Jan 30 2012
Adventures in defending science-based medicine in cancer journals: Energy chelation
My co-bloggers and I have spent considerable time and effort over the last four years writing posts for this blog (and I for my not-so-super-secret other blog) bemoaning the infiltration of quackademic medicine into what once were bastions of evidence- and science-based medicine. We’ve discussed at considerable length reasons for why this steady infiltration of pseudoscience into medical academia has been occurring. Among other potential explanations, these reasons range from the ascendence of postmodernism in areas where it really doesn’t belong; to a change in our medical culture to a more “consumer”-oriented, “keep the customer satisfied”-sort of model in which patients are often referred to as “clients” or “customers”; to the corrosive influences of moneyed groups (such as the Bravewell Collaborative) and government agencies (such as the National Center for Complementary and Alternative medicine, a.k.a. NCCAM); to the equally corrosive influences of powerful woo-friendly legislators who use their position and influence to create such agencies (such as Senator Tom Harkin and Representative Dan Burton) and otherwise champion “complementary and alternative medicine” (CAM) and “integrative medicine” because they are true believers in quackery; to cynical legislators, like Senator Orrin Hatch, who champions such government programs supporting pseudoscience because he represents a state that is home to the largest concentration of supplement manufacturers in the United States and is consequently a master at bringing any initiative to regulate the supplement industry more tightly to a screeching halt.
As a result of our efforts and the need for a counterweight to the quackery that has infiltrated so much of academia, SBM has become fairly prominent in the medical blogosphere. Our traffic is good, and we have a number of “thought leaders” who regularly read what we write. We’ve even caught the attention of Dr. Josephine Briggs, director of NCCAM, and our founder Steve Novella was even invited to appear on The Dr. Oz Show for “balance.” All of this is something that we are justly proud of. On the other hand, I can’t help but keep things in perspective. While our traffic as a blog is quite respectable and we have become prominent in the skeptical and medical blogosphere and even, to some extent, in academia—we’re particularly gratified at the number of medical students who are regular readers—compared to the forces arrayed against SBM in academia and the media, we have to face facts: We are truly a tiny voice in the wilderness. For instance, we average around 9,000 to 16,000 visits a day. Compare that traffic to the many millions who used to watch Oprah Winfrey and still watch her protégé Dr. Oz or to health media and product empires of people like Andrew Weil and Deepak Chopra, and you get the idea.
All of this is why I started looking for opportunities to respond more directly to incursions of pseudoscience into medical academia. Occasional SBM contributor Peter Lipson provided me with just such an opportunity last summer when he sent me a link to a brain-meltingly bad study about the use of CAM in cancer that shows just how bad a study can be and still be published in what I used to consider a reasonably good cancer journal. I say “used to consider,” because the fact that this journal accepted a study this ludicrous indicates to me that its peer review is so broken that I now wonder about what else I’ve read in that journal that I should now discount as being too unreliable to take seriously. Maybe everything. I don’t know. What I do know is that seldom have I seen such a bad study in such a good cancer journal. Studies like the one about Tai Chi in fibromyalgia or placebo acupuncture applied to asthma don’t even come close.
Soon after this study appeared online ahead of print, James Coyne contacted me and asked me if I wanted to be co-author on a letter to the editor of the journal. Honored by Dr. Coyne’s request, I immediately said yes (of course), and together with Dr. Christoffer Johansen at the Survivorship Unit of the Danish Cancer Society, we submitted our letter to the editor. To my surprise, given the utter failure of past efforts to publish letters to the editor about studies of this sort, our letter was accepted for publication. Last week, the study in question saw print, and our letter was published online ahead of print, along with the response of the authors. All are instructive and, to me, show just what we are up against in trying to prevent pseudoscience from creeping into academia.
The study: “Energy chelation”? I kid you not!
No doubt at this point, some of you are thinking that perhaps I’m being way too harsh when I called this study “brain-meltingly bad.” That is why, even though Peter has already discussed this paper, I feel obligated to describe the study and my objections to it at some length. So let’s dig in, shall we? The journal is Cancer, which is the official journal of the American Cancer Society and has an impact factor of 5.131. That is, as we say in the biomedical research biz, not too shabby. The investigators are from the Samueli Institute (which, as you might recall, published a recent survey on CAM adoption by hospitals), the University of California San Diego, the RAND Corporation, and Healing Light Center Church, and the paper is entitled Complementary Medicine for Fatigue and Cortisol Variability in Breast Cancer Survivors A Randomized Controlled Trial.
Fatigue is a huge problem in cancer patients, and this study was designed to test the effect of what the authors call “biofield” therapies on fatigue in 76 breast cancer patients with significant fatigue during chemotherapy. For purposes of this study, “biofield” therapies were defined to be more or less the same thing as energy healing, which encompasses reiki, therapeutic touch (TT), healing touch (HT), and others. In actuality, from a strictly scientific standpoint, the experimental design of this study wasn’t half-bad. The problem comes from how this study examines a therapeutic modality for which there is no evidence, namely something the authors call “energy chelation.” (I kid you not. That’s actually what they call it! In an actual scientific paper!) To sum up the study in a nutshell, this was a phase 2 randomized, intention-to-treat clinical trial that compared biofield healing (“energy chelation”) with a “mock healing” control and a waitlist control.
Never having heard of “energy chelation” before and having written a lot about chelation therapy as a form of quackery claimed to be useful as a treatment for autism caused by “vaccine injury” and for cardiovascular disease, I was very curious. So I read with interest how the authors described this modality:
The specific technique used in the biofield healing group is termed energy chelation, and was selected by 1 of the authors (R.L.B.), whose healing techniques have been incorporated in modalities such as Healing Touch and Therapeutic Touch.26,27 During energy chelation, the practitioner practices hands-on healing with standard hand positions, beginning with hands on the feet, then to the knees, hips, bladder area, stomach, hands, elbows, shoulders, heart, throat, head, and back to the heart. The practice of energy chelation is 45 to 60 minutes, with a practitioner generally focusing for 5 to 7 minutes on each position.
Naturally, my next question was: Who is “R.L.B.”? R.L.B., it turns out, is Reverend Rosalyn L. Bruyere from the Healing Light Center Church. I did some Googling and found her quickly enough. On Bruyere’s website, she is described thusly:
Founder and director of the Healing Light Center Church, Reverend Bruyere has committed her life to the teaching of these sacred and ancient disciplines, thereby providing her students with practical tools for living the spiritual life, while introducing them to the venerable traditions from which those tools are derived. Her goal is to encourage the compassionate healing and empowerment of the individual, believing that as we each heal, we can be of greater assistance in the healing of the world.
She is the originator of the whole-body technique known as Chelation which has become a classic, taught in many modern healing schools, as well as Brain Balancing and a pain-reducing skill which some have called Pain Drain.
Her book, Wheels of Light, A Study of the Chakras, is an invaluable text for the bridging of ancient and modern healing arts. Rev. Bruyere has studied extensively in areas of Egyptian temple symbology, Sacred geometry, ancient Mystery School rites, international shamanic practices, the pre-Buddhist Tibetan Bon-Po Ways, and various Native American Medicine traditions.
Rosalyn’s knowledge of ancient traditions and practices has led to requests for her technical assistance on several films and documentaries. Among the more notable features on which she has served as technical consultant are “Resurrection” and “The Last Temptation of Christ”.
Although I don’t recall having blogged about “Brain Balance” before, fortunately Harriet Hall already has and quite correctly concluded that it is “based on speculation, not on credible evidence.” Pain Drain is an HT technique in which the “practitioner” holds one hand above an area of complaint until the pain recedes and then places the other hand near the area of relief. In other words, it’s yet another variant of “energy healing” modalities like TT and reiki. As for energy chelation, I Googled that as well and found quite a few links describing it. For instance, here is a Q&A by a healer named Kay Morris Johnson, who charges $65 an hour for her energy chelation (righteous bucks for waving your hands around people) and ensures us that it “works by moving heavy or stagnated energy, once this movement takes on a transformation then your whole body system reacts similar to downloading, accepting the changes in your energy field into your physical being” and that there is indeed detoxification with energy chelation (much like real chelation, I would imagine). She even gives a helpful primer on the difference between energy chelation and reiki:
Reiki is best use for general consistent work to maintain your energy whole field balance. Energy Chelation is best applied to detailed energy needs in defined areas of one energy field. Energy Chelation also has different vibrations associated with it, such as sound energy. Sound Energy is described as a deep vibration and is very effectively use on areas of old stagnate energy, such as childhood issues. These old issues are stubborn dense often times large energy blocks that require that extra boost of vibration to initiate movement.
Well, that’s useful. Reiki is faith healing in which the person being healed is usually not touched but the practitioner believes that he’s channeling healing energy into the patient from a “universal source,” while energy chelation “hands on” energy healing. They’re totally different! Really!
Another website helpfully proclaims the “physical reality on which human energy chelation therapy is based” as:
Human Energy Chelation Therapy (HECT), a process of transmitting or channelling energy, is based on the electromagnetic nature of the human body. The body’s electromagnetic or auric field is generated by the spinning of the chakras. As it spins, each chakra produces its own electromagnetic field. This field then combines with fields generated by other chakras in the body to produce the auric field. An individual’s auric field is manifested via a combination of energies from three chakras. Generally these are the first, third and fifth chakras, which empower the person’s physical, intellectual, and etheric bodies. It is a combination of these three chakras that produces the primary auric field (the inner shell of the aura), which can be physically felt by the therapist’s hand as it is passed over the client’s body in the process of scanning.
And where does energy chelation get its name? Here’s an explanation:
Heavy metals are toxic to the human body. Chelation has been a tried and true method in removing them from the body. The toxins must be removed before the body can benefit from any health promoting actions.
Stuck emotions are very similar to heavy metals in that they too are toxic to the body, mind and spirit. Healthy emotions are energy in motion. However when emotions are stuck, not acknowledged, stuffed and ignored they become like heavy metals and are toxic to the human system. They need to be removed before health-promoting actions can produce beneficial results. Just like chelation removes heavy metals from the body, energy chelation is a method which removes sticky, heavy dark energy from the human energy field.
Is “sticky, heavy dark energy” anything like the long, dark tea-time of the soul? It rather sounds that way to me. In actuality, it might as well be, because energy chelation is every bit as much a work of fiction as anything ever written by Douglas Adams, except that Douglas Adams had far more imagination. In any case, it amuses me to no end when CAM advocates start using metaphors as names for their nonesense. Be that as it may, the next question I had, after learning that energy chelation is “hands-on energy healing” was what the control group would be. In other words, what, exactly, was “mock healing”? Here is a description of the mock healing control group taken straight from the Methods section of the paper (yes, this is verbatim):
Mock healing practitioners were skeptical scientists who were trained to use the identical hand placements as biofield healing practitioners. Mock healing practitioners were asked not to intend to heal the patient when touching, but rather to disengage into “planning mind” by contemplating current and upcoming research-oriented studies and grants they were currently involved in. Given that biofield healing practitioners would have more familiarity with working with patients than mock healing practitioners, to preserve participant blinding mock healing practitioners practiced procedures with study personnel until the mock healing practitioner demonstrated mastery of the hand placements and confidence interacting with and fielding potential questions that a patient might ask the mock healing practitioner before or after the session.
It never ceases to amaze me how science drives out magic; even practitioners of energy chelation seem to accept that. After all, if they didn’t, then why would they have chosen the control group that they did and gone to all the trouble to train scientists to put their hands on people in the same positions that Rev. Bruyere uses while thinking extra super hard about how they don’t believe any of this nonsense? In actuality, it’s not a bad control group–if you accept the premise of the study. What is that premise? It’s that there is a human energy “biofield” that healers using “energy chelation” can manipulate to therapeutic intent and that there has to be a degree of belief for that to work. I do like how that evil “planning mind” (as opposed, I suppose, to a “believing mind”) can destroy the magical rays that supposedly heal by chelating all that bad energy. In any case, this is exactly what Harriet Hall meant by “tooth fairy science” when she wrote:
We can study the amount of money left by the Tooth Fairy in different settings, but since we haven’t determined that there is really a Tooth Fairy, any conclusions we reach will be falsely attributed to an imaginary being rather than to the real cause (parental behavior). In acupuncture studies, the acupuncture points/meridians/qi may be imaginary and we may be studying an elaborate placebo rather than a real physiologic phenomenon.
It has not been established that such a thing as a “human energy field” (at least not what “energy healers” mean by the term) exists, that humans can perceive and manipulate it, or that that perception and manipulation of energy fields allows them to heal. In fact, it’s about as clear as clear can be that humans can’t, as a 12-year-old girl named Emily Rosa demonstrated so clearly back in 1998.
So, after all that introduction, what were the results? What do you think they were? I’ll give you a hint. These results were entirely consistent with placebo responses. Basically, there was no difference in total fatigue levels between biofield healing and mock healing. Both produced a decrease in fatigue that patients on the waitlist control did not. In other words, for the primary outcomes measured in the study “biofield” therapy didn’t work compared to the “mock healing” placebo control. So, given this completely negative result, what did the authors do next? They did what any good CAM believer does (and, for that matter, all too many scientists do) and started mining the data for associations, delving into the Multidimensional Fatigue Symptom Inventory short form subscales. Not surprisingly, they found barely statistically significant differences between biofield healing and mock healing in a couple of measures, as is frequent whenever researchers start making a bunch of pairwise comparisons. They also measured salivary cortisol levels and found a significant decrease in cortisol slope over time for the biofield healing versus both mock healing and control. What this means, I have no idea, given that salivary cortisol “variability” (which they calculated) hasn’t been validated as a reliable diagnostic tool for much of anything that I’m aware of or correlated with fatigue.
I’m not impressed. Here’s why. First, I can’t help but note that none of these differences were mentioned in the abstract, which implies to me that even the authors didn’t consider them particularly significant. More importantly, we have multiple comparisons among small groups of patients. (Remember, there were only 76 patients in this study.) Finally, fatigue is a variable symptom that waxes and wanes frequently. it’s very prone to regression to the mean, placebo responses, and reporting bias. It’s very hard to say a lot about whether these barely detectable differences in a couple of subscale measures are in any way clinically significant. Probably not. Not that that stops the authors from laboring mightily in the discussion section to make it sound as though their biofield therapy is the greatest thing since sliced bread. Let me ask you a question whose answers regular readers of SBM should know: What do we normally call it when there is no difference between the real treatment and a sham treatment in a clinical trial testing a drug or device? That’s right. We say there’s no effect greater than that of a placebo and that the trial is negative; i.e., the tested experimental intervention doesn’t work.
Not this study:
This RCT examined whether biofield healing, compared with both active (mock healing) and waitlist control groups, positively affected fatigue as well as cortisol slope, depression, and QOL in breast cancer survivors with persistent fatigue. In addition, this study explored the role of belief in receiving healing as a potential predictor of responses. Findings indicate that both touch-based interventions reduce fatigue in fatigued breast cancer survivors, with considerable effect sizes. Previous research by our group on a separate sample of breast cancer patients indicated that the mean Multidimensional Fatigue Symptom Inventory-short form total scores was 5.99 immediately before the start of anthracycline-based chemotherapy, and rose to 19.9 immediately before the fourth cycle.38 Our fatigued survivors in the mock healing group (mean postintervention score ¼ 10.9) dropped to fatigue scores lower than those found for breast cancer patients toward the end of chemotherapy, and the biofield healing group (mean postintervention score ¼ 4.2) fell to fatigue scores that were below prechemotherapy scores, as well as below previously published means noted for breast cancer patients overall.28 This drop in fatigue appears to have clinical as well as statistical significance.
In other words, according to the authors, because both the “real” biofield healing and the “mock” biofield healing resulted in a decrease in fatigue scores and a barely statistically significant difference in a chosen surrogate marker, biofield healing “works.” This is the same sort of dubious rationale frequently used to claim that acupuncture “works” when they find that sham acupuncture results in the same apparent measured effects as “real” acupuncture. The correct interpretation of this study is that it’s a negative study, and “energy chelation’ does not work. It is placebo. Stick a fork in it; it’s done. Or, as Drs. Coyne, Johansen, and I wrote in our letter:
The registered primary outcomes of the trial were self-reported fatigue, depressive symptoms, and quality of life. No significant differences were obtained between TT and the mock treatment, whereas both conditions were superior to waitlist control. Essentially, the authors examined 3 primary outcomes, with secondary analyses of 5 subscales of the fatigue measure, and a secondary outcome, cortisol, with all pairwise differences explored between the TT, mock treatment, and waitlist control conditions. With any control for multiple comparisons, the modest difference between TT and mock treatment in cortisol is no longer significant.
And:
There is no known therapeutic benefit to changed cortisol slopes. To justify cortisol as a secondary outcome, the authors selectively cite findings that flatter cortisol slopes are modestly related to metastatic disease and predict mortality in breast cancer patients. These limited correlational data alone do nothing to establish that cortisol is a suitable surrogate endpoint.
We concluded that this trial is negative, something I believe to be even more true when one takes into account prior probability and the lack of correcting for multiple comparisons, which led us to wind up our letter thusly:
We believe that publication of this TT trial encourages more pseudoscientific studies of energy fields or auras and gives the wrong message to clinicians and patients.
The authors respond
Not surprisingly, the authors were not too happy about our letter. Even less surprisingly, in their response they retreated to common tropes used by apologists for reiki and “energy healing.” Their response to our letter is a veritable template for defending tooth fairy science. First, the authors tried to disabuse us of our “misconceptions” about the study by pointing out how very wrong we were to lump “energy chelation” in with HT, TT, and reiki as an “energy healing” modality:
We wish to clarify some misconceptions put forth by Coyne, Johansen, and Gorski regarding our reported randomized controlled trial.1 First, the intervention used was not therapeutic touch but a specific hands-on technique commonly used in many types of biofield therapies for ameliorating fatigue.
Which matters not at all. It was the authors, after all, not we, who said that energy chelation was a biofield therapy, which is another name for “energy healing.” In any case, their complaint reminds me of arguing that reiki is different from TT because reiki masters use different hand motions to channel the “healing energy” or that in reiki the energy comes from the “universal source” while energy chelation removes “energy blocks” in the patient. Until you can convincingly demonstrate that the “universal source” exists and can be manipulated by reiki masters and/or that there are “energy blockages” that “energy chelation” practitioners can remove, all you’re doing is comparing two different forms of magic. Alternatively, you can demonstrate with overwhelming indisputable evidence so powerful as to make us question previously understood laws of physics indicating that these techniques cause objective responses, but unfortunately for the authors of this paper this study does nothing of the sort. We’re looking at effects no greater than placebo on primary endpoints in the study, all of which are subjective responses, and an unvalidated surrogate endpoint that demonstrates a barely statistically significant effect (p=0.04), after no correction for multiple comparisons. In other words, the authors’ criticism completely misses the point.
Here’s their next objection:
Second, there is an evidence base for biofield therapies.2,3
The authors cite this Cochrane Review and one of their own reviews. The problem with this argument, of course, is at the very core of the reason why we call this blog “science-based medicine” rather than “evidence-based medicine.” There is no consideration of prior plausibility in the studies examined, where were all over the place as far as quality goes. Add to what the Cochrane Review characterizes as poor quality, equivocal data the fact that the clinical trials involved testing a class of healing modalities whose explanation if effective would require, like homeopathy, that huge swaths of well-established physics, chemistry, and biology (particularly neurobiology) to be overthrown, and the reasonable conclusion is that “biofield therapies” do not work. In particular, this is a case where “statistically significant” doesn’t mean “clinically significant,” given that the decrease in pain reported in the Cochrane review was less than 1 unit on a typical pain scale that goes from 1 to 10. One unit has commonly been viewed as the smallest decrease in pain that a patient can perceive.
Objection number three follows:
Third, the study was designed to examine nonspecific and placebo elements that may drive responses: This is why we used the mock healing group as a comparison along with the waitlist control group. We also examined patient expectancy, belief, and patient ratings of practitioner attributesall elements of placeboas potential predictors.
So what? It was the authors who concluded against the evidence in their very own study that, in essence, their “energy chelation therapy” works to relieve symptoms of chemotherapy-induced fatigue even though the “real” energy chelation and the “mock” energy chelation were indistinguishable. The correct conclusion should have been that energy chelation performed no better than placebo and therefore did not work. Again, if energy chelation were a drug therapy, would the authors conclude from a result in which the drug does no better than placebo for the primary outcome measures that the drug worked? Why the double standard?
Up next, is this objection:
Fourth, despite Coyne et al.’s seemingly contradictory statements (stating that the study is underpowered while also suggesting cortisol slope results should have been Bonferroni corrected), the power analysis and statistics are correct and clearly described.
“Contradictory”? I fail to see what’s “contradictory” in pointing out that the study was underpowered and that the cortisol slope results should have been Bonferroni-corrected; i.e., corrected for multiple comparisons. They are separate criticisms. Even if the study were adequately powered, it would still be flawed because of the lack of correction for multiple comparisons. At least if the authors had properly corrected for multiple comparisons then they could have blamed their negative result on the inadequate statistical power of the study!
Finally, the authors write something that both amused and depressed me at the same time:
The larger issue is what constitutes “pseudoscience” and what information is worthy of dissemination to the public. Should the data from our well conducted, rigorous, randomized controlled trial be dismissed because the mechanisms are unknown or because some scientists do not believe in the specific therapy? We make no claims surrounding mechanisms. We do note that this intervention has significant promise for reducing fatigue, which is the most common complaint among cancer patients, and the therapy produces no harm. Therefore, it merits further investigation. Premature rejection of findings from rigorous randomized controlled trials are as big a threat to science as the continuation of falsehoods based on belief. Thus, as clinicians and scientists, our highest duty to patients should be to investigate promising solutions with high benefit/risk ratios, not to act as gatekeepers of information based on personal opinion.
There’s so much wrong in this paragraph that I could spend an entire blog post deconstructing it line by line. Note the wounded cry about “dismissing” results based on dogma rather than science. Note the straw man argument that we reject the results of this study because we “do not believe in the specific therapy” or because the “mechanisms are unknown.” The first trope is a massive misstatement of our objections. What we argue is that the results of this trial do not mean what the authors think they mean. The authors conclude that the trial indicates that energy chelation shows “significant promise.” (They even repeated that assertion in their response!) We conclude that the study’s own results indicate that energy chelation functions no better than placebo and therefore does not work. It would have been nice if the authors had addressed our actual criticism than such an easily revealed straw man version of it. The second trope is commonly used in defense of pseudoscience because it is difficult for many to understand that there’s a huge difference between a mechanism that is “unknown” and a mechanism that is physically impossible based on current scientific understanding. An example of the former is a drug whose mechanism of action is as yet unknown but whose effects are easily documented. We know that the drug must function through some sort of biochemical interaction with a receptor, enzyme, or other macromolecule within the cell that we can discover and that we do not need to invoke mechanisms that break the laws of physics and chemistry to explain the drug’s effects. Again, to illustrate the difference between such a drug and impossible mechanisms, I like to use the example of homeopathy, which, if it worked would necessitate the overthrow of huge amounts of exceedingly well-established science in multiple disciplines, including physics, chemistry, and biology. Let’s just put it this way. Energy chelation is the same. For it to “work,” the same sorts of vast quantities of well-established science would need to be overthrown.
As a skeptic, I have to admit that it’s certainly possible, albeit infinitessimally so, that so much of what we understand about science is not just wrong and/or incomplete, but so incredibly wrong and/or incomplete that there might be an as yet undiscovered physical mechanism by which energy chelation and “biofield therapies” could work. However, if you’re going to convince me that something like energy chelation can truly work as a treatment modality, you’d better have evidence far more compelling than a small, equivocal clinical trial like this in which the effect on primary outcomes was no greater than placebo and whose analysis of secondary outcomes didn’t even bother to correct for multiple comparisons. Heck, even Dr. Pasche’s data that I discussed last week was far more compelling than this study, and his results are still not particularly convincing. Bringing a study like this “energy chelation” study to argue that “biofield therapies” work (or even that they might work) is akin not just to bringing a knife to a gun fight. It’s akin to bringing fists to an M2 Browning machine gun and grenade fight.
And that’s not just our “personal opinion,” either. Of course, it’s far easier to dismiss criticisms that one can somehow label “personal opinion” than it is to address our actual criticisms. That’s probably why the authors try to characterize our objections to their study as nothing more than a disagreement of opinion, before floating off into the ether of a self-righteous and condescending lecture to us about our “highest duty” as clinicians and scientists. I retort that, as clinicians and scientists, it is our highest duty not to engage in magical thinking that subverts science-based medicine. It’s our highest duty not to waste precious resources investigating therapies so utterly implausible that their efficacy requires that the laws of physics be overturned in favor of magic. It’s our highest duty to base our treatments in science, not in prescientific vitalism and religion, which is all that most “biofield” therapies are: faith healing, the laying on of hands. I would also retort that our tax dollars should not be funding magic like this. Yes, you guessed it; this study was funded in part by NCCAM.
As I conclude, I’m left wondering, jaw agape: What were the editors of Cancer thinking? I know what I’m thinking now: From now on, I’m going to be extra skeptical of any articles I see in Cancer, and you should too. I’m also depressed. If such a study and such a trope-laden response to criticism of that study can find its way into Cancer, the official journal of the American Cancer Society, what other cancer journals are publishing pseudoscience?
REFERENCES:
- Jain S, D Pavlik, J Distefan, RR Bruyere, J Acer, R Garcia, I Coulter, J Ives, SC Roesch, W Jonas, and PJ Mills (2012). Complementary medicine for fatigue and cortisol variability in breast cancer survivors: A randomized controlled trial. Cancer 118: 777-787. DOI: 10.1002/cncr.26345
- Coyne JC, C Johansen, and DH Gorski (2012). Letter re: Complementary medicine for fatigue and cortisol variability in breast cancer survivors: A randomized controlled trial. Cancer, E-pub ahead of print. DOI: 10.1002/cncr.27415.
- Jain S, D Pavlik, J Distefan, RR Bruyere, J Acer, R Garcia, I Coulter, J Ives, SC Roesch, W Jonas, and PJ Mills (2012). Response re: Complementary medicine for fatigue and cortisol variability in breast cancer survivors: A randomized controlled trial. Cancer. E-pub ahead of print. DOI: 10.1002/cncr.27421.
- So PS, Y Jiang, and Y Qin (2008). Touch therapies for pain relief in adults. Cochrane Database Syst Rev CD006535. DOI: 10.1002/14651858.CD006535.pub2
133 Responses to “Adventures in defending science-based medicine in cancer journals: Energy chelation”
The authors of the study referred to their technique as “biofield healing.” That’s cute, by attaching the word “healing” to their technique they can give the false impression to the gullible that their technique does more (it heals!) than what they claim (symptom relief for fatigue).
That’s the problem with placebos. They don’t actually heal. They mostly don’t even provide symptom relief. Mostly they provide the subjective impression of symptom relief, whilst objectively not much changes. Even then, the subjective impression of symptom relief is mostly only temporary.
You didn’t at all dismiss their data. It was on the basis of their data that you concluded EC was no different than placebo. You dismiss their opinions which don’t follow from their data, but that is not the same thing.
There is no data from the trial that indicates this might have “significant promise” as a treatment modality.
This is a negative trial. It is good to see that prestigious journals are finally publishing trials with negative results. I hope you complimented the journal for doing so.
“These results were entirely consistent with placebo responses.”
It wouldn’t have mattered if they hadn’t been. As I think I’ve mentioned here before, rational inference applied to real world science implies that strong positive results from this sort of experimental ‘test’ of tooth fairy activity would be strong positive evidence of error – not evidence of the perversely and pseudoscientifically hypothesised tooth fairy activity¹. Consequently, such ‘research’ is /ab initio/ meaningless and worthless cargo cult science. The actual results of these absurd ‘clinical trials’ are irrelevant and can and should be completely ignored.
¹ http://www-biba.inrialpes.fr/Jaynes/cc05e.pdf
While daedalus2u is correct that there should be more publication of negative trials, the problem here is not the negative result, but the dishonest spin in the discussion. If Cancer had published these results with a discussion section that honestly and simply said, “This modality is indistinguishable from placebo,” nobody here would be upset. It’s the stubborn refusal of quackery researchers to say that negative results are negative results that’s the problem.
They published the criticism, which annihilated the paper, so we might judge the journal anti-CAM.
I certainly don’t get how the authors can come back with saying their stuff has “significant promise”, and concluding it should be investigated more.
To get persnickety on one detail: The claim that their study was underpowered may not have been the best tactic, and it’s not even clear that it is true (no details are given). If this touching was really great, 30 vs 30 may have sufficed to show that. The authors thought it was sufficiently powered to detect pretty small effects, for tests that I am not inclined to study deeply (they don’t make it that easy), and failed to get significant differences where they mattered. So they should conclude the real effects are probably smaller than the minimum they had thought actionable. I don’t think we want them to do bigger studies to (theoretically) enable the detection of effects so small that they are not worth following up on. Normally you bonk folks about the power when you think they want to accept the null, but we think the reverse is true here.
Well said. I should steal your sentence and put it somewhere in my post.
I think the unjustified and false accusation in their response that you are dismissing their “data” because of bias and opinion deserves another reply to set the record straight. They have accused you of unscientific bias, you should have the right to respond to clear your reputation.
This was a negative study. The treatment group didn’t have outcomes different than the placebo group. If they want to claim this study demonstrates a need for more research, they need to be more explicit in how they arrive at that conclusion. I know they can’t be more explicit because there isn’t a chain of logic that leads from their data to a conclusion that this intervention has significant promise.
This is an important point in doing clinical trials and evaluating treatment modalities. It is not acceptable to reject positive or negative results on the basis of opinion and bias. That is what they are doing; rejecting these negative results and imputing them to be positive because of their opinion and bias that biofield healing “works”, and accusing you of bias because you take these negative results at face value. Biofield healing is indistinguishable from placebo, for treatment of fatigue it is equivalent to placebo, positive effects are due to placebo effects.
The really important conclusion from the study, your comment and the response is exactly what cervantes said:
“If Cancer had published these results with a discussion section that honestly and simply said, “This modality is indistinguishable from placebo,” nobody here would be upset. It’s the stubborn refusal of quackery researchers to say that negative results are negative results that’s the problem.”
It is the “meta” conclusion, the conclusion about how practitioners of CAM treatment modalities “think”, or rather how they allow their bias and opinion to cloud their analysis of data and lead them to unjustified conclusions about their pet CAM treatments that is most important.
A useful question might be what was their null hypothesis and what “data” would have been necessary for these researchers to reject the null hypothesis?
The editors might not want to allow such a discussion to continue, but I think it is really important that there be a discussion of the methodology of clinical trial evaluation so that there is a citation where unacceptable methodology is demonstrated to be unacceptable (as in this case).
This is really a good case to illustrate this. It was a careful, well run study with a really good placebo leg. It was run by experts in biofield healing. That a well run study can be badly interpreted by its authors is important to illustrate.
Not to “pile-on” these researchers, but in a meta-discussion, you could bring up the acupuncture = toothpick studies showing similar cognitive bias on the part of CAM researchers.
The whole thing might be too long for correspondence, but it does deserve what ever journal space it takes.
So, in short, their response is:
1. We were actually using magic legumes, not magic nuts.
2. Our ideas are nonsense, but here’s a stack of paper.
3. Our test group got bullshit results, but the control group also got bullshit results so everything is OK.
4. Since we screwed up 2 or more things, we can always pretend that any one of your criticisms is pointless or contradictory in light of some other thing we screwed up.
5. Why shouldn’t we publish medical fan fiction, so long as it is well-written and not disprovable in a religiously agnostic sort of way?
Cervantes said: “It’s the stubborn refusal of quackery researchers to say that negative results are negative results that’s the problem.”
Indeed! Despite all efforts to direct grants to more promising things, if money is still going to be spent on a study with an implausible hypothesis at the -very least- the results should be accurately stated. There is no excuse in any published study in any field for the conclusion not to reflect the results of the study.
Do the journals themselves ever respond to criticism, such as why they allowed a study to published that had negative results but spinned them into positive results?
Dr. Gorski wrote:
Couple this with the reasonable idea that “extraordinary claims require extraordinary evidence” and you’ve got something. But this is where CAMers drive me absolutely nuts. They take the possible and instead of applying science to look for extraordinary evidence they apply science fiction and find whatever it is they think they were looking for in the first place.
I’m all for reading a good story and have had a long appreciation for and enjoyment of science fiction. But they are exercises in the imagination, not something you want to find in a clinical setting or published in what is supposed to be a journal of science. Perhaps Cancer should change its name to “Amazing Medical Stories!” or “The Magazine of Fantasy & Medical Fiction.”
I wonder if part of the problem is the peer review process? As in the journal selected peer reviewers based on their “expertise”, and if their expertise was CAM then they saw nothing wrong with the results and conclusion? You’ve got entire professions based on ignorance, if you get an expert in ignorance to review a scientific study, it’s hardly surprising that the conclusion is wrong.
While the peer reviewers may have fallen short in this case, journal editors have some responsibility. They need to read the damn papers and contribute their own judgment — particularly in the case of journal like Cancer that has a large editorial board and significant resources. Just because the reviewers give something a pass doesn’t mean the editors are obliged to go along.
phayes:
“rational inference applied to real world science implies that strong positive results from this sort of experimental ‘test’ of tooth fairy activity would be strong positive evidence of error”
Yes, a virtually zero prior probability strongly suggests that a positive result of the clinical trial must be the result of error. And yes, a virtually zero prior probability means such trials should not even be done.
cervantes:
“While daedalus2u is correct that there should be more publication of negative trials, the problem here is not the negative result, but the dishonest spin in the discussion.”
I think you may have missed his irony.
As one of David Gorski’s co-authors on the letter to Cancer, I would like to talk about our sweet victory of having even gotten it published. Previously, I submitted a letter to Cancer concerning another clinical trial that claimed to have shown that psychotherapy prolong the life of cancer patients. My letter argued that the authors had disguised with multivariate voodoo statistics but was actually a set of null results stretching across multiple psychological and immunological measures.
At first the journal declined to publish our letter because the authors refused to respond, and the journal had an existing policy of not publishing letters without an authors’ response. My colleagues and I successfully argued that this was a ridiculous policy and furthermore we should get extra space because we taken issue not only with the shortcomings of the target article, but with the journal having published it despite obvious statistical flaws and confirmatory bias. The journal ended up giving us 10 pages, rather than the usual 600 words.
In a similar situation with Journal of Clinical Oncology, an appeal was not so successful.
if we want to fight junk science effectively, we need to strengthen post-publication commentary and critique, given the obvious limitations of prepublication peer review.
See the critique that got published as a result of our agitation, and keep up the good fight.
Finding What Is Not There http://db.tt/T1gb2LM
James C. Coyne
follow me on twitter @CoyneoftheRealm
This sort of publication and study is vastly more insidious than even Dr. Gorski has stated. I am curently in a 52 email long “debate” with an underclassman about the utter ridiculousness of Reiki. In brief, it is clear that his opinion is scientifically based, but goes vastly off the rails because he doesnt have the time or wherewithal to truly go in depth about these “treatment” modalites. He has recently admitted that, even after I have supplied him with ample literature on Reiki he just doesn’t know quite what Reiki is. So he opts to go ahead with the equivcations, special pleading, and fanciful “mechanisms” to explain the MOA f or something as ludicrous as Reiki. Of course, he has learned that from the BS that one finds in abstracts beause, well, what do most busy medical students read? Certainly not the details of the methods and results! A few times throughout the years I’ve had colleagues post of creduluous articles and in reading the M&R completely destroyed the conclusions. The response? I kid you not: “You sound extremely knowledgeable on statistics and study design so I would never question you there but…. Medicine is an art, not a science… You need to take into account people and their humanity…”
So wait, my analysis is spot on and you admit it but you still want to argue that the author’s conclusions are correct? Or that I should “take into account humanity” which, in this case apparently, means that I should ignore my hard earned understanding of statistics and study design and… What? Just give it a bye because someone just feels like it?
And I just heard from one of my friends in the year behind me whom I respect very much regarding a professor at our medical school. The same one I mentioned in previous posts here – apparently now he islecturing that attitude can cause and cure cancer. He is a very minor part of the curriculum, but look at the myriad avenues by which my colleagues are shown that we can ignore solid study analysis to favor whatever conclusion we desire.
People (like pmoran and indeed my 52-email-long compatriot) would have us believe that the science of medicine and academia in general will win out eventually and we needn’t worry nor even vigorously combat these bad studies and lectures. I heartily disagree. More and more, both thruogh this blog (and other sources) and in my own personal experience, I see how insidiuous and pervasive such bad thinking is becoming. And the “propriety” of professionalism means that the likes of myself and Dr. Gorski (well, much moreso myself since Dr. Gorski is a well established and respected physician and I am still a mere student) cannot flat out say that s-and-so is wrong. It is somehow impolite. As Dr. Novella once said so well I often use it, “Standards are being sacrificed at the altar of equality.”
The real danger with these studies and publications is that to properly understand why it is absolutely mad to scientifically study modalities like Reiki and energy chelation requires a background of the history of these specific modalities and CAM in general. Most don’t have the time or desire, and even if they do they often find no compelling reason to actually learn it. I have an entire degree in exactly this field so I know it better than most and it still took me some effort to really dig down to the nitty gritty of it.
Publishing studies like this in prestigious journals and allowing credulous physicians to lecture about the utility of acupuncture, reiki, and attitude curing cancer to medical students lends an imprimatur of legitimacy that cripples an otherwise overwhelmed student rendering him or her incapable of perceiving the problem and/or actively reacting to it. So you end up with a minority like muyself, another (larger) minority of creduluous future physicians, and a majority of otherwise well educated shruggies. And that is the serious and insidious danger of all this.
At least, that is my perception.
The correct conclusion should have been that energy chelation performed no better than placebo and therefore did not work.
My present thoughts, should anyone be interested –.
More accurately, on the face of it for normal folk, it did work but pretty certainly (after adjusting for scientific absurdity and likely artifacts within clinical studies) merely not via any kind of “energy chelation”.
The authors acknowledge this to some extent in the first sentence of their abstract: “Nonspecific factors are important in responses to biofield interventions for fatigue.” They also say elsewhere, but with considerable inconsistency, that they are “making no claims regarding mechanisms”.
Whether non-specific factors including placebo influences truly “work” in a useful sense for our patients (Oh, yeah! — I remember them!) depends upon whether the intervention has sufficient value to a person or a medical system in cost/risk/benefit terms (I have insufficient information for now on which to judge the present example, but 8 hours is a lot of someone’s time to pay for) , also, importantly, whether the same results are likely to be reliably reproduced under other conditions of medical practice.
This last is an additional reason why it is difficult for doctors to incorporate pseudoscientific placebo-type methods into their practices in any direct way even when accepting that they may be somewhat inadvertently helpful to some people in other settings.
Nevertheless, we should not necessarily be too obstructive or intolerant while there is a chance that such methods are significantly helping some patients with otherwise distressing and sometimes difficult-to-treat conditions like fatigue and the irritable bowel syndrome and chronic back pain.
Then again, we are entitled to point out that we can now predict what such studies of elaborate healing rituals will show. There is thus not much point in doing them other than to demonstrate cost/risk/effectiveness in as “real” terms as possible within a particular practice setting. And even those resources might be better spent in exploring newer, more plausible methods.
With regard to “quackademia”, are you sure that we are not being sent a coded message : “Hey fellows, we were doctors before we were scientists!” It is unwise to regard integrative medicine colleagues as having any less concern for patient welfare or any less basic respect for science. They may simply have a more “needs must!” approach to medicine and that is a defensible position. Science will do OK and if anything is validating the reality of placebo responses as we speak.
Nybgrus, the main objections to use of placebo-type medicines by doctors are not even scientific. They are ethical. practical (where do you stop?), and economic . So what science are you trying to protect ? There is ample science supporting the likelihood of placebo influences.
We have much clearer places to draw lines that must not be crossed when dealing with actual disease processes.
Oh formatting again! The first sentence is David’s.
Dr. Coyne is actually too kind in that he did most of the heavy lifting of writing the letter and laying the groundwork to get this letter accepted through his activities. However, emboldened by this, I hope that more skeptically minded physicians will complain when editors allow tooth fairy science like this to be published.
I’m not so sure about that. I used to think there was a lot more to placebo responses. There was a time when I even thought they might be clinically useful. However, the more research I read about placebo responses, the less impressed I’ve become. I’ve yet to see any evidence of a clinically useful placebo response or any evidence that placebo responses affect any objective outcomes, such as survival in cancer. All of this is why I’ve been drifting closer and closer to Dr. Crislip’s view on placebo responses, although I’m not there yet.
As for “regarding integrative medicine colleagues as having any less concern for patient welfare,” certainly I do not. I have no doubt that most of them have only the best motivations and want to do well by their patients. I only wish they would accord me the courtesy of making the same assumption about me. Certainly the authors of this study did not. The reason I got a bit sarcastic in my retort was because the authors, in essence, implied that in criticizing their study we were not acting in according to the “highest duty” in medicine. Worse, they did more than just imply that we had reflexively dismissed their study based on personal bias (because we “disliked the therapy”) rather than science. They out and out said it in no uncertain terms. Yeah, that ticked me off a bit.
With regard to whether integrative medicine colleagues have less “basic respect” for science, well, I’m not so sure that’s true in a lot of cases. Some probably have such respect but are misguided regarding what constitutes good science. I rather suspect that the authors of this study fall into that category. However, others, I think, believe no matter what and only attempt science because it’s expected of them if they want to be taken seriously. Alternatively, they have respect for science, but they value the good feeling they get from being respected and liked by their patients or from being “brave maverick doctors” more.
“I’m also depressed.”
Sorry to hear it. Sounds like you need some biofield therapy to blow away all that negative energy.
I disagree. Well, not exactly. I won’t split hairs over what is the “main” objection, but a significant one at least is the fact that placebo responses are indeed ephemeral and clearly do not effect (or affect for that matter) obective processes nor actual disease pathology and progression. That much is actually pretty darned evident.
However, once again, if studies like this came out and came to a conclusion such as:
Yep, this was a pure placebo response. Shame we can’t ethically use it in mainstream practice. And double shame that the effects are rather ephemeral and require significant time and interpersonal interaction, likely rendering it an uneconomical intervention
That was clearly not the conclusion reached by these authors, nor the vast majority of “integrative” medicine authors. No matter what you may want to say about the redeeming qualities of these sorts of studies, the point is you have to dig for them. They are not self evident and are consistently mired in the language of woo. No matter how you slice it, it is bad science and unhelpful to the progression of medical science – and as Dr. Gorski and I have argued, quite likely actively detrimental rather than just neutral.
As usual this line of commentary from you hits home for me as well. It is beyond clear that Dr. Gorski is not accusing the authors of such a transgression and that they (and the vast majority of other such authors) clearly do not afford him the same courtesy. I also do not (for the most part) believe that they do not hold their patient’s interest dear to heart. That doesn’t make them any less wrong in their assertions nor poor in their science.
Also, a “need must!” approach is indeed defensible. I think any physician here would and does put their patients ahead of themselves regularly. However, I do not think it is applicable here. The argument being made is that this is a very provincial and short term “needs must!” rather than a long term, sustainable, and more efficacious “needs must!” It is a quick fix, a patch, a band aid on a penetrating chest wound.
How are reviewers chosen? And how are they got rid of? Is there a formal system of “dismissal” or are they just neglected to death if they review something unfavourably that the editor wants to publish as is?
Why I ask is that I was once asked to be a reviewer for papers in my field, in a big journal (no names, no packdrill). The very first paper that was sent to me was poor stuff and heavily padded. I wrote back with my crits, and suggested that the author be requested to cut it down … even used the dreadful expression “salami science” … and have never in the following 20 years been sent another paper.
No reasons given of course, nothing formal at all, so I’m just surmising. Maybe my review was just too bad to be acceptable. But I’m wondering in the light of what you say, if there is a system for ousting reviewers who are too blunt or who express unpopular views. Or whether it is done only according to the opinion of the editor, without review or voting or anything more formalised.
David: :As for “regarding integrative medicine colleagues as having any less concern for patient welfare,” certainly I do not. I have no doubt that most of them have only the best motivations and want to do well by their patients
Well, I rarely get from SBM’s writings or the comments pages any sense of the collegiality with fellow physicians that such understandings might engender.
Those who display the least rapprochement with CAM are often met with full-on condemnation, outrage, and more or less permanent intellectual ostracization. It doesn’t matter that their rationale may be cautious and pragmatic, or even that they accept the scientific viewpoint that any benefits are based largely upon non-specific influences — or they may simply prefer not to know.
I accept that there are outrageous alternative claims that merit the stiffest challenge. But a certain level of mutual respect is surely a prerequisite where you expect or hope for productive debate. I have often felt that I would like to invite some of the IM medicos here. so as to find out what their true beliefs are.
Dr. Moran,
This is essentially an example (I think, tell me if I’m wrong) of CAM proponents lying and managing to publish their lies in an otherwise trustworthy, reliable source of medical data. In light of what happened when Andrew Wakefield did something similar, shouldn’t this type of thing (along with the legislative issues discussed in earlier blogs) invoke the strongest reaction from SBM proponents? Small numbers of people seeking help from CAM practitioners for their symptoms might not be a huge problem, but it seems to me that CAM practitioners attempting to use the laws or mainstream medical journals to give their practices a false appearance of legitimacy ought to be of much greater concern because the possibility of harm is so much greater (isn’t it?).
I genuinely don’t have the time to search for it, but if I did I could pull up countless examples of posts here that actually specifically say something to the effect of “I have no doubt most of these folks are true believers and think they are helping their patients but….” or some such caveat. However, the focus of this blog is not how wonderful their intentions may be, but how bad their science is.
I can imagine myself, since I don’t want to speak for the authorship here, having a beer with Andrew Weil or Mehmet Oz and being quite civil, collegial, and flat out saying “I get that you are trying to help yadda yadda… but that just doesn’t negate that this is bad science and for the following reasons is a detriment to society and medical advancement.”
And once again your critique boils down to tone trolling.
“It is unwise to regard integrative medicine colleagues as having any less concern for patient welfare or any less basic respect for science.”
I disagree. What CAM practitioners are most concerned with is the narcissistic injury they will feel if they allow themselves to acknowledge that they are treating patients with “tooth fairy” treatments. The history of medicine is filled with treatments that were once thought to be good, which later testing showed to be not good. CAM has never abandoned any treatment.
A clinician who cared about his/her patients would take seriously the heuristic of “first do no harm” and continually scrutinize their treatments so as to ensure themselves that they continue to be “best practices”.
I see no need for this article to be retracted. This is nothing like the Wakefield case. Wakefield lied and put fake “data” in his paper. These authors simply have a wrong analysis of their data, but their data seems to be legitimate and correct. What there should be is an analysis published that refers to the paper and shows why the analysis of the original authors is wrong and flawed. Wrong analysis is very common in the scientific literature.
My preference would be for the discussion in the journal to continue until the differences in the analysis of the data are resolved. Two honest and rational parties with the same priors can’t disagree on what those priors lead to.
https://en.wikipedia.org/wiki/Aumann%27s_agreement_theorem
What I would like to see is the discussion continue until the authors of the study understand and appreciate how their analysis is flawed or until they are able to articulate a legitimate analysis procedure that leads them to their conclusions.
Unfortunately, some health care professionals care more about their own egos than about patients and won’t admit when they are wrong, to save themselves from narcissistic injury at their patients’ expense.
One of the many disturbing things about the original article and the exchange is that the lead author on the other side in the exchange (also an author on the original article) is a respected conventional scientist who happens to be an expert on cortisol and stress. Having agreed to be an author on the original paper with a real loony, he then became quite defensive of what they did and made assertions they otherwise would make, when called upon to defend the study.
I think this represents a cognitive process that should concern us. Namely, people doing CAM research will torture the data and distort their hypotheses post hoc in order to have a positive study. When criticized for doing so, they drop all critical faculties and defend the study and interpretations. For instance, the strong statements that this author makes about the role of cortisol in cancer are patently absurd tooth fairy science.
Francis Collins’ idea that rigorous research will sort the little bit of truth from the nonsense in CAM does not anticipate these kinds of processes. Basically, we witnessed the conversion of conventional scientist with excellent credentials to a defender of CAM nonsense.
I rather suspect that this scientist was ignorant of just what he was getting into when he agreed to collaborate. Now that it’s been pointed out just what an embarrassment of a study he has co-authored, he has two main choices: Admit he was wrong and disavow his work, or double-down on the tooth fairy science and defend what he did. It’s very hard to admit it when one’s made a mistake; so unfortunately this scientist appears to have decided to double down. On the other hand, all is not necessarily lost. He might have learned his lesson. It’s quite possible that the embarrassment from this incident might dissuade him from doing further work of this sort. We can only hope.
David and James, if that senior researcher in cortisol did “learn a lesson”, good for him. The “Scientific Literature” has not “learned a lesson” until it is explicitly pointed out in a form that can be cited.
It is a shame that there is so much politics in science, that people can’t admit they were wrong without losing something other than their ignorance. Admitting when you are wrong shows you are a better scientist than you were before. It should be viewed as a positive thing.
Have you at SBM thought of putting in a concerted effort to increase the readership of the blog? I was thinking of things like putting together a list of good quality science based medical blogs and sending it to sympathetic professors at medical institutions to give to their students as extra reading material.
Or maybe seeing if you can convince some of the large skeptical blogs to pimp your site once a month or so.
SBM is such a high quality medical blog with exceptional analysis that it is a shame that it isn’t being read by everyone and their dog.
On the topic of increasing readership of this blog, one observation I’d make is that there is a bit of a tendency here to preach to the choir in a way that I worry might be off-putting to “shruggies,” who are probably the most important audience to reach. For example, I thought that Steven Novella’s recent post about TCM was excellent, and I agreed with all the points that he made. I thought about sending the link to a family member who is fairly rational yet sympathetic to TCM, largely because she doesn’t know enough about it to gauge it accurately. However, I ultimately decided not to send it because of the tone of the article, which was a tiny bit snarky, and I didn’t think she would respond well to it. In a similar way, I think quackwatch is a great resource, and I’ve often thought about giving articles from that site to patients who ask me about alternative medicine, but the name of the website is a problem, as it reduces the site’s credibility in appearing objective. I don’t want to come across as overly critical of SBM, which I think is an excellent blog, but I do wonder if it’s possible to appeal to a broader audience.
@EvilRoboto
I could not agree more while at the same time disagreeing… lol
I think I have done the exact same thing. Not send a link to someone because although the content was excellent the tone was such that I figured it would put them on the defensive.
However I love the snark and I feel it is almost impossible to treat many of these topics without a hint of snark and ridicule. The snark helps put perspective on just how outlandish some of these treatments are. I also think it may be more difficult to maintain a consistent readership if there was nothing to give us a giggle.
I do wish there was a few more articles on literature review like the article last week by Dr. Novella on aspirin. I think they do a lot to show how the science and understanding behind medicine progresses.
Nybgrus:
I genuinely don’t have the time to search for it, but if I did I could pull up countless examples of posts here that actually specifically say something to the effect of “I have no doubt most of these folks are true believers and think they are helping their patients but….” or some such caveat. However, the focus of this blog is not how wonderful their intentions may be, but how bad their science is.
One of the problems with a lack of basic respect for those presenting contrary viewpoints is that it interferes with the listening process.
I was not referring to “true believers”, I was referring to ” “integrative medical practitioners”, who have a variety of more sophisticated understandings of what they are doing. Many understand that they are relying on non-specific influences including the placebo.
That is, in fact, all that “science” can say about any medical activity of CAM. It cannot yet say that “they don’t work” in any complete, final, simple sense because thousands of clinical trials show that almost anything given as medicine seems able to elicit beneficial therapeutic responses with subjective and psychosomatic complaints. We are not yet able to clearly distinguish those responses from reporting biases, but neurohysiological and other kinds of study suggest that there is something “real” in there somewhere.
So I think we should pay heed to our own science and stop saying baldly “CAM doesn’t work”. Better is to say “to the extent that it works, it is as placebo” (but preferably finding a less loaded term). The public and our politicians can understand that, through already knowing how psychology can influence illness, but they cannot cope with the dissonance of voices they want to be able to trust saying “it doesn’t work”/”it bloody well does –”.
Daedalus2 was also not listening when he responded with comments about “CAM practitioners”.
There are many examples of similar carelessness in SBM responses to differing viewpoints and I am sure it reduces confidence in our opinions where it really does matter.
I also don’t care to root out specific examples, but, David, you at least, should have known enough not to refer to “energy chelation” as “therapeutic touch”. You and I know it is almost indistinguishable nonsense but we also know that this “error” would inevitably be picked up upon, giving responders a cheap, if largely spurious, point to score and a distraction away from the key issues .
“to the extent that it works, it is as placebo”
Why phrase it in such a positive manor. This just leads people to say that it worked better than no treatment and thus justify their product. When in reality their product had no specific effect that was attributable to their chosen modality. Their chosen modality could have been acupuncture, healing touch, homeopathy or dressing up as the hamburglar. The results would have been the same…Small non-specific subjective benefit.
When something is said to do as well as a placebo in a trial that should be and is in my eyes the same as saying it did nothing.
Spare me, Peter. They are indistinguishable, and I said they were indistinguishable, and I make no apologies for having said they were indistinguishable. It’s such an important point, in fact, that I want to make sure that our readers understand unequivocally that they are indistinguishable, and I want shruggies who come here to encounter an unequivocal statement that they are the same. When a CAM apologist tries to play “gotcha” over arguments over how many angels dance on the head of a pin (an appropriate analogy for arguments about whether TT and EC are or are not the same thing), I simply reiterate that very point and will do so however many times it takes.
At the risk of being accused of Godwinizing the thread, I’m going to use a quote from one of my all time favorite movies, The Great Escape. In this scene, Big X’s second-in-command is cautioning him about going too far in trying to escape the German prison camp, using this argument, which Bartlett (a.k.a. Big X) doesn’t find at all convincing.
TT, TH, reiki, and EC are the same.
My point here is not to compare CAM apologists to Nazis, which is why I intentionally left out the rest of Bartlett’s response to Ramsey. That is most definitely not what I’m trying to say (fans of the movie will know what I’m talking about). Rather, it’s to point out that there are distinctions without practical differences. The claim that TT and EC are different healing modalities is just such a distinction without a real difference, and I reject it. I refuse to pussyfoot around the point out of the fear that a CAM apologist will use the point to play “gotcha.” In fact, I hope they do, the better to allow us to reiterate the point again and again and again that these “energy healing modalities” are nothing but magic.
Far more importantly than such arguments above, I refuse to pussyfoot around the issue of placebo effects. If a treatment does no better than placebo in a clinical trial, it doesn’t work. That’s how we decide that a drug works, and it bloody well should be the same way we decide how other treatments work. Why do you support a double standard in this area whereby we have to phrase it in such a wishy-washy manner? When a drug fails to do better than a placebo, we conclude that it doesn’t’ work for the condition in question. No equivocations. No bending over backwards to be accommodating. Why can’t you do that for a CAM modality? In fact, I think this is one of our most powerful arguments, particularly given how little we trust drug companies.
@pmoran,
If the treatment in question were a drug, and testing showed it worked no better than a placebo, would you recommend using that drug to elicit beneficial therapeutic responses through non-specific effects? I wouldn’t, and I think it would be universally frowned upon by medical ethicists.
@dwpeabody:
I agree, the snark is a big part of what I like about this site, and I guess I can’t have it both ways. Still, it would be great if some of the posts on here could be desnarked and posted somewhere as SBM reviews that I could refer shruggies to.
David, do you think I don’t know, and ad nauseam, everything that you are trying to say?
Cannot YOU grasp the central importance of the placebo question to our understanding of, and how we deal with CAM and pseudoscience, or at least a substantial component of it?
IF placebo responses can be as strong as some of the experimental evidence and considerable anecdotal evidence suggests they can be, we have a conundrum that I don’t think any other branch of human enquiry has ever had to confront.
That is, a substalack of coherence between our “science” and what we can expect in clinical practice with the more we know, the fewer helpful treatment options are available to us.
Sorry another misfire. Big fingers, little keyboard.
David, do you think I don’t know, and ad nauseam, everything that you are trying to say?
Cannot YOU grasp the central importance of the placebo question to our understanding of, and how we deal with CAM and pseudoscience, or at least a substantial component of it?
IF placebo responses can be as strong as some of the experimental evidence and considerable anecdotal evidence suggests they can be, we have a conundrum that I don’t think any other branch of human inquiry has ever had to confront.
That is, a substantial lack of coherence between “the science” and what we can predict will help within many common areas of medical practice. These don’t matter much wherever we have reliable and safe treatments. They do matter, or they are at least worthy of some passing thought, in those areas where science has not yet provided adequate solutions.
This is what I believe. It is what many other people are trying to tell us, but in different ways.
Harriet, I have already given many reasons why doctors might personally or as a profession not find it useful to engage in these practices themselves. I am concerned that our rhetoric is not exaclty reflecting the state of scientific knolwedge and that it contaisn counterproductive elements.
PM, the article being discussed here is not a high school science project where nurturing the naïve sensibilities of budding scientists might have some benefit. It is a publication in Cancer, the Journal of the American Cancer Society.
It isn’t an in vitro experiment, or one on animals, it is a clinical trial on human beings. If the peers doing the peer review for the Journal of the American Cancer Society are bamboozled by this quack-speak, where are people to look for how to do trials?
The response of the authors to very well founded criticism was essentially the Courtier’s Reply.
http://rationalwiki.org/wiki/Courtier's_Reply
Tut-tut-tutting of the supreme ignorance in confusing therapeutic touch with energy chelation.
“First, the intervention used was not therapeutic touch but a specific hands-on technique commonly used in many types of biofield therapies for ameliorating fatigue.”
They have no clothes. They are as the Emperor. The editors, the peer reviewers, the authors of the study are all deluding themselves.
I disagree with you:
“That is, a substantial lack of coherence between “the science” and what we can predict will help within many common areas of medical practice.”
We know that wait-listing won’t do as well as an “intervention” that provides nurturing comfort to the patient. Providing a high degree of nurturing comfort doesn’t require more science, it requires different funding mechanisms so that nurturing comfort can be delivered to patients who will do better with it (essentially everyone). It doesn’t take many years of schooling to provide nurturing comfort to patients.
If an “intervention” works to make people feel better and heal faster, it has to be “working” through physiology. We know it is not working through magic.
Pretending that magic hand waving is doing “something” is not helping. It is confusing the issue and delaying progress in understanding the physiology behind why nurturing comfort does help people to recover faster and feel better. This paper is proof that pretending that magic hand waving is doing something is not helping. The authors of the paper are so deluded by their magical thinking that they are unable to appreciate that the magic hand waving and the placebo hand waving had equivalent effects.
Their own (very well collected) data shows that there is no difference. What possible trial could they propose that would show a difference? All of us here at SBM are pretty sure that no well done trial will show positive results over placebo. Poorly done trials might show positive results, but we know that will be due to artifact.
@pmoran,
“I have already given many reasons why doctors might personally or as a profession not find it useful to engage in these practices themselves”
And yet you keep implying that they have some mysterious value that we are failing to acknowledge, that they “matter” in areas where medicine doesn’t have any good answers. Despite your denials, you come across as an apologist for placebos. I think we all agree that there is much we don’t know about placebo mechanisms, and that research like Benedetti’s is very worthwhile, and that we can learn how to take advantage of placebo mechanisms to enhance patient care. But it sounds like you’re saying more than that, that you think we shouldn’t be so antagonistic to CAM because it offers some special benefits and really helps some patients.
“a substantial lack of coherence between “the science” and what we can predict will help”
What does that mean? How could we reliably predict that something will help if we haven’t tested it?
http://astore.amazon.com/docartemis-brainscience-20/detail/0156033909
Mistakes Were Made (But Not by Me): Why We Justify Foolish Beliefs, Bad Decisions, and Hurtful Acts
Ginger Campbell MD interviewed the author Carol Tavris for the brainscience podcast.
A few interesting quotes from the interview and how it’s relevance pertains to the discussion of concern/tone trolling, the reaction of the Cortisol researcher.
“But one important thing for all clinicians to understand—in medicine, too—is that science may not tell us how to be a better therapist or a better doctor, but it can sure as Hell keep us from being a bad one; from fostering outdated ideas, ideas that have been discredited, practices that we should really give up now and move on to the next thing. The radical mastectomy lasted far longer than it needed to, in spite of the research showing that lumpectomies were as effective. You know? So, that kind of discrepancy is crucial to understand in medicine, as in psychology.”
“Many books that have been published recently about human irrational information processing are really another rendering of Dissonance Theory as Festinger originally proposed it. But it was his graduate student, and my good friend and co-author, Elliot Aronson, who advanced Dissonance Theory into a theory of self-justification: meaning, you will feel dissonance if you and your best friend disagree about Woody Allen movies. You will try to persuade your friend that your view of Woody Allen’s movies is the right one, and the smart one. But it’s trivial, it’s not major; you can live happily with that friend and have different points of view about movies.
But when the dissonance is about something that deeply affects our self concept— our view of ourself as a competent professional, a good human being, a kind person, an ethical person—and now I’m confronted with information that I did something unethical, or foolish, or stupid: I, a skeptic, a scientist, I did something stupid? Oh, get lost. OK? What Elliot showed was that when the dissonance is information that challenges that central belief about ourselves, we will be much more likely to justify our mistake, our foolish action, our act of cruelty, than we will be to accept the information that we did something so wrong, foolish, or cruel. That is what is not obvious about Dissonance Theory, and why it is so important for us to understand how it works.”
http://astore.amazon.com/docartemis-brainscience-20/detail/0156033909
Mistakes Were Made (But Not by Me): Why We Justify Foolish Beliefs, Bad Decisions, and Hurtful Acts
Ginger Campbell MD interviewed the author Carol Tavris for the brainscience podcast.
A few interesting quotes from the interview and how it’s relevance pertains to the discussion of concern/tone trolling, the reaction of the Cortisol researcher.
“But one important thing for all clinicians to understand—in medicine, too—is that science may not tell us how to be a better therapist or a better doctor, but it can sure as Hell keep us from being a bad one; from fostering outdated ideas, ideas that have been discredited, practices that we should really give up now and move on to the next thing. The radical mastectomy lasted far longer than it needed to, in spite of the research showing that lumpectomies were as effective. You know? So, that kind of discrepancy is crucial to understand in medicine, as in psychology.”
“Many books that have been published recently about human irrational information processing are really another rendering of Dissonance Theory as Festinger originally proposed it. But it was his graduate student, and my good friend and co-author, Elliot Aronson, who advanced Dissonance Theory into a theory of self-justification: meaning, you will feel dissonance if you and your best friend disagree about Woody Allen movies. You will try to persuade your friend that your view of Woody Allen’s movies is the right one, and the smart one. But it’s trivial, it’s not major; you can live happily with that friend and have different points of view about movies.
But when the dissonance is about something that deeply affects our self concept— our view of ourself as a competent professional, a good human being, a kind person, an ethical person—and now I’m confronted with information that I did something unethical, or foolish, or stupid: I, a skeptic, a scientist, I did something stupid? Oh, get lost. OK? What Elliot showed was that when the dissonance is information that challenges that central belief about ourselves, we will be much more likely to justify our mistake, our foolish action, our act of cruelty, than we will be to accept the information that we did something so wrong, foolish, or cruel. That is what is not obvious about Dissonance Theory, and why it is so important for us to understand how it works.”
I’m sorry Peter, but for being so insanely pedantic about the proper wording of our scientific criticisms you are smoking some serious dope.
EC intervention = sham intervention > waitlist
The claim is that the EC intervention “does something.” The experiment very, very clearly demonstrates that the EC intervention does nothing. It is the placebo response that has done “something” (whatever that may actually be in this case).
So explain to me how I cannot say that the CAM in question here “doesn’t work in any complete, final, simple sense?” We are not discussing the utility of placebo in relation to this article. That is a separate discussion that you and I disagree on, but is completely immaterial.
Energy chelation does not work. Period. In the simple sense. In the complete sense. In the most scientifically pedantic sense. In any sense.
Thanks. You beat me to it. Unfortunately, Peter just doesn’t seem to get it, for all his accusations that I don’t “get it.” How this study was spun is not about placebos. It’s about an erroneous spin put on a study to make it seem that a treatment worked when it did not. The treatment did no better than placebo; therefore it didn’t do anything beyond placebo. That means it didn’t work. It’s just that simple, for all of Peter’s contortions of language.
“It is unwise to regard integrative medicine colleagues as having any less concern for patient welfare or any less basic respect for science.”
Their intentions are more or less irrelevant. In the real world it is results that matter. In other professions the behaviour we see in medicine would earn condemnation and scorn.
No-one says “It is unwise to regard alternative accountants as having any less concern for their clients.” Instead they sue them for not doing things properly (and, yes, there is plenty of “art” in accounting, or it could by done by trained chimps).
Not only would no mechanic who attempted to fix your car by “holistic” methods stay in business, there would be no-one willing to pretend he had any concern for your safety in attempting to do so.
Yet in medicine we are meant to give charlatans the time of day? Spare me!
nybgrus,
You are very wrong when you write that energy chelation doesn’t work. It works very well for Rosalyn Bruyere.
Nybgrus, I agree that most of the effect of these “healing” rituals lies in the associated non-specific influences including those associated with placebo, but can you explain how these can be fully exerted without also exhibiting some kind of “treatment” program, when trying to help something like fatigue in cancer survivors?
How do you equal the impact of an hour of relaxation twice a week, while some well-meaning, empathic, confident, chatty(?) individual is engaged in some kind of “treatment” metaphor? If it produces meaningful benefits, is safe and it is sufficiently cost-effective, and reliable within different settings (not yet shown and rather dubious), we need a very good excuse for ridiculing the pracctice, no matter what “the science” says and no matter what we choose to recommend for funding within our own practices. The “treatment” may not “work” in any accepted scientific sense, but it remains the hook upon which everything else hangs.
We can argue what it all means for science somewhere else, as Dr Gorski and Coyne have and as we are doing here.
I can understand why this makes people uncomfortable, but it is not my fault that the complexities of the human species seem to be resulting in competing concepts of therapeutics in subjective and psychosomatic conditions. Emerging science and my own critical review of the evidence has made me entertain a different view of placebo potential to that which I once had, sufficiently to get me thinking about its implications.
I also warn that the challenge from placebo-type medicines is not yet fully played out. Already there are a few studies that suggest that placebo-type studies can perform as well as commonly used medications with some conditions. That is not an entirely implausible study outcome and such studies may strain the capacity of the public and politicians to absorb our “debunkings” of studies producing results that we clearly do not like.
@pmoran,
“How do you equal the impact of an hour of relaxation twice a week, while some well-meaning, empathic, confident, chatty(?) individual is engaged in some kind of “treatment” metaphor?”
Maybe with an hour of relaxation with a well-meaning, empathic, confident, chatty individual who honestly offers comfort care measures, TLC, personal attention, and support without inventing any fairy tales or rituals to pretend it is a medical “treatment,” metaphorically or otherwise.
Harriet: Maybe with an hour of relaxation with a well-meaning, empathic, confident, chatty individual who honestly offers comfort care measures, TLC, personal attention, and support without inventing any fairy tales or rituals to pretend it is a medical “treatment,” metaphorically or otherwise.
Yes, sounds great. How would you represent this to the patient so that they would commit to eight sessions over four weeks? Would it work as well without the “treatment” gloss and an enthusiastic “healer”? I suspect
not, but perhaps close.
PM, the main objection I have to the paper is its abuse of the scientific process and prioritizing the wishful thinking of the authors that energy chelation “did something” to their actual data that said it was the same as placebo.
The authors have a delusion that the energy chelation did something that the placebo did not do.
It doesn’t matter how much the clinicians care about their patients. If they are able to take accurate data on how the patients are doing, but then substitute their own delusional conclusions which don’t follow from the clinical data, how is that being helpful to the patients?
People who are unable to think logically should not be in charge of patient treatments. Maybe people who can’t think logically would be good at delivering nurturing comfort care, but they are unable to evaluate the effects of that nurturing comfort care.
Maybe the thing to do is start up a new specialty for the delivery of nurturing comfort care. It doesn’t take any great education or cognitive skills, just empathy and the ability to nurture. Such people might be very helpful in a clinical setting. You could probably train high school graduates to do it in a week or so.
The French do it. Regularly. And boom goes the dynamite
At various points in history, physicians routinely prescribed spa attendance and mineral bathing practices.
But somewhere along the way we’ve lost the health connection. North American spas today seem to focus on esthetics, pampering, and relaxation. But not exactly on preventive health or medical treatment, per se. In contrast, European spas have retained the health aspect. In fact, spa treatments are often covered by the national health insurance plan in France.
I have very long said that I think “spa days” with some massage, a lot relaxation, maybe a nice hot mineral bath with soothing music playing through the room, etc would be extremely helpful for people with chronic disease, and actually particularly cancer patients. I’ve even suggested having chemo infusion stations be the fancy-pants style manny/peddy type chairs so that the patients can actually get a manicure, pedicure, foot soak, foot massage, scalp massage, what have you whilst the chemo is going in. I think that would actually be extremely beneficial.
And not only achieve the same results, but IMO better results, than having some credulous buffoon wave their hands over you thinking that they are Harry Potter.
(Oh, BTW I knew to instantly look up the French and their spa treatments because of my undergrad degree in medical anthropology because this book was required reading for one of my courses. I actually have a priori knowledge to this discussion, not just a post hoc scramble to address criticisms. Granted the majority of that book is a load of garbage, and since the French health benefits scheme is ballooning out of control because the reimbursed not just spa treatments but essentially every “CAM” they are cutting drastically. It is actually kind of sad because they in effect went whole hog on the “CAM” coverage including things which are actually reasonble – and not actually CAM – and are know slashing it all in an effort to save money [link to follow so my comment doesn't get held up]. But my point is that indeed there is a way to get people to relax and enjoy the benefits without resorting to lying to them about magical powers and wizardry.)
You know almost every time pmoran comments on this board at some point the word “apologist” comes up. That word seems to be a big favorite in the skeptical community.
Maybe it’s my age, but I can not hear the word apologist without thinking of the context I always used to hear it in, which is “Nazi apologist”, which trigger’s immediate Godwin’s Law suspicions.
But, I’m sure the SBM community would never, ever use subtle references to Nazis in the attempt to win an argument about placebos.
And of course, if you expressed a concern about that approach, suggesting it may be counter-productive or hyperbole, then you are likely to draw labels such as apologist or concern troll yourself.
pfffft – ridiculousness. It all seems to have much more to do with ego, wanting to win and loving some snark, than it does actually offering useful information to the public.
Here is the link
@michele:
I am sorry that it evokes a Godwinesque reference in your mind, but that has nothing to do with the actual definition or usage. It can be that the apologetics in question are in defense of Nazi’s, but there is absolutely nothing inherently tying the two together. The definition is rather clear:
a person who makes a defense in speech or writing of a belief, idea, etc.
And in the common rhetoric and discourse of the past many decades it almost always refers specifically to religious apologism:
Apologetics (from Greek ἀπολογία, “speaking in defense”) is the discipline of defending a position (often religious) through the systematic use of information.
So I’m sorry Michele, but it not only does not (except in a narrow and specific sense) have to do with Nazi’s any any way, but also fits perfectly the type of rhetoric the pmoran often uses. The fact that it leaves the distaste of Godwin in your mouth is purely a personal predilection on your part, I’m afraid.
Sorry, hit send too soon.
And yes, of course, no one here is trying to “win an argument” through subtle Nazi references. That would just be…. well… stupid.
And furthermore, the current discussion is not about placebos at all…. which is why pmoran continually attempting to spin it in that direction makes the moniker “apologist” reasonably apt.
You’ve got to be kidding.
I gotta be honest; that has to be the most contorted stretching of a definition that I’ve ever seen anyone use in order to try to accuse someone of argumentum ad Nazium. I can understand objecting to the term apologist. Really, I can, even though it’s a fairly neutral term. If I wanted to be more “strident,” I’d use loaded terms like “propagandist” or “partisan,” terms I use frequently to describe blogs like Age of Autism and which are entirely appropriate to apply to crank organizations like AoA. Peter is not a crank; so such terms would not be appropriate under any stretch of the imagination to apply to him, which is why I didn’t use them. In any case, what I can’t understand is ascribing Nazi connotations to a term for which there are no such connotations. Remember that I’ve been pretty active in combatting online Holocaust denial and Nazi beliefs. I’ve also criticized, for example, Richard Dawkins quite roundly on my not-so-super-secret other blog for his use of Neville Chamberlain analogies that are clearly intended to imply that the group being “appeased” must be…like Nazis! So if anyone has a hypersensitive argumentum ad Nazium detector, it’s me (and believe me, I’ve been accused of just that on more than one occasion), and I just don’t see the Nazi inference in the use of the term “apologist.” In fact, the most common use of the term that I see is in terms of religion: Christian apologetics.
So, I guess my retort would be: I’m not going to let my use of language be constrained by your thought processes that erroneously lead you to infer nonexistent Nazi connotations to the term “apologist.” That’s on you, not me. I’m sorry if that’s blunt, but I think bluntness was called for here. You might criticize me for having used that bit of dialogue from The Great Escape as flirting dangerously close to Godwin territory;. Even though I tried to put it in context and explain why I chose that particular line, it’s always a risky move. And if you think I went too far there, I understand. In retrospect, it might have been better if I had resisted the temptation to quote one of my all time favorite movie lines. What I do not understand, however, is focusing on the term “apologist” as a Godwinization of the thread.
The answer to that problem is simple: If a drug or modality doesn’t perform better than placebo, then it should be shed from the armamentarium of medicine. The answer is not to widen the definition of science-based medicine to include placebos, particularly when they do not impact the pathophysiology of the disease being treated.
David Gorski “I just don’t see the Nazi inference in the use of the term “apologist.” In fact, the most common use of the term that I see is in terms of religion: Christian apologetics.”
Huh? Really? I assure you I’m being sincere, I’m not making up some reference just to zap you guys. Outside this board and other skeptical sites, (meaning talking to friends, family, listening to politics), I’ve only ever heard the word used in reference to Nazi apologists.
Maybe it’s that art school education, to lacking in liberal arts, of mine, but I’ve never heard of Christian apologetics, although, yup that’s definitely googlable.
Coyne says “if we want to fight junk science effectively, we need to strengthen post-publication commentary and critique, given the obvious limitations of prepublication peer review”.
First: My compliments to all on your success.
First point: we could work in the quality of peer review too. I am not giving up.
My other point is that it is too risky for me to do what you folks did, in areas where I have expertise. It will usually be bashing other folks in my own field (nothing to do with CAM), and they review our papers, and perhaps grants too, and they may have data I want to see someday. On occasions when I have wanted to write that letter, my colleagues plead with me not to. It’s hard enough to call bullshit when reviewing some papers where the pool of folks that might be asked to review it is small, and reviewer 3 that is crying bullshit sounds just like that pesky nerd the authors already know.
I keep hoping for some new invention. Try this. We form a group of 300 people called the Bourbaki, or what you will. Small groups of us write up criticisms, but are not specially identified (we are all co-authors, and all can review the document). I need them to be mostly (bio-) statisticians to fight the horrors I see. Our balls are tiny, you see.
Funny, but I’m pretty familiar with the skeptical blogosphere, and the context in which I most commonly see the word “apologetics” is “Christian apologetics.” I can’t recall the last time I saw Nazi apologetics, although I’ve probably used the term at some point myself in the past, probably in reference to Pat Buchanan. Both here and on my not-so-super-secret other blog I know I’ve referred to Dana Ullman as a homeopathy apologist, and I don’t recall you ever complaining. Ditto my referring to Dr. Jay Gordon as an antivaccine apologist, Dr. Michael Egnor as an intelligent design apologist, and Steve Milloy as a corporate apologist. Recently, I think I’ve been using the term to refer to Burzynski defenders as “Burzynski apologists.” None of this, as far as I can recall, has drawn even the mildest rebukes.
So color me still puzzled.
David Gorski “So, I guess my retort would be: I’m not going to let my use of language be constrained by your thought processes that erroneously lead you to infer nonexistent Nazi connotations to the term “apologist.” That’s on you, not me.”
Umm, well language is generally constrained by the thought of the person you are communicating with, the question is not whether my reading of apologist is erroneous or not, it is whether my association (erroneous or not) is common or uncommon or how the audience that you are trying to reach views the word.
That is testable, but I don’t think either of us have the results of that test handy. Since I don’t have time to engage in speculative arguments as the what the result of that test would be, I’ll leave it at that.
David Gorski, sorry about the last post, didn’t give you a chance to respond.
The word has always driven me crazy. I’ve never complained before because I was trying to be polite. But I think I hit the millionth customer, “Oh my god I’ve just had it with that word.”
If you all sincerely say that you genuinely don’t mean to elicit any Nazi connotation, I guess I’ll just take it at that and think ‘oh skeptic use that word differently’.
Although really, it’s strange, maybe a cultural thingy.
@micheleinmichigan,
“I’ve only ever heard the word used in reference to Nazi apologists.”
I, on the other hand, don’t recall ever hearing the word “apologetics” in reference to Nazis. I am familiar with its use in religion, specifically Christian apologetics.
micheleinmichigan
“That is testable, but I don’t think either of us have the results of that test handy. Since I don’t have time to engage in speculative arguments as the what the result of that test would be, I’ll leave it at that.”
My experience on many various blogs on topics is much the the same as Dr. Gorski’s in regards to the term apologists, and I am genuinely surprised that you have not encountered a broader usage of the term before. I frequently (at least once a week, if not several times a week) encounter that term on many other subjects without any hint of Nazi references, often in the same context as the term accommodationist, (and some times compatablist) which has a different nuance to it. Other contexts I have seen the term used in are in discussions of creationism/intelligent design and free will.
Frankly I see the term Nazi revisionist used far more than apologist.
Do you have another equivalent term that you would suggest as an alternative? I hope that your position isn’t that the use of the very concept of an “apologist” is what you find objectionable rather than the term which you believe invokes thoughts of references to Nazi apologists.
Also, do you have the same feelings about the term “denier” and if so what do you propose for an alternative synonym?
Sometimes we do need to learn to use better words, but sometimes we need instead to find ways to educate people about the the words we use. In this case, I really think it’s likely that you are in the minority with your understanding of the term apologist, though of course, I’d have to defer to quality evidence to the contrary.
@HH, no it’s not Nazi “apologetics” it’s Nazi apologist. You can google it if you don’t believe that people use the term. But it actually explains alot that you haven’t heard of the usage, since I was always kinda confused as to why you would use apologist with my connotation. It seemed kinda out of character.
KW “Do you have another equivalent term that you would suggest as an alternative? I hope that your position isn’t that the use of the very concept of an “apologist” is what you find objectionable rather than the term which you believe invokes thoughts of references to Nazi apologists.”
It’s really possible that the blogs we frequent are not comparable (except this one). But, I was basing my understanding of the word on hearing it in conversation with family friends and some typical liberal political blogs.
But, actually, I’m kinda bemused by the suggestion that my association isn’t standard. It’s kinda like someone telling me that the phrase “hung like a horse” is actually used to describe a particular horse butchering process. At this point, now I don’t really know if my association is standard or yours is or if the connotation varies by sub-cultures.
Actually, as much as I know I probably offended numerous people. I’m kinda glad I brought it up so strongly, because this result is not something I imagined and it might explains a few things that have bothered me.
@pmoran,
“How would you represent this to the patient so that they would commit to eight sessions over four weeks? Would it work as well without the “treatment” gloss and an enthusiastic “healer”? I suspect not”
How would we represent this to the patient? By honestly saying we are offering measures that will make him feel better and that will improve his life. How to engage the patient is a challenge, but one that we should welcome. It may not be easy, but it is certainly a worthwhile goal. The hospice movement is already doing these things and is widely accepted by patients. It could involve an enthusiastic “helper” rather than “healer,” and we will never know if works as well without the “treatment gloss” fairy tales until we test it properly. I can assure you it would work much better for me without the fairy tales.
As anecdotal support for my position…
During my five minute drive to lunch just now, the word apologist was used on the radio by a sports journalist. Bernie Miklatz (local sports columnist and on air personality) was commenting on the local contrvaversy over the hiring of Brian Schottenheimer as offensive coordinator for the Saint Louis Rams. He said that it was a legitimate discussion whether you were a Schottenheimer defender or apologist and that Scottenheimer had a good deal of success, but also had hs struggles as an Offensive coordinator with the NY Jets, etc.
I kid you not.
also KW – denier, besides being a grammatical travesty? (ha, coming from me, that’s saying something) denial, Holocaust or Global Warming or Evolution, Moon Landing…doesn’t have a concrete association for me.
@micheleinmichigan,
“it’s not Nazi “apologetics” it’s Nazi apologist.”
Apologetics is what apologists do. Same thing.
“It’s really possible that the blogs we frequent are not comparable (except this one). But, I was basing my understanding of the word on hearing it in conversation with family friends and some typical liberal political blogs.”
The simplest conclusion is that my blogging experience includes things yours does not. The real question is which experience is more typical.
Of course if you are perceiving that context here when it’ not intended, it’s possible that you may be mistaken in some of the other contexts where you have perceived that meaning as well. Seek and you shall find: sometimes it’s fairly easy to think you have found what you are predisposed to find.
As per my above example, it’ not just the blogs I visit where I hear that term used. it’s a relatively commonly used term often when opposing viewpoints are discussed without any intention of Nazi references.
In my experience, I have heard more people take offense at the use of the term denier on Godwin grounds. You are the first person I have ever heard take issue with the use of the term of apologist in regards to thinking it implies a Nazi reference. (I have, of course heard plenty of people object to the term because they felt it did not apply, but not because they opposed the use of the term itself)
My understanding of the terms apologist and apologetics are in accord with Dr. Gorski and Karl. It is also based on my education (two masters in the humanities) and having been an editor of many academic papers including several ones in the history of World War II that dealt with the words in question.
Nevertheless, Dr. Gorski did put in a nearly direct reference to the Nazis. This is a classic case of what editors often call Favorite Child Syndrome meaning that the one, special, much-loved quote or passage that a writer doesn’t want to cut is exactly the one he should cut.
Personal attachment often occludes clear judgement. Be that as it may, contemporary use of the noun apologist and plural noun apologetics is still more often than not related to Christianity except perhaps in the general blogosphere where it seems to mean anyone defending a position you don’t care for.
KW “The simplest conclusion is that my blogging experience includes things yours does not. The real question is which experience is more typical.”
Yes, that’s pretty much what I said to David Gorski. But actually the real question is whether I can assume there is an intention to raise the specter of Nazi’s when I see someone using the term apologist. Based on my personal experience, I thought I could, easily. Based on other’s experiences*, it seems I can’t. **
I’m going to accept Quill’s educated assertion that the term apologist (or apologetics) is more often than not used in relation to Christianity rather than Nazi’s, at least in academic circles.
So it seems that I’ll have to adjust my annoyance to to exclude the use of apologist unless the context makes direct reference to Nazi’s (ie Jack Boots, Lock Step, Fascist, etc)
*Unless, you are ALL just screwing with me, in which case I’d have to give you a thumbs up for being convincing.
**Jeez, is this just an anomaly of my weird family and upbringing? I really didn’t think I was being an oddball on this one, but oh well. It’s not the first time it’s happened, probably won’t be the last.
Me: Already there are a few studies that suggest that placebo-type studies can perform as well as commonly used medications with some conditions. That is not an entirely implausible study outcome and such studies may strain the capacity of the public and politicians to absorb our “debunkings” of studies producing results that we clearly do not like.
David: The answer to that problem is simple: If a drug or modality doesn’t perform better than placebo, then it should be shed from the armamentarium of medicine. The answer is not to widen the definition of science-based medicine to include placebos, particularly when they do not impact the pathophysiology of the disease being treated.
I think such studies have involved drugs that have been shown to perform better than placebo in controlled trials, so as to attain FDA approval. Acupuncture in prevention of migraine is an example — e.g. http://www.acupuncturetoday.com/archives2001/apr/04migraines.html
So what will you say to migraine sufferers, having withdrawn the only “evidence-based” options?
Harriet: How would we represent this to the patient? By honestly saying we are offering measures that will make him feel better and that will improve his life. How to engage the patient is a challenge, but one that we should welcome. It may not be easy, but it is certainly a worthwhile goal. The hospice movement is already doing these things and is widely accepted by patients. It could involve an enthusiastic “helper” rather than “healer,” and we will never know if works as well without the “treatment gloss” fairy tales until we test it properly. I can assure you it would work much better for me without the fairy tales.
Yes, me too and I suspect for very many. But I think there is an element of make-believe, or perhaps a knowing temporary suspension of disbelief, when people are driven to try out unlikely treatments. These may enable expectancy responses even in the presence of rational doubts.
pmoran
One of the big problems I have with the use of various CAM practices as a non specific placebo, besides the ethical considerations and my suspicion that any apparent subjective, non-specific effects will likely decay to zero over time, especially with more widespread use is that embracing modalities based on fairy tales encourages belief in the validity of those and other medical fairy tales
When Dr. Novella was on Dr. Oz’s show, I was slightly amused by Dr Oz’s off hand comment that homeopathy should only be used for non serious, self limiting conditions, without any explanation of why that is. The practice/philosophy of homeopathy itself makes no such distinction; why does he?.
Should we tell people that the philosophy and understanding behind a particular modality is unproven, prescientifc, pseudoscience/bunk , but it works anyway, or should we lie to people and tell them the basis is valid, or just remain silent so as not to harm the illusion?
CAM modalities carry way too much woo baggage to be valid or productive applications of placebo medicine, even if you think that placebo medicine is a valid approach.
Indeed. That’s the very reason the awkward term “denialist” was coined. The term “denier” had the connotation of “Holocaust denier,” and, of course, Holocaust deniers are virtually always anti-Semites and/or Nazi sympathizers (Nazi apologists, if you prefer). When people referred to, for example, “anthropogenic global warming deniers” (AGW deniers), the AGW deniers would cry that they were being compared to Nazis. Ditto HIV/AIDS deniers. So, to decrease that inflammatory connotation while saying in essence the same thing, the incredibly awkward terms “denialist” and “denialism” were coined and applied to things like evolution denialism, AGW denialism, vaccine denialism, HIV/AIDS denialism, etc. In fact, a certain “friend” of mine explained this situation several years ago:
http://oracknows.blogspot.com/2005/08/pseudohistory-and-pseudoscience.html
In any case, the connotation of “denier” is linked mostly with Holocaust denial, which makes it so easy for these others to grasp at that connotation to try to discredit critics of other forms of denialism by claiming the term itself likens opponents to Holocaust deniers (a.k.a. Nazis, anti-Semites, or Nazi sympathizers). In any case, I remain skeptical that the term “denialist” has defused the inflammatory nature of the connotation, but I can’t think of a better term than “denialist.” So I sometimes still use it.
In any case, Mark Hoofnagle has a pretty good primer on denialism here:
http://scienceblogs.com/denialism/about.php
@michele:
“Apologist” is a useful word that does not imply the object of the apology; that entity must be separately specified. In common use, various objects of “apologist” are too numerous to count. The word does not, by itself, suggest an association with Nazis, Christians, antivaxers, Republicans, members of NORML, or any other group. If it does elicit such an association, the explanation must lie in the experience of the beholder, but not in any property inherent to the word. That beholder ought, then, to recognize that her impression of the word’s meaning, or perhaps of its use, has been incorrect. “Quack apologist” is probably the most common example of it appearing in my own writing on SBM, but I would never think of limiting its use to that context, and I don’t automatically think of “quack” when I read the word “apologist.” I’m also quite certain that the thought of Nazis has never crossed my mind when I’ve written the word “apologist,” unless I happened also to be writing about Nazis.
@nybgrus:
That French thing is interesting. I haven’t read the article that you linked, but what if the French experience with “CAM”-heavy entitlements is just the ‘test’ that many, well, “CAM” apologists would like to see? A common claim is that if people have free access to “CAM,” they’ll be less likely to cajole real doctors to prescribe expensive, potentially dangerous, but unnecessary, “conventional” treatments. Looks like that didn’t pan out, if the French have found their “CAM”-basket too expensive and are cutting back.
KA ” That beholder ought, then, to recognize that her impression of the word’s meaning, or perhaps of its use, has been incorrect”
Actually, I thought I did that…once presented with a reasonable argument to oppose my interpretation.
I think “apologist” is a slipshod way of referring to what I do, but I suppose I would be bound to think so.
What I do object to is when such terms as “tone troll” and “CAM apologist” are used in such a way as to imply that my earning of the label (in whose opinion?) automatically means that my arguments have no merit and are hardly warrant thought or effort because of that.
Our tribal instincts offer us a feeling of security and of righteousness whenever we can come up with spuriously explanatory names such as “shruggie” but it is a schoolyard rhetorical device hardly worthy of a supposedly scientific enterprise.
@pmoran,
“means that my arguments have no merit”
I would call you an apologist not because your arguments have no merit but because they sometimes smack of special pleading and a double standard. I think you see yourself as a questioner but you often come across as a defender.
I would call you an apologist not because your arguments have no merit but because they sometimes smack of special pleading and a double standard. I think you see yourself as a questioner but you often come across as a defender.
Well, if you see me that way, it may be true. I think your judgement is good on most things. Although I would like to know where the special pleading and double standard lies. These kinds of exchanges are very prone to misunderstanding and sometimes mere looseness of expression.
What do you see me as an apologist for? I need to know, because I see myself as merely closely following where certain scientific evidence is pointing. Everything else is opinion which all sides should be constantly reassessing. Received medical wisdom has often been shown wanting.
I see you as an apologist for unproven methods because of the benefit their placebo effects might bring.
I see a double standard in that you show a tolerance for things like acupuncture that I don’t think you would show for a pharmaceutical with the same level of evidence.
I see you as the proverbial kindly elder physician who is frustrated when science-based medicine doesn’t have much to offer and who wants to do “something” to help patients, even if it is not evidence based.
And I hear a hint of paternalism, a suggestion that maybe in your wisdom you know more about what is best for your patients than science does.
I may be wrong, and I don’t mean to be insulting, but that’s the perception I’ve gotten. I know you are on the side of science-based medicine and share our goals, so we shouldn’t be fighting about this, but I think we all see you as a bit too “soft” on CAM.
Thankyou very much, Harriet. I can understand those perceptions except for the second one. I have never held or expressed that kind of double standard. I am actually far more prejudiced against CAM than I am against pharmaceuticals where they are effective and safe-ish.
And I hear a hint of paternalism, a suggestion that maybe in your wisdom you know more about what is best for your patients than science does.
We are all paternalistic towards our public. Why would we be otherwise? It seems we can only see it as bad in others.
And which science is that? I am following the implications of scientific studies that I know you are familiar with. Am I merely be a little more fearless in following them through to their logical conclusions, for a de facto pluralistic global medical system, within which large sections are beyond our direct control but which behave in a largely reactionary mode to us?
Time will tell.
Let us suppose that Merck were to publish a study finding that their new pain drug has the same effect as a sugar pill, but that both produced superior outcomes to the no-treatment group. Should Merck then be allowed to market this new drug as a treatment for pain?
Unless you say “yes,” that’s quite a clear double standard, since you support CAM treatments in precisely the same situation.
@Peter,
FWIW, I don’t think of you as a “CAM” apologist (well, maybe just a little) and certainly not a shruggie. I understand your argument, which you’ve stated quite well. In a logical nutshell (if you’ll excuse the presumption): IF placebo or sham treatments make some people feel better, THEN physicians ought to consider such nonspecific treatments when there are no specific alternatives. Moreover, “CAM”=placebo or sham, so why wouldn’t physicians consider (‘harmless’) “CAM” methods when there are no specific alternatives?
I don’t usually join this recurrent discussion both because you and I mostly completed it years ago (here, here, and here, for the newbies), and because I, like Harriet, don’t consider your argument to have no merit. On the contrary, your argument is logically valid.
Your argument is not logically sound, however, because the premise is shaky. We’d all agree that there is something about interacting with a reassuring ‘healer’ (whether real doctor, quack, or some hybrid thereof) that, all by itself, makes some people feel better. This is not news and it happens automatically, no matter what diagnostic methods or treatments, including none, may follow. We don’t know, and we may never know, whether this effect can be substantially enhanced by some purposeful strategy. That is the hypothesis, not the conclusion, of ‘placebo research’ to date (I know you know this, because you’ve written it many times). Thus none of it currently justifies real doctors embracing “CAM,” or fake doctors being taken seriously by real doctors, medical schools, governments, etc. At best it justifies placebo research, but even that has been, like most things in this postmodern world, overhyped.
Nor is it ethically sound, because ‘healers’ shouldn’t systematically lie to patients. That also has something to do with its not being logically sound: there are no harmless “CAM” methods, because lying about them will inevitably, at least sometimes, cause harm. (Oh, and Kaptchuk did deceive, in the IBS study: the a priori claims that he made for placebos were based on other studies in which subjects DID NOT KNOW that they were receiving placebos; thus it was not the case that “placebo pills…have been shown in clinical studies to produce significant improvement…” Other studies had found that some experimental subjects, who had received inert pills but who thought that there was at least half a chance that they’d received active pills, REPORTED enough improvement in some outcome(s), according to some subjective ‘metric’, for that measure to have achieved “statistical significance.” Far cry.).
There’s a big “CAM” credibility problem in medicine right now, and it has far more to do with shills (Oz, Katz, Weil) making false claims, apologists (Briggs, “IM” programs in medical schools) overstating the promise of such claims or merely restating them without critique, and shruggies (most of the rest, and a useful term it is) not speaking out to refute those claims than it does with skeptics poo-pooing the modest-at-best possibilities of placebos and the even less likely possibility that nonspecific effects of “CAM” treatments can somehow be made so robust as to warrant changing medical ethics to accomodate them.
.I can understand those perceptions except for the second one. I have never held or expressed that kind of double standard. I am actually far more prejudiced against CAM than I am against pharmaceuticals where they are effective and safe-ish.
Scott: Let us suppose that Merck were to publish a study finding that their new pain drug has the same effect as a sugar pill, but that both produced superior outcomes to the no-treatment group. Should Merck then be allowed to market this new drug as a treatment for pain?
Unless you say “yes,” that’s quite a clear double standard, since you support CAM treatments in precisely the same situation.
Well, not “precisely the same situation”.
The most straightforward of the questions I am considering is whether CAM, with its exploitation of non-specific medical influences, is serving useful medical purposes within its domain outside of and largely complementary to the mainstream medical system.
We have very limited capacity to stop anyone marketing anything as a medical treatment in that domain so long as they keep their claims vague. Merck itself would in any case not bother further with such a product.
The answer is “no” to the allied question of whether the mainstream should embrace such a treatment. But that is dictated by a combination of ethical, practical and economic considerations that may not always outweigh clinical imperatives (in my personal view).
I would also rather have doctors trying more harmless palliatives than over-prescribing unnecessary powerful, risky and expensive pharmaceuticals. But I do understand the factors militating against that as a general policy.
It may be a good option for selected patients. Some doctors attract those patients who enjoy trying so-called “natural” medicines as a first option. I was stunned in the latter part of my medical career by the number of new patients who said before they even sat down, either “i don’t like taking drugs” or “i am ‘allergic’ to all drugs” (of course they are not, but a message is clear). Medicine can be a far more complex undertaking than many seem to think
@pmoran,
“I would also rather have doctors trying more harmless palliatives than over-prescribing unnecessary powerful, risky and expensive pharmaceuticals. But I do understand the factors militating against that as a general policy.”
So you do think there are times when there should be a special exemption from general policy? That’s where you begin to sound like an apologist for CAM. Wouldn’t avoiding drugs entirely be a better approach than prescribing an ineffective remedy as a “harmless palliative?” Before the rise of CAM, I had lots of patients who didn’t like taking drugs, and we always managed to arrive at some mutually agreeable course of action
And you create a false dichotomy: it’s not a question of “over-prescribing” drugs vs using placebos. Over-prescribing unnecessary drugs is bad practice and should not even come into this discussion.
David Gorski wrote: “TT, TH, reiki, and EC are the same.”
I agree. I admit I am not that familiar with the term “Energy Chelation,” but the description in the study makes it appear kin to the others. Where these energetic healing differ in practice is almost entirely a matter of style and emphasis. EC seems to resemble a style of TT done early on by some Canadian nurses who focused on removing negative energy with their hands. With great dramatic effect, they would shake the bad stuff off their hands and then stomp on it with their foot.
This EC study curiously does not opt for an interpretation used in a number of TT studies that ended up with similar results for both treatment and sham groups: the researchers would conclude that the sham practitioners are incapable of NOT having positive intentions towards the subjects.
Alas, this study seem to be an example of multiple system breakdown, from funding source, to human subjects review board, to peer review, to editorship. Where were all those gatekeepers?
Harriet: So you do think there are times when there should be a special exemption from general policy? That’s where you begin to sound like an apologist for CAM. Wouldn’t avoiding drugs entirely be a better approach than prescribing an ineffective remedy as a “harmless palliative?” Before the rise of CAM, I had lots of patients who didn’t like taking drugs, and we always managed to arrive at some mutually agreeable course of action
And you create a false dichotomy: it’s not a question of “over-prescribing” drugs vs using placebos. Over-prescribing unnecessary drugs is bad practice and should not even come into this discussion.
Well, true, but we will be judged by what we do collectively rather than what we aspire to, or what our best doctors are able to achieve with amenable patients.
My point about patients seeking out compatible doctors is also valid. Potential CAM users may well be better off with a doctor who is prepared to be flexible, than with an ND or TCM practitioner.
Again, I am not suggesting that anyone does anything that they are not comfortable with. I think we could be a tad less judgemental of those who are marginally more tolerant of CAM and perhaps more aware of the fact that there will be unintended consequences of too-purist approaches.
Don’t be judgmental of those who are “marginally more tolerant of CAM”? Who’s doing that? The authors of this study are not just ‘marginally” more tolerant of CAM. They’re so tolerant of CAM that they hooked up with an “energy chelation” quack, did a study, and when that study didn’t show what they wanted spun the results to make it sound as though energy chelation is a promising therapy by doing multiple comparisons and finding a couple of marginally statistically significant differences that would disappear if the proper test for multiple comparisons were done. Then a journal whose editors were apparently ignorant of just how far down the rabbit hole of quackademic medicine this study had gone, actually published it and published a response that basically told us we aren’t upholding the “highest ideals” of science and medicine by criticizing the authors!
That is way more than “marginally” more tolerant of CAM. Hell, yes, I’m “judgmental” about this, and I make no apologies for it, either.
I am curious, however, what “unintended consequences” come from a too “purist” approach that we haven’t already considered.
[...] effects. When CAM practitioners find no difference between the treatment arm and placebo arm, they conclude that their treatment has promise. I love the double standard, don’t [...]
“I think we could be a tad less judgemental [sic] of those who are marginally more tolerant of CAM and perhaps more aware of the fact that there will be unintended consequences of too-purist approaches.”
I personally might be more comfortable/tolerant if those people were (or at least made it clear that they are) more aware of the probable fact that there will likely be (for numerous reasons) unintended consequences of promoting, embracing, or practicing the various CAM modalities. It’s my opinion that those unintended consequences are likely to be more serious than any unintended consequences of the “too-purist” approach.
How do you encourage, promote, or even accept the use of a modality without increasing the acceptance of the philosophy underpinning that modality? How do you get people to understand that when you prescribe them snake oil it’s OK, but that snake oil salesman down the street is not to be trusted with their health? I think homeopaths, acupuncturists, naturopaths, etc are too well established to think they’re either going to go away or change their scope of practice to become placebo providers. If you think placebo medicine is appropriate and useful, you’re trying to catch a tiger by the tail if you try to use just about any existing CAM practice for placebo medicine.
@ pmoran:
You didn’t answer very specifically, but I gather that your answer is effectively “yes, Merck should be so allowed.” In which case I agree that you are not applying a double standard. Not one I really agree with, but a consistent single standard.
.David: That is way more than “marginally” more tolerant of CAM. Hell, yes, I’m “judgmental” about this, and I make no apologies for it, either.
In relation to the Cancer article, all I complained about was the reference to TT, which seemed intentionally provocative, in effect spoiling for a fight.
I am curious, however, what “unintended consequences” come from a too “purist” approach that we haven’t already considered.
I am not complaining about a purist approach to the science, when claims obviously need challenging. and the science is clear (which it is not yet in relation to possible placebo influences within CAM even from nonsense like energy chelation) . I am also not sure what unintended consequences you have “already considered”.
I suppose my main concern, is that a lot of patients are looking around for doctors who are prepared to go along with their CAM use an I would prefer that they remained under the care of a proper doctor than an ND, chiropractor or TCM practitioner.
I have also mentioned the dissonance that is created when we insist that “X doesn’t work” when other voices are saying otherwise and the person in the middle lacks the intellectual equipment with which to sort out the truth (or in some instances the middle ground that helps explains that paradox) .
I personally might be more comfortable/tolerant if those people were (or at least made it clear that they are) more aware of the probable fact that there will likely be (for numerous reasons) unintended consequences of promoting, embracing, or practicing the various CAM modalities. It’s my opinion that those unintended consequences are likely to be more serious than any unintended consequences of the “too-purist” approach.
Karl:How do you encourage, promote, or even accept the use of a modality without increasing the acceptance of the philosophy underpinning that modality? How do you get people to understand that when you prescribe them snake oil it’s OK, but that snake oil salesman down the street is not to be trusted with their health? I think homeopaths, acupuncturists, naturopaths, etc are too well established to think they’re either going to go away or change their scope of practice to become placebo providers. If you think placebo medicine is appropriate and useful, you’re trying to catch a tiger by the tail if you try to use just about any existing CAM practice for placebo medicine.
Well, you might be right and I appreciate the feedback. On the other hand these methods will never be presented to the public in such a way as to support the shonky theories. The message will be “these methods may help some patients via psychological and incidental aspects of the care provided, but they should NOT, NEVER EVER, be relied upon alone for the treatment fo serious diseases.”
I need convincing that this more moderate (but likely more accurate) description of the true scientific position will reveal the medical profession in its proper role of having the interests of the patients as its first concern no matter what.
There is a “not” missing in the last sentence, of course . I am writing in a hurry as I still want to get aroudn to Kimball’s comment.
@pmoran, Suggested revision:
“these methods may help some patients via psychological and incidental aspects of the care provided, but so do sugar pills, and our patients deserve more than sugar pills. And they should NOT, NEVER EVER, be relied upon alone for the treatment fo serious diseases.”
“a lot of patients are looking around for doctors who are prepared to go along with their CAM use an I would prefer that they remained under the care of a proper doctor than an ND, chiropractor or TCM practitioner.”
That is a legitimate concern, but it is not our responsibility to give patients what they want, but rather what is ultimately in their best interests. We can find ways. A truthful explanation of why we don’t provide CAM and a willingness to continue managing overall care even if the patient insists on using CAM. Tolerating without condoning.
Harriet: @pmoran, Suggested revision:
“these methods may help some patients via psychological and incidental aspects of the care provided, but so do sugar pills, and our patients deserve more than sugar pills. And they should NOT, NEVER EVER, be relied upon alone for the treatment fo serious diseases.”
Yes, patients deserve better than sugar pills, when we’ve got something obviously better to offer.
But, I am working from the observation that these methods are mainly used where mainstream treatment is lacking. CAM usage is an approximate mirror image of mainstream medicine’s effectiveness. It is an attempt to fill in gaps and perceived gaps.
So any benefits from it have to be looked upon as not readily available otherwise. There may simply be too few doctors of the HH kind.
“a lot of patients are looking around for doctors who are prepared to go along with their CAM use an I would prefer that they remained under the care of a proper doctor than an ND, chiropractor or TCM practitioner.”
HH:That is a legitimate concern, but it is not our responsibility to give patients what they want, but rather what is ultimately in their best interests. We can find ways. A truthful explanation of why we don’t provide CAM and a willingness to continue managing overall care even if the patient insists on using CAM. Tolerating without condoning.
Isn’t it a bit paternalistic to claim that you know what is in a potential CAM users” best interest”?
I am sorry to have to tell you that they may also be listening politely while not being very interested in your opinion — they probably already know it in spades — the Internet is awash with caricatures of it. They are also not that interested in the science when the carrot of feeling a lot better is dangled before them. . They have heard that something works for their condition and would like to try it, and often before they take on the risk of may be unnecessarily powerful and risky pharmaceuticals for the specific complaint.
The real pain in the neck for SBM is that they are more likely than not going to later express considerable satisfaction with whatever CAM they decide to use (when for many common complaints).
That is a paradox that we might have learnt to better deal with by now if we had at the very beginning asked explored “why do people use CAM, and what do they get from it?” rather than leaping to the conclusion that because “it can’t work” it does nothing at all for users. That has led us into the rather quixotic task of trying to explain to the not-very-interested why “it can’t work”, while one windmill after another increases the complexities of the material we have to expound in order to try and justify that statement.
Whereas everyone understands that people can feel a lot better through psychological inputs.
Kimball, I am still considering your closely reasoned response. In the meantime I note that you never responded to this comment of mine in response to one of your pieces that you link to. Would you like to do so now? Try and look at it as as a factual matter independently of any consideration of the implications for mainstream medical practice. I am not suggesting wholesale changes in policies relevant to that.
Quote –
Kaptchuk: A major shift had occurred. A medical intervention was now scientifically justifiable only if it was superior to a placebo: method became more important than outcome.
An outlandish assertion to most doctors. But Kaptchuk is proposing a tenable hypothesis that raises this exact point.
Along with Andrew Weil, the homeopath Peter Fisher (I think), Moerman, and others he is toying with a fairly plausible, modestly supported scientific hypothesis — i.e. that CAM is well-suited to helping some kinds of patient with some conditions* via enhanced placebo influences.
While placebo-controlled RCTs rightly provide a logical foundation for most modern medical practice, is it not obvious to all that they are not designed to answer that question? They ask only (usually) “does this treatment have intrinsic therapeutic activity?.”
They provide no information at all about what is going on in the placebo group or about “placebo potential” in its broadest sense.
In fact, no simple clinical trial design can do so unequivocally because of the difficulty of mimicking real world factors governing psychological responsiveness to non-specific aspects of medical attentions, including cultural factors, patient selection and self-selection and the fact that any way of trying to enhance placebo influences is likely to also increase patient reporting biases.
So when these persons say “you need to look at our methods differently” they are not necessarily invoking post-modernist views of science, seeking a double standard, or challenging the logic of modern medical science.
We, in fact, DO need to look at them differently if we are to find evidence that would directly refute or support the specific hypothesis.
(*The “some patients with some conditions” in the above is, I admit, my qualification, as these authors typically speak in broad generalities, rarely ever specifying exactly what their methods do or don’t do in terms of human symptoms and patho-physiology.
If we allowed ourselves to get into a proper dialogue with them we may be able to persuade them to start setting such limits. That is where patients mainly come to grief, when they are allowed to seek extremely improbable outcomes.)
PS Oh, and it is not that the placebo controlled trials have not been of value in the above scenario. They have forced upon CAM the need to find different explanations for what they believe they are observing in their patients.
@pmoran,
“patients deserve better than sugar pills, when we’ve got something obviously better to offer.”
So if we don’t have something better to offer, we should pretend we do have something better to offer and trick them? I don’t think so!
“Isn’t it a bit paternalistic to claim that you know what is in a potential CAM users” best interest”?”
Isn’t the truth always in their best interest in the long term? Isn’t it more paternalistic to unilaterally decide that honesty is not the best policy? Aren’t you trying to justify questionable actions under the guise of clinical judgment?
“if we had at the very beginning asked explored “why do people use CAM, and what do they get from it?” rather than leaping to the conclusion that because “it can’t work” it does nothing at all for users.”
Straw man. I think we know very well why people use CAM and what they get from it, and we have discussed it on this blog. We have never claimed that it “does nothing at all.” We have said that its nonspecific effects create perceptions of short-term, subjective improvements. We have said that is not enough to justify using it.
“They have heard that something works for their condition and would like to try it,”
If a clinician can’t deal with that reality appropriately without alienating the patient, he needs to improve his skills.
So if we don’t have something better to offer, we should pretend we do have something better to offer and trick them? I don’t think so!
Medical practice is always a cooperative collusion between doctor and patient, with both parties imposing requirements and restrictions on the interactionn. There is no reason at all why that should not sometimes include a bit of “let’s pretend” or “let’s try this out” or asking “gee, where do we go from here?” or anything else that satisfies the complicated set of needs that different patients bring into medical interactions.
A good doctor working within a sound medical system knows his patient very well before such matters ever arise and he will adapt to that knowledge (which is much the same thing as you are saying).
“if we had at the very beginning asked explored “why do people use CAM, and what do they get from it?” rather than leaping to the conclusion that because “it can’t work” it does nothing at all for users.”
Harriet: Straw man. I think we know very well why people use CAM and what they get from it, and we have discussed it on this blog.
I am not sure how you can say that. I have read it all. Casual readers of most of the articles and comments on this blog would derive the impression that CAM is believed to be mostly due to sinister political and commercial forces manipulating a passive, insouciant public, also that it would very probably be banned if that was politically feasible.
I believe I am the only one ever to to refer to at least equally important factors: the almost irresistible pull of the personal testimonial, the unmet medical needs and the compulsiveness behind much medical consumption.
HH We have never claimed that it “does nothing at all.” We have said that its nonspecific effects create perceptions of short-term, subjective improvements. We have said that is not enough to justify using it.
We shouldn’t “use it” as a general policy for a variety of reasons, NOT because we have a secure handle on on the potential of non-specific influences as the above mantra suggests. There IS evidence for strong, and even some enduring responses to some CAM treatment programs, including ones that may rival commonly used FDA-endorsed drugs. If that evidence firms up we will have a very tricky job explaining it away.
Certainly no published study precludes strong responses under the right conditions, especially at an individual level.
@pmoran “There is no reason at all why that should not sometimes include a bit of “let’s pretend”
Let’s pretend means let “us” pretend; it is only ethical when both parties know they are pretending.
“the impression that CAM is believed to be mostly due to sinister political and commercial forces manipulating a passive, insouciant public, also that it would very probably be banned if that was politically feasible.”
That isn’t incompatible with a compassionate understanding of why patients use CAM.
“no published study precludes strong responses under the right conditions, especially at an individual level.
Without evidence, there is no way to predict that an individual will have a response contrary to the evidence from clinical trials, but we can be reasonably sure such responses will be few and far between, because if they were common, it would have shown up in the statistics. The alternative to going by published evidence is to feel free to individualize treatment by just making stuff up, which is exactly what many CAM providers do.
“no published study precludes strong responses under the right conditions, especially at an individual level”
Harriet: Without evidence, there is no way to predict that an individual will have a response contrary to the evidence from clinical trials, but we can be reasonably sure such responses will be few and far between, because if they were common, it would have shown up in the statistics. The alternative to going by published evidence is to feel free to individualize treatment by just making stuff up, which is exactly what many CAM providers do.
Again, framing the question as “what does this matter for what treatments doctors provide/endorse”? It’s our intensely proprietary attitude towards medicine again. The question on the table for me is “what do users get out of CAM?”
One reason we need a clearer answer to is that question is that the more we minimise the “incidental” aspects of medical attentions, the ones that are obtainable anywhere with any well-meant medical attentions, or that may sometimes demand the right key to an unusual lock, the greater the need for us to portray positive outcomes from CAM as being due to people either being foolishly misled or lying about the purported benefits.
This, in my view, despite highly suggestive evidence and considerable plausibility to such outcomes.
So this has public relations implications, as well as involving a challenging exercise in understanding our own science and craft. Others can see it, but we don’t, because it is a subtly different way of looking at the evidence and implies that we, the supreme interpreters of all that is scientific are missing something.
We need, as Kimbal says, to examine our premises more carefully. That should be next.
@pmoran,
“our intensely proprietary attitude towards medicine again. The question on the table for me is “what do users get out of CAM?”
Proprietary attitude? Come on! It’s not a matter of who owns health care, it’s a matter of what treatments are effective and non-deceptive. We are all asking what users get out of CAM and I think we have a pretty good idea. The question for me is “How can we give the patients the same things they get out of CAM while treating them in the context of science-based medicine and honesty?” And I think a partial answer is to spend more time with patients, communicate better, and improve our understanding of psychology.
“the greater the need for us to portray positive outcomes from CAM as being due to people either being foolishly misled or lying about the purported benefits.”
Straw man again, although I suppose some readers might get that impression. I think we all acknowledge that apparently positive outcomes are due to well-known psychological and social factors that affect all of us, not just the foolish. CAM providers may lie and mislead, but I think it is more common for them to sincerely believe in what they do.
“a subtly different way of looking at the evidence and implies that we, the supreme interpreters of all that is scientific are missing something”
What does it mean to have “a different way of looking at the evidence”? What exactly are scientific interpreters missing? Do you think you know of something better than the scientific approach, or are you saying that some of us are not using a properly scientific approach?
[...] week, I discussed a rather execrable study. Actually, the study itself wasn’t so execrable, at least not in its design, which was a [...]
Harriet:What does it mean to have “a different way of looking at the evidence”?
There is an example above in my post to Kimbal concerning Kaptchuk’s “enhanced placebo” hypothesis.
In relation to placebo potential in general, even Hrobjartssson seems to be coming to understand some of the limitations of his systematic reviews of studies comparing placebo to “not treatment” groups. (His is the data always referred to as showing that placebo influences are small or due to bias.)
Quote–
“It is a question of definition whether the effect of a placebo intervention equals the ‘placebo effect’, as this term is sometimes also used for other aspects of the patient–provider interaction, for example psychologically mediated effects in general, the effect of suggestion, the effect of expectancies, the effect of patients’ experience of meaning, etc. [3]. Patients in a no-treatment group also interact with treatment providers, and the patients are therefore only truly untreated with respect to receiving a placebo intervention. Hence, our results do not exclude the possibility that other aspects of the patient–provider interaction, or interactions between the treatment ritual and different ways of informing patients, could have clinically useful effects.”
http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2796.2004.01355.x/full#t1
Which is basically what I have been saying.
Do you think you know of something better than the scientific approach, or are you saying that some of us are not using a properly scientific approach?
Fair questions. It’s a patchy thing. The opinions and attitudes expressed here are most of the time informed by a highly sophisticated and rigorous application of indisputable scientific principles and reasonable interpretations of the evidence. At other times, usually when the comments involve having some understanding of CAM and why people use it and how best to try and deal with its dangers, not so much, in my opinion.
It is assumed that our first, and least CAM-favorable knee-jerk reactions must be right because, after all, we are the scientists here. I have given quite a few examples where conventional skeptical wisdom can be seriously challenged. There are also internal inconsistencies in some stances.
I should say that I don’t claim to be better at anything than anyone else here. The only difference is that I am, I believe, completely free of bias (where undeserved).
@pmoran,
If patients in the no-treatment group are interacting with providers, the data are contaminated. A more accurate comparison would be with patients awaiting treatment who have not yet interacted with providers. These are details of experimental design and ruling out possible confounders, not “a different way of looking at the evidence.”
“It is assumed that our first, and least CAM-favorable knee-jerk reactions must be right”
Straw man. We try not to have knee-jerk reactions, and are always ready to revise first impressions in the face of evidence.
“I am, I believe, completely free of bias.”
I don’t believe you or I or any human is completely free of bias.
I think SBM authors are biased in favor of scientific rigor; I think this is a good thing. It enforces a kind of disciplined critical thinking that is hard for humans to achieve.
It’s been my experience that those who claim to be free of bias tend to be the most biased. This seems to be due to them not realizing their biases, and consequently being unable to try and compensate for them.
Anecdotal and non-rigorous, of course, but food for thought.
“On the other hand these methods will never be presented to the public in such a way as to support the shonky theories. The message will be “these methods may help some patients via psychological and incidental aspects of the care provided, but they should NOT, NEVER EVER, be relied upon alone for the treatment fo serious diseases.”
First of all, I assume you mean that you will not present them to the public in such a way as to support the shonky theories. I’m not sure how you can be so sure what others will do.
Also, presenting the modality at all inherently supports and lends credibility to the shonky hypothesis. How do you expect your message on CAM modality X to trump the message on CAM modality X from the people who have been promoting and practicing it since “ancient times”, when you yourself have said, “They are also not that interested in the science when the carrot of feeling a lot better is dangled before them.”. I still maintain that what is likely to happen is nearly the exact opposite of what you think. It’s not as if we don’t already have various CAM modalities and mind-body medicine being promoted for all sorts of serious conditions (including cancer), often by MDs.
How can you prescribe acupuncture or a homeopathic remedy and expect your patients to understand that the underlying philosophy isn’t really not valid, even though it appears to work when many supposedly skilled researchers and MDs can’t even figure that out?
“I need convincing that this more moderate (but likely more accurate) description of the true scientific position will [not] reveal the medical profession in its proper role of having the interests of the patients as its first concern no matter what.”
And I need convincing that any avocation of pseudoscientifcally based modalities won’t lead to acceptance of the underlying philosophies and broader application of said modalities.
“a lot of patients are looking around for doctors who are prepared to go along with their CAM use an I would prefer that they remained under the care of a proper doctor than an ND, chiropractor or TCM practitioner.”
And apparently you think that proper doctors can co-opt various CAM modalities and steal them away from CAM praticioners such that most people don’t go to CAM providers any more. I think this goal is more difficult than convincing people that CAM doesn’t really do anything. I could also make a comment about where the best place for a heroin addict or anabolic steroid user to get their supply from would be.
“But, I am working from the observation that these methods are mainly used where mainstream treatment is lacking. CAM usage is an approximate mirror image of mainstream medicine’s effectiveness. It is an attempt to fill in gaps and perceived gaps.”
So what do you do if a new, genuinely effective treatment does come along? When does it become unethical to keep using the placebo, and how do you contain the placebo-CAM in your defined realm?
“They have heard that something works for their condition and would like to try it, and often before they take on the risk of may be unnecessarily powerful and risky pharmaceuticals for the specific complaint.”
…And on the other hand, we have the people who are more likely to follow the advice of their physician when they know they can trust what the doctor is telling them and recommending for them. I have a hard time respecting a physician who prescribes an antibiotic for a cold or the flu just to make me happy. Maybe I’m seeing the doctor just to make sure it’s not something more serious, and I don’t need a knee jerk placebo to make me feel like they’re helping me.
Also, at what point does the placebo-CAM become the de facto first line of medicine by the physician? I have a whole blog post I’ve been way to lazy to write about health insurance companies using CAM as a way to control costs that if I had ever gotten around to writing it would have been inspired by a program recently introduced by my insurance company.
Also, you seem to have moved from placebos for thing for which their is no effective treatment to placebos because someone may not want a genuinely effective treatment for various reasons: Already we have scope creep of when it may be ethical use placebo-CAM.
If patients in the no-treatment group are interacting with providers, the data are contaminated. A more accurate comparison would be with patients awaiting treatment who have not yet interacted with providers.
That’s impossible. The essence of a properly controlled trial is knowing that the patient populations are comparable. You cannot do that without preliminary patient assessments and, presumably, reassuring the waitlist group that proper treatment will soon follow.
These are details of experimental design and ruling out possible confounders, not “a different way of looking at the evidence.”
The one you selected is. There are hints of a significant conceptual change concerning the placebo, a shift from the old vision of it as a more or less stable, easily measurable, constant wittin medical interactions towards it varying greatly depending upon how patients are informed and treated otherwise and what influences you care to include or exclude under that name.
What does my challenging of fondly held skeptical opinions signal other than a lack of bias against CAM? I am savagely opposed to certain other claims of CAM but that is because I can more clearly see their lack of merit.
Karl you may be right in your predictions concerning bad consequences from tolerating CAM in limited ways. I don’t know.
But this conventional skeptical attitude is also not obviously wholly right tactically. Violent attacks on CAM, even in its silly but relatively harmless guises such as “energy chelation” gives us that buzz of justified scientific outrage, but it also exaggerates the importance of flummery that most of the public would think is a bit of a giggle, entirely without our help. Sections of the media and even the sitcoms now treat this New Agey stuff as a joke.
It may even be counterproductive if what looks like disproportionate concern about pretty innocent medical pastimes is misinterpreted as turf protection, or the urge to control or suppress measures that some people are claiming to give them relief wihtout harm from difficult to treat and unpleasant conditions such as fatigue in cancer survivors.
The public will understand that it may all be placebo and incidental influences even if we, for a variety of sound reasons, are required to remain focused solely on the physicochemical aspects of therapeutics.
.
“What does my challenging of fondly held skeptical opinions signal other than a lack of bias against CAM?”
A subtle bias against SBM.
@pmoran,
“you may be right in your predictions concerning bad consequences from tolerating CAM in limited ways. I don’t know.”
You don’t know.
And yet you presume to know that our approach has bad consequences.
And you misrepresent our position as an absolute refusal to tolerate CAM in limited ways. (I, for one, am willing to tolerate it as long as patients are not lied to.)
And yet you claim to be free of bias. I think you have demonstrated that you are not.
I would argue that it’s not so subtle, at least when it comes to proponents of SBM. For all his hammering of me for using “loaded language” against CAM, Peter’s no slouch, as I’ve mentioned time and time again, at using more than a bit of loaded inflammatory language against us. To Peter, our attacks on CAM are “violent,” as though we’re about to go out and grab CAM practitioners out of their offices and beat them with truncheons. To Peter, we get a self-satisfied “buzz” of “justified scientific outrage.” We “exaggerate” the importance of flummery. We’re “intolerant.” We assume that our “least CAM-favorable knee-jerk reactions must be right.” We have an “intensely proprietary” attitude towards medicine.
Peter, I submit to you that your bias against SBM apologists (yes, I’m using that word proudly) is not subtle at all. It’s quite blatant and obvious, at least to me. You spend far more time attacking SBM apologists and making excuses for CAM apologists than you do criticizing CAM pseudoscience. Your criticisms of CAM are almost always followed by a “but” which is then followed by an attack on those who argue against CAM too stridently for your apparent liking.
Ah, just when I was planning to leave this for now.
It’s not bias if the statements contain some truth, and it is a a sign of immaturity to be so unwilling to accept criticisms of this nature, especially when it is clear that public perceptions are so crucial to whatever influence we can exert. I have previously gone to some lengths to show how certain commonly expressed public viewpoints necessarily imply zero tolerance for CAM.
So I suggest again that there IS a profound public intolerance of all things CAM even if there is a somewhat hypocritical and begrudging preparedness to yield to patient autonomy in private consultations.
Moreover, following on the Karl interchange, I am fairly sure any PR firm would also be advising us to capitalise upon prevailing more sensible public perceptions concerning CAM, rather than trying to browbeat the waverers with scientific esoterica or influence them via character assassinations of people who may look to them to be quite well-meaning.
In my last post I admitted that “I don’t know” something, but even that admission was appalling misused by Harriet so as to tyr to make make a fairly temperate comment look like a “presumption to know”. So I was going to suspend this dialogue for now.
And, apparently, SBM advocates are now “immature” for pointing out the flaws in criticisms directed at us, not to mention that apparently we “appallingly misuse” admissions, as well. You’re making my case for me better than I can even make it myself, Peter. Ah, well, I guess that not all of us can have the saint’s patience that you apparently do. Except when you don’t.
From my perspective, though, it’s “appallingly” naive of you to argue that you can’t be biased just because you think your statements contain some truth. Do you think that most people who are biased aren’t using at least some truth in their arguments? Given that we’re in the heat of the Presidential election here in the States, I’m reminded every day that that it is not true that “truth” does not equal “biased,” given that it’s how such “truth” is told that reveals the bias. Politicians, for example, are clearly biased but there is often some truth in their public utterances. Of course, their truth is very selective, with information chosen to support their bias.
No, I”m not accusing you of being as biased as one of our Republican presidential candidates. I’m merely using this example to illustrate the speciousness of your retort. Using your logic, for example, Mitt Romney and Newt Gingrich are not biased when their statements happen to contain some truth.
Sadly, between moving in to a new place that still needs the majority of its furnishings, the long awaited and delayed arrival of my significant other, beginning my first rotation in a new hospital, and managing my duties to the students and faculty as Academic Officer of my cohort I have not had the time to sit and contribute to this conversation.
It has nonetheless been extremely interesting and enlightening. And forgive the inevitable “pile-on” nature of the following comment, but sadly brevity demands it: I must continue to side with the authorship here and further comment that Peter’s stance is indeed shaky. One point I will take a second to add to is that indeed, Peter consistently critiques primarily on the PR aspect of what is said here as a distinct negative and claims to be free from bias, yet consistently chooses rhetoric that is in itself an inflammatory PR disaster, as Dr. Gorski pointed out.
Also, I can’t help but notice that Peter has not yet managed to respond to Dr. Atwood’s riposte. It was, in my opinion, an excellent response – one of a calibre I aspire to match…. and as such remains unanswered. (In particular the third paragraph).
Nybgrus:Also, I can’t help but notice that Peter has not yet managed to respond to Dr. Atwood’s riposte. It was, in my opinion, an excellent response – one of a calibre I aspire to match…. and as such remains unanswered. (In particular the third paragraph).
Nybgrus, “pile on” all you like.
I have, above, indirectly responded to Dr Atwood’s “riposte” by giving him an opportunity to think again about Kaptchuk’s hypothesis of enhanced placebo influences. That is what he was mainly disputing. He did not respond when I submitted that months ago, nor yet to my resubmission of it.
Since you ask for a direct response, this is Kimball’s main point —
“Your argument is not logically sound, however, because the premise is shaky. We’d all agree that there is something about interacting with a reassuring ‘healer’ (whether real doctor, quack, or some hybrid thereof) that, all by itself, makes some people feel better. This is not news and it happens automatically, no matter what diagnostic methods or treatments, including none, may follow. We don’t know, and we may never know, whether this effect can be substantially enhanced by some purposeful strategy. That is the hypothesis, not the conclusion, of ‘placebo research’ to date (I know you know this, because you’ve written it many times). Thus none of it currently justifies real doctors embracing “CAM,” or fake doctors being taken seriously by real doctors, medical schools, governments, etc. At best it justifies placebo research, but even that has been, like most things in this postmodern world, overhyped. “
This is placebo envisaged as a more or less constant, but probably insignificant undercurrent within medical interactions.
But that is a strongly challengeable concept of placebo. It is held despite the inherent unlikelihood that a psychological influence would be so “automatic”, or so evenly active over different patient types, conditions and practitioners, aslo despite other evidence of profound effects of psychological influences upon some kinds of illness. One of our very own “placebo dismissers” even states “I have long realized the importance of what we referred to as a resident as the supratentorial component of illness.”
More recently, studies (many discussed here) are suggesting that placebo responsiveness can be titrated up or down merely by manipulating patient perceptions and modifying other aspects of medical interactions, just as you might expect!
As I indicated in a response to Harriet above, Hrobjartsson er Al, by far the most quoted authors in dismissing placebo influences, have found that studies of large size and equal quality are producing substantially different “effect sizes” of placebo over “no treatment” groups, leading even them to have to allow that placebos “could have clinically useful effects”. It is only when pooled together that the net effects are small enough to approach the disregardable (or attributable entirely to bias? — hard to say, when biases will be increased by the same influences).
Those different outcomes in seemingly similar studies are understandable if placebo responsiveness is as sensitive to various incidental influences as the other studies suggest. The modest overall (pooled) “effects” in such studies can also be easily explained by dampened patient expectations in presumably properly informed clinical trial subjects.
We also now have evidence from more laboratory-style studies that suggestion can reduce the effect of active pharmaceuticals as well as the need for them (e.g. for morphine in severe pain, as Beecher first showed sixty years ago).)
So whose premise is more likely to be wrong? Why am I the obvious villain here, when it can be argued that all of SBM was making far more dogmatic assertions about the placebo without even being up-to-date with, or having critically evaluated the relevant evidence?
Can we reach any agreement on this, before getting into the even more complex areas of the implications for various aspects of medicine?
@Peter,
It is only now that I’ve noticed that you’ve been waiting for a reply from me–apologies.
I never answered your previous statement (in another thread) because I hadn’t interpreted it as a question; I thought that it was simply a statement of your opinion, not requiring a response from me. In any event, my response is mostly included in my post about Kaptchuk and placebos: http://www.sciencebasedmedicine.org/index.php/dummy-medicine-dummy-doctors-and-a-dummy-degree-part-2-2-harvard-medical-school-and-the-curious-case-of-ted-kaptchuk-omd-cont-again/
In summary: even if placebo effects vary by the nature of the interaction, including the attitude of the practitioner, the presence or absence of an invasive procedure, etc., placebos will never be more than modest symptom-improvers, temporary for things that don’t get better (chronic pain, etc.) and without any real effect on natural history of diseases. What makes this so obvious is that all of medicine was placebo–in all of its conceivable manifestations–until very recently. All of that placebo was characterized by two outcomes: all patients and practitioners were entirely convinced that their ministrations worked; they didn’t work for what was important.
We’ve known this for decades, if not centuries. Why should some corners of the medical profession suddenly think of it as news? Merely because a pretend-doctor, taken seriously for silly reasons, is just figuring that out for himself?
@Peter,
Sorry, I was in a hurry before and couldn’t finish. To finish: even if it turns out that “placebo responsiveness can be titrated up or down merely by manipulating patient perceptions and modifying other aspects of medical interactions,” which I agree that it probably can, that remains the hypothesis, not the conclusion, of placebo research to date. “Placebo envisaged as a more or less constant, but probably insignificant undercurrent within medical interactions” is still the standard, as it were, and the use of “CAM” to elicit ‘enhanced’ placebo effects is yet another leap beyond the not-yet-realized body of literature that could convince us of the reality of predictably titrating placebo up or down by various ministrations.
Therefore: to suggest to the public that real doctors ought to take “CAM” treatments seriously–right now–as anything other than one of several bases for thinking that there may be some use to investigating placebos–a la Benedetti, not Kaptchuk, I’d argue, both because clinical trials are nearly impossible to purge of responder biases and because Kaptchuk faked his ‘doctorate’ and has written reams of pseudoscientific garble, and thus can’t be trusted not to do other deceptive things–is premature at best. It remains perfectly reasonable–no, a virtual ethical requirement–for real doctors to call “CAM” claims what they are: quackery. Even if some people swear by them. Remember, some people have sworn by every ‘healing’ claim that has ever existed. I don’t think you’re the villain here for predicting that the titration of placebo responsiveness may become a reality. I think that you are using that opinion to argue for other things that don’t, yet anyway, follow.
BTW, some time ago you wrote (can’t remember when) that in your opinion, the rise in “CAM” popularity over the past several years demonstrates that the dismissive attitude of SBM types has been counter-productive. I can’t remember why, but I never responded to that. In my opinion the truth is essentially the opposite: if SBM types had stuck to their guns beginning in the late ’80s or so, and continued to call quacks “quacks,” I doubt that “CAM” would have gained the grotesque foothold on real medicine that it has been able to do. That was one of the points that I was trying to make in this old post: http://www.sciencebasedmedicine.org/?p=62
I reiterate that medicine’s “CAM” credibility problem is overwhelmingly one of appearing to give implausible claims much more credibility than they deserve, not the other way around. I also wonder what you think of my occasional references to real disasters that have occurred as a result of this, such as the NIH having funded the terrible TACT trial–in which at least two subjects have died because of incompetent care given by the quacks who are among the investigators–after the know-nothings on the NCCAM Advisory Committee, including Kaptchuk (who praised the placebo in so doing) voted nearly unanimously to go ahead with the trial.
@Peter,
To be more precise about my second sentence above: I agree that placebo responsiveness will vary IN SOME PEOPLE and according to the nature of some ministrations, but I am far less certain that this can be “titrated up or down” in a predictable way or that it will be possible to accurately predict which people will respond to such schemes. Such predictable titrations and recipients, of course, would be necessary in order for the phenomenon to offer a distinct improvement over the haphazard placebo effects that we have now and have always had.
Thanks, Kimball.
You do allow for the existence of placebo influences and I am confident that the kind of studies that are being performed now will eventually convince you of their “titratability”. I, too, don’t expect that to be very predictable at the individual level but it is also at the individual level that the most dramatic outcomes are likely to be evident. Part of the importance of all this lies in the accurate interpretation of the CAM testimonial.
If, OTOH, we think that palcebo “responses” can all be explained by bias, we should as a matter of urgency find some way of showing that; I can’t see this challenge going away simply because we say so — as I keep saying, even the man in the street suspects that people can think themselves into feeling better or worse. Our main task is point out there are serious limits to what placebos can do, which everyone also can understand in their more rational moments.
With regard to other implications of placebo influences, there are valid reasons why placebo influences cannot be exploited in any systematic way within the mainstream medical system. I wish everyone would stop telling me that or assuming that I am wishing to promote anything majorly different.
Yet that in no way diminishes the potential value of placebo influences elsewhere within our intensely consumerist and pluralistic medical system (i.e. mainstream vs over-the-counter, folk, hobbyist, spiritualistic medicine, and of course, “organised” CAM).
We can’t make any of these “alternatives” go away, and unlike you, I don’t think anything could have stopped any of it. We may however be able to shape it in such a way as to preserve any medical usefulness while minimizing the obvious risks. The best ways of doing that may not be the instinctive ones — in part, again, because of the quirks of human psychology and the complexities of some kinds of medical need.
Sticking ruthlessly to what the science shows, or permits, would be a good start. Otherwise we will be found out in embarassing ways, for example should placebo-type CAM be able in some hands match or outperform commonly employed conventional approaches with weak effects or low benefit-to-risk ratios. The usual “working better than placebo” concept forbids that, whereas it becomes theoretically possible under enhanced placebo theory.
@pmoran,
“If, OTOH, we think that placebo “responses” can all be explained by bias”
Does anyone think that? I doubt it.
I don’t think we should “shape it in such a way as to preserve any medical usefulness.” I think we should dissect out any part that is medically useful and find ways to use it without the CAM.
“should placebo-type CAM be able in some hands match or outperform commonly employed conventional approaches with weak effects or low benefit-to-risk ratios.” It does. That’s the essence of the the problem with pragmatic studies that I wrote about here: http://www.sciencebasedmedicine.org/index.php/pragmatic-studies-and-cinderella-medicine/
“enhanced placebo theory” – what do you mean?
“the accurate interpretation of the CAM testimonial.” And just how do you think we are inaccurately interpreting those testimonials?
Harriet: “If, OTOH, we think that placebo “responses” can all be explained by bias”
Does anyone think that? I doubt it.
That is getting to be the only reasonably tenable position from which to reject the possibility/likelihood of enhanced placebo “effects” (within the usual limitations, not as per the CAM fantasies David described). It was also how Hrobjartsson et Al were inclined to initially interpret their findings. IIRC, STeve Novella and others here have suggested something approaching that. I know you don’t share this view.
HH I don’t think we should “shape it in such a way as to preserve any medical usefulness.” I think we should dissect out any part that is medically useful and find ways to use it without the CAM.
Why not do both since we are forced to coexist with CAM for the forseeable future? The science permits us to say “these approaches can probably help many people feel better, but they cannot be relied upon in serious illnesses”.
That neutralises in a few simple words 90% of the arguments used by CAM to explain away our inability to embrace CAM. It is displaying tolerance while also a more easily understandable concern for patient welfare where it really matters.
We still have solid arguments against the public funding of CAM, and the teaching of pseudoscience in medical schools. They are merely less dependent upon the semantics of the word “works”, and upon scientific esoterica, and they are less likely to provoke the stark conflicts of opinion that can lead to compromises being made where there should be none.
HH “should placebo-type CAM be able in some hands match or outperform commonly employed conventional approaches with weak effects or low benefit-to-risk ratios.” It does. That’s the essence of the the problem with pragmatic studies that I wrote about here: http://www.sciencebasedmedicine.org/index.php/pragmatic-studies-and-cinderella-medicine/
That is an excellent account of the factors that can contribute towards enhanced placebo “effects”. They help explain the results of some studies to the detriment of CAM theory, but what do they mean for the user and hence for rational, humane attitudes towards CAM?
HH “enhanced placebo theory” – what do you mean?
What you have described yourself.
HH “the accurate interpretation of the CAM testimonial.” And just how do you think we are inaccurately interpreting those testimonials?
That wasn’t an accusation of anything. Placebo potential obviously influences whether people may genuinely feel better from CAM use and why they might.
@pmoran,
“HH I don’t think we should “shape it in such a way as to preserve any medical usefulness.” I think we should dissect out any part that is medically useful and find ways to use it without the CAM.
PM “Why not do both since we are forced to coexist with CAM for the forseeable future?”
Why should we have any involvement in trying to “shape” CAM? We can co-exist with it without joining it.
“the stark conflicts of opinion that can lead to compromises being made where there should be none.” Are you saying a rigorous SBM approach leads to compromises? I thought a less strict approach would be more likely to lead to compromise.
“HH “enhanced placebo theory” – what do you mean?
PM What you have described yourself.”
I described some of the factors that contribute to placebo response. I see no use for the word “enhanced.”
As Dr. Atwood stated, this is indeed correct, but that is the hypothesis, not the conclusion. Challenge it all you like – I agree that the challenge is reasonable and indeed likely true. The degree to which it is true is completely open at the moment. Thus advocating for some sort of “enhanced” placebo effect that can be better induced via CAM practitioners is still very much putting the cart before the horse.
Indeed. Exactly as I would expect myself. I won’t rehash what Dr. Atwood said since I agree with him, but I also think that there does and should exist a mechanism by which to titrate placebo effects. How to apply those, what the effect sizes are, if they will have a lasting effect, if they can actually be used to alter the natural course of any disease process, and if any of that can be done ethically (whether that means within the current construct of social and medical ethics or via a necessitation of augmenting the construct to accomodate new legitimate breakthroughs in this field) are wholly unanswered. As of right now, however, it is clear that the induction of placebo effects as a stand-alone therapeutic modality by anyone, but especially CAM practitioners, delivers none of these positive outcomes in any meaningful way.
I also agree that placebos could have clinically useful effects. I disagree that they can do so outside of actual medical care or as stand-alone therapy. I am ready to change my mind on the latter assertion should that become warranted by evidence and allowed by ethical considerations. However, as it stands now, there is no clinical applicability of placebo effects in actual medicine and it is certainly not a viable crutch for sCAMsters to lean on.
You aren’t the villian here. You are also re-iterating a lot of what the SBM authorship and myself already know and agree with. It is your extension of this and application of it that we disagree with. Getting to the right answer by accident is almost as bad as getting the wrong answer. And the very premise by which these CAM modalities means that any answer they get is going to be by accident. It is that which we stringently dismiss. Not the actual utility of placebo effects on our patients and how that may currently and in the future apply to our clinical practice. The reason you are oft labeled the “villian” as you say is because you genuinely (whether you realize it or not) come across as advocating for the acceptance of CAM modalities based in purely placebo effects via accident as a reasonable adjunct to actual medical care.
So yes, for the most part I agree with you factually. It is the implications of these facts and the extent to which they apply that you and I disagree on.
So can we agree that everyone here understands there are indeed legitimate placebo effects beyond study biases but that their utility is the hypothesis of future research, and not the conclusion by which are are to base clinical practice?
Moving on…
And there’s the rub. If it is truly unpredictable, and we must violate some medical ethics (autonomy, informed consent) to get any response, then it becomes a useless therapy, despite the fact that some people may benefit enormously from it. Placebo is not the only therapy to fall victim to such a fate. But once again, we need actual data to determine the extent of it all.
Dr. Hall and I were both confused here. I can only take it to mean (in context) that the CAM testimonial of efficacy may be an instance of that high variability in which that person did genuinely experience an objective benefit from said CAM placebo. Unfortunately, that is of little use, since the resolution of scientific inquiry cannot (at least for the foreseeable future) allow us to determine whether that is the case or not. As such, it makes for an interesting question to hopefully be answered in the future.
There are many ideas that Hollywood and the popular media have planted in the heads of people. That doesn’t mean it is our responsibility to bend to it.
I agree. However, how that is framed is vital. In the case of this article in question, we can unequivocally say the EC did not work, since it did no better than placebo. If the authors of the article wanted to go on and say something to the effect of “EC is total BS, but we can see that placebo interactions may have some benefit for fatigue. As such we can reasonably recommend stress relief and more patient contact during chemotherapy as a useful adjunct” that would be, IMO, a very acceptable conclusion. The point is that this data all demonstrates that the medical field should find ways to give patients more time and attend to their non-physical symptoms as well. The first is a systemic problem. The second can be easily accomplished via a non-mysitical inclusion of “spa day” type activities. Perhaps a study comparing that to things like Reiki and EC would be useful. My guess is that it would elicit the same clinical effects. The point being that the conclusion cannot be one that advocates the use of EC or Reiki since it is NOT the EC or Reiki that effected the changes!
Then let your rhetoric reflect this. If even Dr. Hall is consistently snowed by your rhetoric into incorrectly believing that is what you are advocating, it would behoove you to turn the light towards yourself and inspect how you come across. Consistently blaming everyone else over the course of quite some many months means you are usually wrong. As the old adage goes, when everyone else is crazy, maybe you are the crazy one.
How often is the notion of 4 humors used? How about trepany? Of course ideas will never completely go away, but through increasing education they can certainly fade into complete obscurity.
As Dr. Hall said – it is not our role to shape CAM at all. It is to demonstrate why it is wrong and what it actually is. The shape must then form on its own. Just as Richard Dawkins won’t debate creationists since it is pointless and only serves to give them legitimacy, the same can be said for genuine medical scientists and CAM. Studying EC as an energy biofield therapy, no matter what, lends creedence to that notion.
I myself, and I don’t think any of the authorship here (save perhaps Dr. Crislip) believe that all placebo effects can be explained away by study biases.
I agree. However, see the above about genuine medical scientists handling CAM.
@pmoran,
“HH I don’t think we should “shape it in such a way as to preserve any medical usefulness.” I think we should dissect out any part that is medically useful and find ways to use it without the CAM.
PM “Why not do both since we are forced to coexist with CAM for the forseeable future?”
HH: Why should we have any involvement in trying to “shape” CAM?
I think it is our public health duty, for the same reasons that we encourage healthy life-styles and discourage smoking.
HH We can co-exist with it without joining it
Who said “join” it?
HH “the stark conflicts of opinion that can lead to compromises being made where there should be none.” Are you saying a rigorous SBM approach leads to compromises? I thought a less strict approach would be more likely to lead to compromise.
I had in mind presenting decision-makers such as politicians with unresolvable contrary opinions that make them look for a middle ground, while other possibly better arguments are left unsaid.
HH “HH “enhanced placebo theory” – what do you mean?
PM What you have described yourself.”
HH I described some of the factors that contribute to placebo response. I see no use for the word “enhanced.”
How about “enhancements”, as in this extract –
“So acupuncture, with no specific effects but many nonspecific treatment effects, will appear to outperform a standard treatment that offers some small specific effects but little in the way of nonspecific enhancements.”
This is all that “the enhanced palcebo” means (to me, anyway).
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