Normally I would not respond to this but it’s really hard to believe any practitioner with any grounding in reality would make these statements.

          SSR, I think you should read the FIRST chapter of Harrison’s textbook of Internal Medicine. (This is from an older but still recent addition as I use on-line sources which are more up to date now, but I am sure the current edition is similar).

          A few quotes and high points. From the very first column:

          “Tact, sympathy and understanding are expected of the physician, for the patient is no mere collection of symptoms, signs, disordered functions, damaged organs and disturbed emotions. The patient is human, fearful, and hopeful, seeking relief, help and reassurance…. Deciding whether a clinical clue is worth pursuing or should be dismissed as a “red herring” and weighing whether a proposed treatment entails a greater risk than the disease itself are essential judgements that the skilled clinician must make many times each day.”

          “guidelines do not – and cannot – take into account the uniqueness of each individual and of his or her illness. The challenge of the physician is to intergrate into clinical practice the useful recommendations offered by the experts who prepare clinical practice guidelines without accepting them blindly or being inappropriately constrained by them”

          “adverse drug reactions occur in at least 5% of hospitalized patients, and the incidence increases with the use of a large number of drugs. ..It is the responsibility of the physician to use powerful therapeutic measures wisely, with due regard for their beneficial action, potential dangers, and cost”

          “No problem is more distressing than that presented by the patients with an incurable disease, particularly when premature death is inevitable…In the face of terminal illness the goal of medicine must shift from CURE to CARE, in the broadest sense of the term”

          There are sections, again in the FIRST chapter, on medical errors, informed consent and respect for the patient’s autonomy, and accountability.

          Finally, for you, SSR:
          “Rigorously obtained evidence is contrasted with anecdotal experience, which is often biased. Even the most experienced physicians can be influenced by recent experiences with selected patients, unless they are attuned to the importance of using larger, more objective studies for making decisions”

          Granted that things are not always done as they should be (and the first chapter also has comments on the difficulties posed by managed care time constraints in the good practice of medicine), but the above are the goals.

          1. windriven says:

            Brilliant!

          2. “Even the most experienced (researchers) can be influenced by recent (trials) with selected (biased) patients, unless they are attuned to the importance of using larger, more objective studies for making decisions.” The same arguments can be said about you guys, the scientific community and this site!

            So as scientists, ya’ll choose to disavow all of the thousands of experiences and collected data from all of my colleagues who practice in a similar fashion?

            You choose to discount office therapy (based on valid documented age-old procedure codes) and outcomes that are beneficial?

            You choose discredit the one to one patient experiences as illegitimate?

            You choose to believe researchers and disbelieve patients or clinical physicians?

            @Hall. Do you really believe Acupuncture does not work?
            @ingraham. You do not believe any of the research and practices of Gunn?

            Please keep your personal choices to yourself or make it known that your conclusions are from a select set of data (thus incomplete) and not to be taken as a prescription or medical advice.

            1. WilliamLawrenceUtridge says:

              So as scientists, ya’ll choose to disavow all of the thousands of experiences and collected data from all of my colleagues who practice in a similar fashion?

              Yes, and here’s why. If you replace “my colleagues” with “priests of Thoth”, or “bloodletters”, or “shamans”, or “homeopaths”, you get the exact same result. Doctors for millennia did not track outcomes, relying instead on their experience, and for millennia, health outcomes remained the same – early death, high childhood mortality, painful suffering. Personal experience is not enough. Oh, and let’s add another group to our discussion – why shouldn’t we trust the thousands of experiences and collected data from surgeons who practice debridement of the knee? Or spinal fusion? You know, the ones who you damn and scourge for doing such harm – but if you asked them, point blank, they would have zero doubt that they are helping their patients.

              Sound familiar? That is why we rely on controlled studies.

              You choose discredit the one to one patient experiences as illegitimate?

              As has been said, repeatedly, the patient experience and interactions with a caring physician are vital to positive outcomes, patient trust and an improved, more humane medical system. It’s just that responsible doctors think they should bring something more than good patient interactions to the table. Good doctors think it is fraud to proudly offer placebos and charge for non-treatments, then pat yourself on the back for not handing out any of that nasty, effective medicine.

              @Hall Do you really believe Acupuncture does not work?

              I think I can speak for Dr. Hall when I say she probably thinks acupuncture “works” through mostly placebo effect, and that effectiveness is grossly oversold.

              @ingraham. You do not believe any of the research and practices of Gunn?

              Why do you spend so much time misrepresenting Paul’s actual opinions? If Paul will permit it, allow me to quote from his tutorials:

              Dr. Chan Gunn, a Vancouver physician and medical researcher, has devoted his career to understanding pain of muscular origin. He proposes a cause of muscle pain that contradicts Travell and Simons, and I don’t think they can both be right. However, just like them, he certainly does an excellent job of explaining exactly how muscle can cause a lot of pain.

              Myofascial pain syndrome, as defined and explained by Drs. Travell and Simons, is more all-encompassing, more thoroughly rationalized and studied, and more “standard” than either Sarno’s relatively simplistic tension myositis syndrome, or Gunn’s neuropathic pain, or any other soft-tissue and muscle pain theory I’ve ever come across. Travell and Simons have simply been at it for longer and done more and better homework. Knowing Travell and Simons’ work is crucial for any serious manual therapist. I think Gunn’s explanation for muscle pain is interesting, well-conceived, and he presents excellent evidence, but it simply hasn’t got the explanatory scope that Travell and Simons offer. Sarno’s case for pain caused solely by ischemia seems relatively simplistic, much less substantive, and likely to be only partially verifiable — and it’s dubious how he’s still promoting it, many years after MPS was established as a much more powerful theory.

              More than a decade ago, Vancouver pain researcher Chan Gunn suggested an interesting mechanism for pain that might help us to understand why stagnancy is uncomfortable, and immobilization torturous. Here’s a translation of his idea from neuro-speak into English:

              Tissue health depends on a normal flow of nerve impulses. If nerves are impaired, tissue can become paradoxically super-sensitive. Once the sensitivity sets in, tissue may become over-sensitive to all kinds of stimulation, and not just injury. Ordinary stretch and pressure, for instance, could become painful.

              Gunn used his idea as a way to explain trigger points. His explanation is outside the mainstream of trigger point science (if there is any such thing) and was summarily dismissed by Dr. David Simons, who wrote: “Neuropathy can be, but is not always, a major activating factor.” Simons’ dismissal was basically, “it’s not the whole story, it’s too simple,” which is always easy to agree with. But I think his dismissal was entirely too quick, and ever since then pain science has relentlessly affirmed the importance of neurological dysfunction and central dis-regulation.

              What you appear to be criticizing is that Paul doesn’t blindly (one might say dogmatically) worship at the alter of Gunn, treat it as an unquestionable TruthTM and repeat it without thought. You seem to object to Paul being a critical consumer and advocate, for attempting to reconcile and acknowledge dissenting information. Why you see this is a problem says a lot about you. Your need for certainty and ignorance (and ignoring) of the contradictory literature for instance.

              But hey, as long as you can keep charging customers and making them feel like they’ve had a caring interaction, who cares if they’re actually getting better because of anything you are doing.

              Please keep your personal choices to yourself or make it known that your conclusions are from a select set of data (thus incomplete) and not to be taken as a prescription or medical advice.

              That’s hilarious, coming from someone whose awareness of the very systems he touts so highly could charitably be described as “incomplete”.

              Do you see how much of a hypocrite you are?

        2. WilliamLawrenceUtridge says:

          Steve, a large number of commenters here are doctors. They practice medicine on a daily basis. Several are active researchers as well, and consistently emphasize the tension between the science of medicine and the practice of medicine, and are well aware of the gaps between the two. Further, those agencies and individuals responsible for producing consensus statements, practice guidelines and similar attempts to produce a best practice within medicine are quite aware of this tension, and almost invariably recommend reconciling those best practices with individual patients and patient histories, including genetics, previous drug reactions, treatment preferences, and so forth.

          Moreover, everyone has been to doctors. All have a concern for their health. Many have read widely on the nature of scientific medicine, history and quackery. Regular readers are probably familiar with why so many CAM approaches can’t and don’t work, and could explain in detail why approaches like homeopathy, and at least conventionally-described acupuncture has little connection to the functioning of the actual human body (beyond, of course, brain function).

          Your straw man of “dogmatic medicine and practitioners” is nonsense, here and beyond, and is merely a rationalization you use to counter the substantive objections we have to your preferred quackeries. Failures are well-recognized. Overdiagnosis is an active area of research and debate within the medical literature. I am currently reading Overdiagnosed by Welch, Schwartz and Woloshin, on Dr. Gorski’s recommendation; tell me again how doctors just try to shove pills? Do you ever consider the harm you might be doing your patients by using ineffective treatments? By using treatments that require active deception in order to maximize the placebo effect?

          The contributors to this blog are not evil pharma drones. It’s not a game for them. It’s the recognition that good science produces good health, and is required to correct the cognitive errors that humans bring to the practice of medicine. It is rigorous self-scrutiny and criticism, the unwillingness to claim definitive answers and the willingness to admit one can be wrong.

          How is that a bad thing?

  19. PMoran says:

    MAdinsonMD: — “Maybe. But your citation only showed 13%, and that included a big chunk of kids who were taking vitamins…. so maybe not all that high.”

    Yet somewhere upwards of that in those in those with poorly controlled asthma is not so trivial.

    Also, Andrey, in his account of that study failed to mention a lengthy list of reasons why that study may have found “unusually” low rates of CAM use in asthma when compared to other studies, including that they considered a narrower range of interventions as CAM.

    – “Anyway, I don’t really understand what you are getting at. Why does it matter if people are using unproven and probably ineffective therapies at 5%, 20%, or 40%?”

    Good point. It doesn’t matter for my contention that unmet (or poorly met) medical needs are an important reason for CAM use. That is important, however, because the failure to recognise this distorts dialogue to adverse effect for our purposes.

    Note how offended MTR was when Windriven thought that medical treatment for asthma was so effective there should be no reason for anyone to look elsewhere.
    Every time we even hint at how great mainstream medicine is we provoke that kind of response in CAM users, because they know, often at first hand, some of its very real failings and typically make no bones about telling us so. They may also possess some exaggerated notions but there is usually a strong germ of truth, and in my view this constitutes one of the main reasons why some become CAM users.

    It will do nothing for our status as a mature and impartial authority if we seem unaware of those failings. Observe how Andrey was able to blithely dismiss from present considerations the side effects of drugs being an important factor in decisions to use CAM.. He could not see how that was supportive of what I am saying.

    Actually most doctors (SN, Harriet, Mark, David, yourself, etc ) are, I am sure, quite aware of the mainstream’s weaknesses, more so than would most lay sceptics such as W, but it is still possible not to connect the dots so as to see their relevance to CAM use. Andrey remains in denial and he usually echoes what he believes to be prevailing dogma.

    1. Andrey Pavlov says:

      Also, Andrey, in his account of that study failed to mention a lengthy list of reasons why that study may have found “unusually” low rates of CAM use in asthma when compared to other studies, including that they considered a narrower range of interventions as CAM.

      Yes, a more reasonable one. They excluded massage from their definition. Doesn’t swing the point back in your favor.

    2. mousethatroared says:

      pmoran “Good point. It doesn’t matter for my contention that unmet (or poorly met) medical needs are an important reason for CAM use. That is important, however, because the failure to recognise this distorts dialogue to adverse effect for our purposes.”

      This wasn’t addressed too me, so pardon my response. To me it doesn’t matter so much if CAM use is driven by unmet medical needs or by cultural habits or advertising. For individuals it probably varies and you have to suss out why the individual (or group) is using CAM to have a relevant discussion with them.

      BUT – At least in the U.S. it’s not hard to find articles on how rates of physician awareness of and adherence to best practices in the the treatment of asthma are not great. Research has shown that use of best practices in asthma treatment result in better controlled asthma and lower Numbers of ER visits. I personally, don’t need the fear of patients resorting to CAM to say that I’m all for doctors getting appropriate education on best practices and then applying them when managing their patient’s asthma.

      Thumb’s up on anything that improves patient outcomes from me!

    3. mousethatroared says:

      pmoran “Note how offended MTR was when Windriven thought that medical treatment for asthma was so effective there should be no reason for anyone to look elsewhere.”

      I wasn’t at all offended by windriven’s question about albuterol. Really, I wasn’t. If I came across that way, I’m kinda bemused. Maybe I just habitually sound more offended than I am.

      I just figured that windriven doesn’t have asthma and isn’t close with anyone who has asthma, so he didn’t know. So I told him.

      I really don’t get the fuss. Of course some people use CAM because they are hoping to get out from under their asthma or would rather not pay $135 a month for medication. But the point is that there is no CAM method I’m aware of that will reduce the airway restriction/inflammation. My doctors says, if there’s inflammation there’s damage taking place. That doesn’t sound good.

      So I don’t get your point pmoran. Do you think people who are using CAM because they have unmet medical needs shouldn’t be informed when a therapy is not effective? I don’t agree.

      I can have a perfectly good reason to buy a new car, but if the car I’m thinking of buying won’t work as well as my present car, I hope my mechanic tells me that.

      1. Harriet Hall says:

        If people have unmet medical needs, there is nothing to be gained by switching to a system that is even less likely to meet medical needs. Perhaps what PMoran is getting at is that people have unmet nonmedical needs – for certainty, TLC, and other psychological factors.The obvious solution is to improve medical practice to better meet those needs, not to condone patients’ seeking solutions elsewhere on the basis of misinformation.

        1. mousethatroared says:

          I agree Harriet, but I was referring to pmoran’s statement upthread “Unmet or poorly met medical needs lie behind most use of CAM, uncomfortable as this news may be for us mainstream supporters.”

          So I think he’s talking about unmet medical needs ie: poorly controlled asthma. But I’ll be darned if I understand the take away on his remarks.

          1. Harriet Hall says:

            Yes, what evidence does he have that the needs of poorly controlled asthma are better met by CAM?

          2. PMoran says:

            ” But I’ll be darned if I understand the take away on his remarks.”

            Good question, again, MTR.

            I suppose this is partly about a dogged determination to be sure I fully understand an intriguing phenomenon. That should be understandable to a nominally science-based group.

            Otherwise, though, it mainly bears upon the misunderstandings, misperceptions and mistrust (on BOTH sides) that I think lead to virtually all interactions between sceptics and CAM sympathisers and supporters to break down into “so’s YOUR father” futility.

            Revisit your surprise at Windriven’s comment about the effectiveness of the mainstream in asthma. and Imagine that out of desperation you were actually trying various CAM methods, understanding that they may well not work, but in the hope of escaping some of the side effects that you were experiencing with mainstream methods, or of merely obtaining better control.

            How would you react to some overbearing, self-important busybody explaining or merely implying in a subtext how ridiculous it was to be doing this when science-based methods have “proven efficacy”. I think such interactions call for a lot more sensitivity than many sceptics display through their belief that they are involved in a righteous crusade against pseudoscience (which is also one of the stances that I am examining)..

            Some do show such sensitivity in private, but support a completely different, aggressively condemnatory face in public. I am uncomfortable with that even though I was once much the same. It smacks of hypocrisy, and in both cases we may be talking to much the same people.

            There is obviously no easy answer, but I hope some will eventually help explore the possibilities.

            1. Andrey Pavlov says:

              Some do show such sensitivity in private, but support a completely different, aggressively condemnatory face in public. I am uncomfortable with that even though I was once much the same. It smacks of hypocrisy, and in both cases we may be talking to much the same people.

              Ahem. Tone troll. Ahem.

              1. David Gorski says:

                Yup. ‘Fraid so. Sadly, Peter can’t seem to help himself and slip into that every now and then. He seems to be admitting that he is overcompensating for a perceived former shortcoming.

              2. PMoran says:

                Since when did hypocrisy or inconsistency become a matter of mere “tone”?

              3. mousethatroared says:

                Well, If his point is that presenting everyday medicine as more effective and reliable than it is tends to alien laypeople/patients. I would have to agree. I will say that I have upon occasion heard commentors make reference to medical care that made me think “wow, what fantasy world is that commentor living in.” But, as I said to pmoran. it seems best to address those concerns as they arise, rather than in a vague general admonition to do better.

                I can’t help but feel, though, that pmoran’s main idea is that everyone (that vaguely appears to be on his side) should just simmer down, and that’s he’s looking for arguments that will support that idea.

                The reality is, the only way you are going to get a large group of people with independent motivation, goals, experiences and views to simmer down and play nice is on a moderated forum with a clear cut rules/guidelines, active and assertive moderators who are willing to shut down posters and threads and probably delete comments.

                It is the internet it makes herding cats look like a walk in the park.

                I would add, if people were easily convinced by criticisms like pmoran’s – which could be summarized as “You shouldn’t do that, I have a theory and a little evidence that it may not be effective in some cases.” Then maybe there wouldn’t be a need for this site in the first place. Or maybe it would be much worse….Hard to tell, I guess.

            2. mousthatroared says:

              pmoran – you are correct – commentors here sometimes overestimate the effectiveness of modern medicine and the current medical system. A patient who has experienced those limitations may well remain unconvinced with an argument against CAM that relies on an overly rosy picture of the medical care they have available. I find that some commentors here are very accurate in acknowledging the shortcomings of medicine and others not so much. If this concerns you, I would encourage you to reply to the particular comment in question and correct the misperception. It is easy to say that Skeptics should have an accurate picture of the limitations of conventional medicine, but harder to actually have an accurate picture. We do not know what we do not know (ya know :))

              I would also suggest you follow up with a specific suggestion of how the patient struggling with the limit of medicine might best or reasonably handle that situation. Because just acknowleging the limitation just leaves people saying “So? What?”

              In addition “Revisit your surprise at Windriven’s comment about the effectiveness of the mainstream in asthma. and Imagine that out of desperation you were actually trying various CAM methods, understanding that they may well not work, but in the hope of escaping some of the side effects that you were experiencing with mainstream methods, or of merely obtaining better control.”

              Imagine I am a patient who is concerned about the health effects of a particular medication that happens to be the proven medical treatment for my symtoms. Or imagine I am a patient undergoing a procedure that will cost our family a several hundred dollars (at least, high deductible medical insurance, you gotta love it). I understand that science shows that these are my best bets for symptoms relief, but people keep telling me how dangerous those medications are or how doctors are just trying to rip me off. I feel worried the medication or procedure might hurt me or I might be wasting my families money. I think maybe it’s more responsible, safer if I just tolerate my symptoms.

              These are also limitations that I, personally face, when dealing with medical care. But when I reprimand SSR for perpetuating these myths, for preying on my fears. YOU completely ignored the realities that I as a patient face in making medical decisions and lectured to me on how SSR wasn’t so bad and inquired why I don’t think his beliefs are genuine.

              I am not alone in this, Many people feel bad about the expense or concerned about long term effects of their medication or procedures (statins, vaccines, blood pressure, blood thinners, steroids, surgeries) They feel pressured into trying alternatives. They should take vitamins or herbs instead or try accupunture. That stress is increased by people like SSR who gleefully spread any myth they can get their hands on.

              In my mind, you can’t have it both ways. You can’t say you are sympathetic to my situation or those of patients like me and still be tolerant of and sympathetic toward doctors or practitioners like SSR who are preying on this situation.

              1. Andrey Pavlov says:

                Imagine I am a patient who is concerned about the health effects of a particular medication that happens to be the proven medical treatment for my symtoms. Or imagine I am a patient undergoing a procedure that will cost our family a several hundred dollars

                An excellent point (all of it was Mouse, and I greatly appreciate your input as someone on the “other side” if you will).

                This is something that I do feel is lacking in medical care and something I personally strive to overcome, both for myself and in encouraging my colleagues to do the same. It is also something that is changing on a systematic level, albeit slowly.

                I take the time to address the fears of side effects and work out care plans to figure out ways to minimize medication usage for my patients. I question and critique colleagues (when I can, which is limited by my status) who I feel are overprescribing. And the concept of polypharmacy, overprescription, and side effect profiles is something explicitly taught in (at least my) medical school. It is also something that is being pushed by the ACGME and is making it into residency education programs as part of the core curriculum. I also take the time to discuss the idea of risk:benefit and balance that in a way that is consistent with the science and the patient’s values and abilities. There are also multiple resources for better communicating this to patients available and in the works.

                In terms of cost, it is exactly paralleled, so I won’t bother almost entirely re-writing what I just did. I often refer patients and colleagues to the NeedyMeds website, it is commonplace at my institution to discuss not just what medication we feel would be best for the patient from a purely academic standpoint but also from a practical standpoint. And I’ve mentioned many times how the “cheap diagnosis and management” game is played in resident rounds.

                Just because we focus here on why CAM is not a reasonable alternative doesn’t mean the rest is being ignored.

              2. mousethatroared says:

                Andrey “Just because we focus here on why CAM is not a reasonable alternative doesn’t mean the rest is being ignored.”

                Argggh – Please tell me that’s not what my comment seemed to imply – cause that wasn’t what I intended at all.

                I am in keynote hell right now. Literally*, I think I must have done something very bad because I don’t think I’m ever going to finish this *&%@ slide presentation.

                So I can’t clarify. But if that’s what it sounded like, just ignore the comment altogether as a failed comment. And light a candle for the lost souls in keynote land.

                *yes, literally.

              3. PMoran says:

                MTR, the question was whether SSR is sincere in his beliefs and what led into that was the fact that many sceptics do talk about CAM and to such people as though it was all outright fraud.

                Yet our audience includes people, practitioners, politicians and others who know or strongly suspect that this is just not the case.

                False perceptions seriously reflect upon our credibility.

                You raise other complex matters. Briefly, we can accept that some aspects of CAM are helpful to some people in some ways without necessarily having broad approval of all aspects of it. Nothing is simple in medicine.

                It is being strongly denied that there is any intention to try and ban CAM. If that is the case, and it is being accepted that for the time being we have a de facto dualist medical system then one thing we should be thinking about is how we might best protect people from some resultant dangers.

                To do that we have to, again, be perceived as a voice that can be trusted, so that this is not seen as merely one more way of demonising CAM. An allied error is to push overly romantic views of present state and capabilities of mainstream medicine and science. I will fiercely defend both of those against unfair attacks but another way in which we can clash with not unreasonable perceptions is to get too wrapped up in our own brilliance. .

            3. Andrey Pavlov says:

              Since when did hypocrisy or inconsistency become a matter of mere “tone”?

              Because you are flat out wrong that it is hypocritical and inconsistent. And because the complaint is that the “softer” side is appropriate whilst the “harsher” side is not.

              1. PMoran says:

                I disagree. One complaint is that it is an unexamined inconsistency. Tell me (quickly) why you would not be saying to a patient face to face “no, that is a useless treatment” , when that is what is commonly said here.

              2. Andrey Pavlov says:

                I do tell them it is a useless treatment. I just do it in a different manner. I gauge the level of commitment to the idea my patient has combined with the amount of risk I feel it exposes them to and use an appropriate level of stridency in my commentary. I frame it by saying (any or all depending on the situation) the likelihood that it works is extremely small to the point where I would be comfortable saying it doesn’t, these are the risks, I do or don’t believe the risks are very serious, and often close by saying it almost certainly isn’t worth the expense (including time).

                You can call it sugar coating, but it is the difference between speaking to a wide and mostly anonymous audience vs a specific individual. The message is the same. The delivery is different.

              3. MadisonMD says:

                Tell me (quickly) why you would not be saying to a patient face to face “no, that is a useless treatment” , when that is what is commonly said here.

                I would say it. In fact, I’ve told a patient that she was scammed by a Tijuana doctor who shipped her monthly laetrile, vitamins, and enzymes at a ridiculous charge. If I were to shuffle my feet and beat around the bush, the message might not get across. Isn’t it a mercy to tell the truth?

            4. Andrey Pavlov says:

              Argggh – Please tell me that’s not what my comment seemed to imply – cause that wasn’t what I intended at all.

              I apologize Mouse. In retrospect and in re-reading my post and yours I probably used yours as a springboard to speak to Peter. Your comment was indeed ambiguous, but in no way implied one way or another. It seems I used that ambiguity as a platform and for that I apologize as much as is necessary.

              I will say, however, that you do have more insight (at least my confirmation bias tells me so ;-)) on the topic than Peter does.

              1. mousethatroared says:

                That’s okay, Andrey. No apology needed. I use comments as jumping off points all the time.

                Sorry about the ambiguity. I will summarize.

                Me HULK patient – feel bad CONFUSED
                HULK like pmoran – nice words, friendly
                HULK no like SSR – scary words, LIES!
                HULK smash!*
                pmoran like SSR?
                pmoran say scary lies OK?
                pmoran say no smash?
                Who protect HULK?

                *no doctors were actually smashed in this performance.

    4. MadisonMD says:

      Good point. It doesn’t matter for my contention that unmet (or poorly met) medical needs are an important reason for CAM use.

      It will do nothing for our status as a mature and impartial authority if we seem unaware of those failings.

      How is it possible to be unaware for any physician, scientist or patient (who experiences firsthand)?
      Call me a simpleton, but I was always under the impression that these failings should actually spawn scientific efforts to overcome them– that they are the very raison d’etre of biomedical research.

      The reason I frequent this forum is because I find the following offensive:
      (a) Limited research funds are wasted on CAM.
      (b) CAM misleads patients.

      Whether this originates from dishonesty, lack of critical thought, wishful thinking, religion, I don’t care. It is still offensive– if we waste time and resources this way, we cannot achieve full potential to actually meet unmet needs.

      Where will we be 50 years from now? Will we still be using CAM for the same unmet needs as today? Or will we actually have met them?

  20. Andrey Pavlov says:

    Observe how Andrey was able to blithely dismiss from present considerations the side effects of drugs being an important factor in decisions to use CAM.. He could not see how that was supportive of what I am saying.

    I did not blithely dismiss it. Certainly not in the way you blithely dismiss disconfirming evidence in acupuncture studies.

    I stated that at core, those unmet needs are not the main driver. Ever wonder why I put certain words in italics? Because they are important. I have never claimed they are not part of driver. But not the main driver. I’d go into some more nuance on this specific instance, but it isn’t necessary and history shows would go right over your head and just be waste of my time.

  21. PMoran says:

    Not sure if this went through.

    H: “How am I to know what others are thinking?”
    You can’t. And yet you presume to when you say you are sure many more would call for a ban if they thought it was politically feasible.”

    Not quite touché, because that is a not unreasonable deduction from much that is said here. I cannot know that people are thinking as critically as I am about common SBM presumptions if they don’t say so.

    “– that the belief systems have scammed the providers, not that the CAM providers are deliberately scamming the patients.”

    It’s not the belief systems so much as the illusions and quirky influences within daily medical practice that misleads everyone (IF they are totally misled in what can be an extremely complicated human interaction).

    And we shouldn’t feel too superior about this — mainstream doctors and its esteemed professors have shown that they can be just as misled about pet treatments, moreover also continuing to believe in them even after studies suggest not intrinsic worth to them. Such is the power of such influences. They leak through our best attempts to eliminate them in extremely elaborate and expensive clinical studies.

    Also, as with politics, we are often dealing with perceptions, and there is little doubt whatsoever how most people will interpret terms such as “sCAM” and “$CAM”.

  22. PMoran says:

    “Tell me (quickly) why you would not be saying to a patient face to face “no, that is a useless treatment” , when that is what is commonly said here.

    MadinsonMD: “I would say it. In fact, I’ve told a patient that she was scammed by a Tijuana doctor who shipped her monthly laetrile, vitamins, and enzymes at a ridiculous charge.”
    ———————————-
    We have clear evidence that none of those can cure established cancer, so I would say something similar, while not making her feel too small for looking for outside help or for being taken in. You are also not likely to be telling her something she would not have suspected when she arranged for this treatment, out of worry, or desperation.

    However, are you not a believer in placebo influences? Would you destroy a patient’s potential for such responses by telling them a treatment was “useless” in ALL contexts?

    Here is a doctor who has been thinking about that problem (look at the last paragraph) . http://www.the-rheumatologist.org/details/article/873613/Is_Acupuncture_for_Pain_a_Placebo_Treatment.html

    I am not so sure about his reference to “lying”. It is not lying or inconsistent with the available science to go so far as “it seems to help some people.”

    Many sceptics are terrified of doing the least thing that might seem to be endorsing pseudoscience, to the extent that immediate patient interests may have to take a back seat. Patients will not be daring to ask these questions of their MD in the absence of significant medical need. If you have no other answer to that, how do you justify poisoning other wells? It’s a bit dog-in-the-mangerish in my view, and it won’t necessarily change the patient’s inclinations. Our position doesn’t have to be all one thing or the other. It can be non-committal, conditional, provisional.

    And we can’t win everyone ether way, perhaps. Sceptically inclined patients will despise us for being flexible, while others will look down on us for not being prepared to consider anything that might help them, even if only remotely. In good medical systems doctors can get to know their patients well enough to know in advance where their sympathies lie.

    1. MadisonMD says:

      However, are you not a believer in placebo influences? Would you destroy a patient’s potential for such responses by telling them a treatment was “useless” in ALL contexts?

      I am not so sure about his reference to “lying”. It is not lying or inconsistent with the available science to go so far as “it seems to help some people.”

      If we are speaking of minimally harmful treatments for subjective symptoms rather than cyanide-tabs for cancer, I can soften up a bit, yes. Perhaps we are not far apart in reality, just in tone?

      Yet somehow I still feel obliged to tell the truth, and “it seems to help some people” just isn’t full disclosure. My primary disagreement with your position is that I believe another level of honesty is required– I feel obligated to tell my patient what the science shows, viz that the intervention operates by placebo. Anything else is less than fully honest. My patients are not children.

      I likely disagree with you–but less strongly–in that I don’t feel obligated to mince words on an internet blog. I understand the concept that a softer tone may gather more folks to read and consider. But alternately, it could play in the hands of quackery by not providing strongly stated, well-reasoned factual information, or expose false arguments.

      1. Andrey Pavlov says:

        I completely agree with you MadisonMD. In the truly extreme scenario I might even give a complete pass to not “poison other wells” as Peter says, but that is an individual exception where I know I am “breaking the rules” and being hypocritical and inconsistent. I personally have yet to really get into that scenario, but I’m sure I will at some point in my career.

        Otherwise it is all about the same message, delivered differently in different contexts. What I have done is include the reasonable caveat “almost certainly it does not work as anything more than a placebo” when the patient seems really keen on whatever the treatment is. I give them a small “out” if they really want to keep using it while making it clear that regardless the patient still has full support from us.

        But this blog is not our consultation office.

    2. mousethatroared says:

      Except, we started out talking about asthma patients with unmet medical needs. Their concerns were incomplete asthma control, side effects and cost of treatment.

      Now you have seamlessly transitioned into OA patients with residual pain. How well does the same approach work with the patient with poorly controlled asthma?

      1. MadisonMD says:

        Poorly controlled asthma can be life threatening and an acute attack may be lethal. I would strongly discourage placebo interventions to manage chronic severe asthma– except perhaps as an adjunct to proper care. For chronic mild asthma, or minor exacerbations, relaxation or placebo-based interventions would be less dangerous, and I would follow the same template as OA for pain.

        As an occasional, mild asthmatic myself, I prefer a calming cup of black tea. It has the calming influence (just like massage, acupuncture, etc.), plus a bit of theophylline which is pharmacologically active in the disease.

        1. mousethatroared says:

          MadisonMD – I don’t know. My problem seems to be that I don’t know when my asthma is a problem. When I last saw the doctor, I was just in for a check-up and health form signature. She listened to my chest because of a history of shortness of breath/asthma – declared wheezing and prescribed the inhaled steroids. The allergist/asthma specialist I saw once said I have asthma, but I’ve been to my doctors at other times for the exact same symptoms and they say my chest sounds fine and my spirometry was normal. I’ve had pulmonary function test (that didn’t rule out asthma) to look for interstitial lung disease – which were normal. So I don’t know, it’s whacky and I just go with the flow, even if it costs a few hundred dollars, I guess.

          I do know that a month ago I was having to pause mid sentence to take a breath, now I feel like I can take alot bigger breath, so maybe the steroid is working…or maybe the shortness of breath was temporary, associated with a cold I was getting the day of the doctor’s visit, and would have got away after a couple weeks and some black tea.

          I have reached the maximum benefit that coffee can provide for asthma, though. ;)

      2. PMoran says:

        The same dilemma could arise with just about any symptoms that are not controlled by optimal medical care. Those with poor asthma control are quite likely to use “alternatives” with or without our knowledge, and “with” would be better.

        While asthma seems to be a very placebo responsive condition, I personally doubt if placebos would mask the serious difficulty in breathing that indicates imminent danger..

        1. Andrey Pavlov says:

          While asthma seems to be a very placebo responsive condition, I personally doubt if placebos would mask the serious difficulty in breathing that indicates imminent danger.

          Then you don’t know much about asthma nor have you read the data we have discussed here honestly.

          Asthma is an inflammatory airway disease. It is unequivocally not responsive to placebo. At all. Period. In fact, one could argue that a placebo would worsen the condition since giving a sense of security decreases catecholamine release which would increase airways constriction. How much that will matter, I won’t speculate, but the point is that the argument can only be no better or worse, but never better.

          The perception of symptoms is what the placebo will modulate. The fact that you think these symptoms won’t be masked should serious danger be imminent shows how little you know about the disease itself and how people deal and present with it. Which is perfectly fine – you were an orthopod not a pulmonologist. But you should really break your bad habit of making concrete assertions based on false assumptions.

          I’ve seen many patients in the ER and the ICU with an asthma attack. And I’ve seen them claim they are “fine” and want to leave the ER after some treatment while still breathing at 30 resps per minute. When asked if they are short of breath, they deny it. I’ve seen people will uncontrolled mild asthma who claim only minor dysfunction. Give them albuterol and they are literally blown away by how much better they feel and easier they can breathe. They knew they were bad off, but had no idea how much better it could be. And that is the danger of CAM in the case of asthma – people adapt and very quickly feel that their low level of chronic inflammation is “normal” and will argue that their treatment (whether it be CAM or real medicine) is “working.” But their lungs are being damaged and their threshold for a severe attack is much lower and they are more likely to consider symptoms leading to a severe attack to be more mild and minor.

          Your personal doubts are ill informed.

        2. mousethatroared says:

          pmoran “The same dilemma could arise with just about any symptoms that are not controlled by optimal medical care. ”

          Who said anything about optimal medical care? Did those kids in the CAM use study you cited up thread all have optimal medical care? I sincerely doubt it. But I’ll make a deal with you pmoran. When all the people in the U.S.* have access to optimal medical care and have a reasonable understanding of how to use the system, I’ll fully support your position on how skeptics should communicate their concerns about CAM.

          pmoran “While asthma seems to be a very placebo responsive condition, I personally doubt if placebos would mask the serious difficulty in breathing that indicates imminent danger..”

          Andrey addresses this but – everything that my doctors have told me about asthma suggests that you are flat out wrong here. Please review the standards of care for asthma and the rational behind it. Also understand that treatment of asthma is not only about preventing death. It’s about quality of life, lowering ER visits, maintaining healthy activity levels, lowering days missed from school and work, etc.

          *It’s not that I don’t care about other countries, it’s just that I think we will be one of the last nations on earth to implement this (Alice has got me down).

          1. Andrey Pavlov says:

            It seems you understood what your doctors were trying to tell you Mouse.

            And yes, asthma is not always the easiest to diagnose since it can exist on a spectrum independently and with other lung diseases. The nice part is that for the most part the lung diseases it can be confused with will respond to the same drugs regardless, with some exceptions (obviously). So it becomes more important to rule out those and then treat empirically and see what happens.

            I can’t tell you how many times I have seen a patient who told me they were breathing just fine, and even actually looked fine from the end of the bedside, and then I listen to their lungs hear a prominent wheeze, give them some albuterol, and watch as their faces literally light up in amazement at how much better they feel.

            But I suppose I could have just given them CAM which would have kept them feeling “just fine” instead. :-p

        3. MadisonMD says:

          While asthma seems to be a very placebo responsive condition, I personally doubt if placebos would mask the serious difficulty in breathing that indicates imminent danger.

          Likely true, but managing asthma is not simply about treating acute severe attacks. Appropriate management includes prevention of these attacks, and early intervention in case of a developing attack.

          If your patient is, for example, using homeopathic preparations to prevent a severe asthma attack, then there may be more flare-ups, hospital visits, and additional risk of death incurred than with appropriate long-term prevention.

          If your patient is, for example, using acupuncture to manage mild-to-moderate attacks, because it alleviates the symptoms without actually improving the underlying disease (Weschler et al. NEJM 365:119), then it seems likely that a small number of these attacks will increase in severity until it a hospital visit is necessary, and perhaps even a small number of avoidable deaths will be incurred.

      3. Andrey Pavlov says:

        @Mouse:

        Both have a common theme that makes the response to placebo essentially the same. In both cases the underlying pathology is untouched but the perception of symptoms is ameliorated. In OA that is significantly less dangerous than in asthma.

        From the data Peter presented and additional that I have read in the past and from those references it seems that most people who do engage in CAM for asthma do so prior to any unmet needs. They do it simultaneously with actual treatment at initial presentation. The next subset engages in CAM as they learn more about the side effects of the medications they are using and begin to try and substitute some real medicine for CAM. This actually has the potential to be useful in a sense since we do tend to overmedicate our asthma patients. Recent studies have demonstrated that for mild to moderate asthma routine daily use of an inhaled steroid is not more effective than intermittent use initiated by the patient at the time of an oncoming attack. What this indicates is that a certain subset of the asthma population will substitute some ineffectual CAM for their inhaled steroid, decreasing the use of the steroid. The data actually shows us that this won’t affect outcomes, so it can become easy to attribute the benefit to the CAM being used when in reality it is just that our recommendations should change. In other words, they are “getting away” with CAM use rather than actually benefiting from it.

        The danger comes in the false sense of security. If we are titrating meds we do so under a state of vigilance to catch attacks before they happen. If under the delusion of placebo from CAM, that vigilance decreases and titrating meds becomes difficult, if not impossible, and outcomes can be worsened.

        Where that balance actually lays in a real world population is anyone’s guess. For mild asthma I would think it actually lays in favor of the CAM and progressively less as the severity increases. But no matter where that balance lay, the method for getting there is fundamentally wrong. So you are getting the right answer for the wrong reasons, and when that “luck” fails it can lead to significant and even grave outcomes.

  23. Mr Peter James Moran says:

    “From the data Peter presented and additional that I have read in the past and from those references it seems that most people who do engage in CAM for asthma do so prior to any unmet needs.”

    Now you are just making things up — a foolish tendency in someone with aspirations to be an important CAM commentator. Don’t be misled by the fact that in this tribal environment few will challenge even quite fatuous statements. Remember how I was the only one pointing out how many utterly contradictory statements you managed to make, one after the other.

    I have been following this stuff for years and I KNOW there is no such data, although some families might already be indulging in various “soft” uses of CAM for other purposes prior to the onset of asthma.

    All (or most) of the studies show a correlation of CAM use in asthma with poor control and episodic recurrences (presumably not being prevented by the medical management). All (or most) of the studies of CAM use in general show a strong correlation with ongoing ill-health (of ANY kind) and the evidence shows that the vast majority of those are also using conventional methods. Go look some more.

    There will be a small core of CAM ideologues (the very few per cent who claim to exclusively rely on CAM ) who will habitually try CAM first and even persist with it at risk of their child’s life, but very few of the remainder of the population will not know that the mainstream has useful treatments and, in my view, use them energetically when a child is gasping for breath.

    They will only then be bombarded with advice from well-meaning friends, and relatives, and less well-intended Internet sites, and that will lead some to try CAM as well. Much of that use will be based upon the knowledge that the mainstream has no “cure” for asthma, in the sense of turning it off. We are thus back to the limitations of mainstream medical care as a major factor in CAM use.

  24. harmony says:

    After reading the not so beautiful truth and your gluten free article i just want to say that you sound as though you are contributing nothing posative or organic to our world people want nature and the gerson therapy plugs you back in with nature you cant patent it or buy it from monsanto ,however it sounds as though you as an author need to get your toes in the mudd and get your earth on my friend……cancer visits us all everyday what will your immune system do ?

    1. Chris says:

      Wow, that is one weird bot comment.

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