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Misleading Language: the Common Currency of “CAM” Characterizations Part II

Background

I promised readers the “Advanced Course” for this week, which undoubtedly has you shaking in your boots. Fear not: you’ve already had a taste of advanced, subtle, misleading “CAM” language, and most of you probably “got” it. That was R. Barker Bausell’s analysis of how homeopathy is “hypothesized to work.” In the interest of civility, let me reiterate that I don’t think of Bausell as a horrible person or an ignorant boor for having written that statement. Rather, I think of him as having been so steeped in the de rigueur “CAM” language distortions of the 1990s that he is largely unaware of their insidious power. I suspect too that he, like most of us who grew up when schools no longer stressed the rigors of English composition, has an underdeveloped sense of the relation between the craft of writing and the integrity of its content. That doesn’t excuse him from writing honest prose, of course.

Last week’s post cited blatant language distortions of “CAM”—euphemisms, slogans, and outright falsehoods—and some that were more subtle: question-begging, misrepresentation, and derogation. It would require a semester’s worth of seminars to delve into the overlapping categories of misleading “CAM” language, but here we can consider a few. Then, perhaps, we’ll engage in an amusing diversion—more about that at the end of this post.

Introduction to the Advanced Course

For the most part, what interests us are not the assertions of “CAM” practitioners themselves, whose misrepresentations tend to be simplistic and obvious. We are more concerned with statements by influential “CAM” apologists in academic medicine and government, because it is they who have the greater capacity to deceive the public. This was illustrated last week by quotations from the Federation of State Medical Boards. Such apologists are frequently somewhat nuanced in their misrepresentations, both because they are more clever than the “CAM” practitioners that they patronize, and because they must address their assertions to a more clever audience—namely, physicians and biomedical scientists whose skepticism of “woo” makes them wary.

Sometimes, however, statements by “CAM” practitioners and those emanating from influential apologists are one and the same, suggesting that the latter are ditzier than their status implies, or perhaps just lazier: witness the statement about “naturopathic medicine,” quoted in last week’s post, from the website of the University of Washington Dept. of Family Medicine (which itself quotes similarly inane language from the U.S. Dept. of Labor). Other examples, from WebMD (“Better information. Better health.”) and InteliHealth (The Trusted Source®), can be found here. InteliHealth has improved slightly since 2002; WebMD has not.

Some “CAM” language distortions are an inevitable result of Evidence-Based Medicine’s (EBM) incomplete definition of “evidence.” We have seen examples written by the “CAM Field” of the Cochrane Collaboration (“The reliable source of evidence in health care”), whose EBM-style reviews are widely respected. More examples can be found on InteliHealth, which now buys much of its “CAM” information from Natural Standard (“The Authority on Integrative Medicine”). Whether or not the authors of such reviews are aware of established knowledge and other external evidence, the arcane rules of EBM (no longer surprising to SBM readers!) give them “plausible denial.”

Bait and Switch

For several years beginning in the late 1990s, there were clusters of “CAM” articles in a few influential medical journals. They are chock full of misleading language, but this discussion must be limited to a few examples. In the fall of 1999, the late virologist Stephen Straus became the first Director of the nascent National Center for Complementary and Alternative Medicine (NCCAM). Like many in the new academic world of “CAM,” Straus seemed innocent of “CAM.” Regarding the script of his new role, however, he was a quick study. In June of 2000 he wrote an article for Academic Medicine:

Both as an art and as a science, medicine is ever-evolving. Before the emergence of the empirical and experimental sciences, physicians relied heavily on the art of medicine. But in the past century, progressively detailed investigations of individual organs, cells, and molecules led to the emergence of biomedicine, with its heavy reliance on science, as the now-dominant and conventional basis for medicine.

A superficially innocuous and uncontroversial, politely deferential (for the benefit of snickering ex-colleagues at the NIH, I’d guess) introduction. But how innocuous is it? In that short passage are the seeds of garden variety “CAM” language distortions: by sleight of pen, the “art of medicine” will quickly change to “CAM” itself and then to “healing arts,” after fleeting stops at “rich dialogue” and “the healing process,” only to return to “CAM.” ”Detailed investigations of individual organs, cells, and molecules” is a thinly-disguised reference to the objectionable “reductionist paradigm” of modern medicine, which by dint of its “heavy reliance on science” has overstayed its welcome.

The declaration that “biomedicine” is “the now-dominant and conventional basis for medicine” manages to “dis” modern medicine in ways that most physicians and scientists would hardly notice, but that the “CAM” crowd and its congressional patrons would hardly miss: “biomedicine” and “conventional” are mildly pejorative misnomers, as discussed last week; “dominant” is a potent adjective, intended to distract the reader from imagining that the emergence of modern medicine had something to do with the emerging understanding of nature over the past couple of centuries—and to replace it with the facile suggestion that medicine, like everything else, is a matter of power vs. oppression or privilege vs. exclusion. This kind of thinking had been fashionable in the academy for more than a generation, and was certain to win approving nods from such ex-hippie “CAM” luminaries as Andrew Weil, who authored an article for the same issue of Academic Medicine, and James Gordon, the Chairman of the White House Commission on Complementary and Alternative Medicine Policy. More from Dr. Straus’s piece:

Historical precedent predicts that a number of contemporary CAM therapies [will prove effective]…some of our most important pharmacologic agents…are derivatives of herbal products. Radiation therapy, once regarded as a radical approach to treating cancer, is now a standard of care, and acupuncture, considered arcane and primitive before Nixon went to China in 1971, is now routinely prescribed to manage pain.

First point: no, it doesn’t, and even if it did so what? Nothing in “CAM” consists of the rational screening, for useful medicinal properties, of substances found in nature (bait and switch). Second point (radiation therapy): What does that have to do with “CAM”? Second point (acupuncture): Routinely prescribed by whom? And even if it were so, it isn’t evidence. The counterpart to the “straw man” argument is the “false premise” argument in which the author asserts the existence of a premise that supposedly justifies the point he is about to make. Unlike the case of the “straw man,” the author approves of the premise; but like that of the “straw man,” the premise is either a figment of the author’s imagination or does not support his subsequent point.

Here is the obligatory, once-an-article skeptical posturing to reassure the reader that she is in the capable hands of the author and of the author’s like-minded colleagues:

Many people believe that if a product has been used for centuries, it must be effective, and if it is natural, it must be safe. To the contrary, there is mounting evidence that some CAM therapies expose patients to potentially toxic components or displace effective conventional treatments…St. John’s wort [and protease inhibitors, for example]…

That passage is particularly rankling for its hypocrisy. The evidence for the dangers of mixing herbs and HAART agents came from legitimate Institutes of the NIH, but not from the NCCAM. The NCCAM, on the other hand, through its funding of the Bastyr (Naturopathic) University AIDS Research Center, may have contributed substantially to the dangers of such herb-drug interactions, and certainly contributed to an ethically-dubious trial of “Garlic for hyperlipidemia caused by high [sic] active antiretroviral therapy (HAART).” Garlic is another substance that reduces blood levels of HAART agents. At about the same time that Dr. Straus must have been writing his article for Academic Medicine, personnel from Bastyr and the University of Washington were presenting an abstract in which they reported having temporarily stopped the garlic trial because of this new information, but “additional funding was later received from NCCAM for implementation of safety mechanisms to allow the trial to resume.” Those “safety mechanisms” did not include “therapeutic drug monitoring.”

More from the article:

Lacking such knowledge yet enamored of the appeal of CAM practices, the American people have demanded that these be studied.

The American people are neither “enamored of the appeal of CAM practices” nor have they “demanded that these be studied.”

The Wooification of Health Care

And now a cynical fest of question-begging, baiting and switching, and stated intentions that should make any reason-loving physician shudder:

…an especially vital role with respect to facilitating the integration of rigorously proven CAM approaches into the ongoing education of physicians and the daily practice of medicine…Dr. Andrew Weil…spoke of the need to train young physicians about CAM. Few would argue against the wisdom of this notion…Medical students should receive instruction about proven CAM methods…the curriculum should be enriched by exposures to the history of medicine, medical ethics, and medical economics…We also wish to work with the AAMC to overcome the reluctance of conventional physicians to consider CAM therapies that are proven safe and effective for their patients…in this way may we succeed in expanding the repertoire of ways to achieve and maintain health and restore an appropriate balance of both the art and the science of medicine.

We might be comforted by observing that there are no “CAM therapies that are proven safe and effective,” nor are there likely to be any; except that we already know that “CAM” researchers, encouraged by misguided shills for EBM, don’t see it that way—and neither, if we don’t speak out, may medical schools, patients, insurance companies, and governments. The passage is yet another language distortion, which means exactly what “CAM” advocates choose it to mean.

The point is made even more pointedly by at least two other articles in that issue of Academic Medicine. The first instance is no surprise, coming from Andrew Weil and his pals at the University of Arizona:

The addition of proven CAM to conventional medicine would be an improvement, yet this combination alone is not what could be defined as integrative medicine….Integrative medicine is defined as healing-oriented medicine that reemphasizes the relationship between patient and physician, and integrates the best of complementary and alternative medicine with the best of conventional medicine. We believe that this synthesis of humanistic medicine, patient- and relationship-centered care, preventive health, allopathy, and CAM is the model for creating an improved system of health care.

So: it isn’t even just something that the ditzy members of the class can elect; if Weil and his gang have their way, it will be mandatory for all—it became so at Georgetown a couple of years ago, as reported by Orac. Such training already exists for ”integrative medicine” fellows at U of Arizona and includes claims that don’t “fit with our Western paradigm,” scrapping RCTs in favor of “outcomes research,” asking “physicians to explore their beliefs about medicine and…the assumptions that underlie medical science,” preparing “physicians for new roles as partner, coach, teacher, motivator, and healer,” heightening “awareness of the different cultural healing systems,” “Chinese medicine, energy medicine, homeopathy, allopathic medicine, manual medicine, and Western herbalism,” and “physician self-care” that includes “therapeutic movement,”

facilitated sessions [for] examining [one's] humanity, including the identities they have left behind and the physician-healers they are seeking to become.

These meetings occur regularly, often offsite, and in addition to traditional group work, include experiences ranging from listening to music, hiking, and reading plays and poetry to participating in Sufi dancing and sweat lodge ceremonies.

Please pass the homeopathic Ipecac.

The final few quotations are from another article in that issue of Academic Medicine, co-authored by Ralph Snyderman, who at the time was the Chancellor for Health Affairs at Duke University:

Integrative medicine is an approach to the practice of health care based on a sound scientific approach with an emphasis on the responsibility of the physician to engage the patient in his or her own unique plan for health. Essential aspects include the recognition of the importance of the mind-body relationship and a willingness to consider unconventional modalities with informed skepticism and scientific evaluation. Above all, integrative medicine encompasses the caring bond between the patient and the caregiver, and the responsibility of the latter to enable the patient to benefit from a full array of modalities that can be shown to benefit health.

What’s so remarkable about that statement is just how unremarkable it is. With the possible exception of “the mind-body relationship” and “unconventional modalities” (which could easily be changed to “psycho-social considerations” and “innovative treatments” without a literal change in meaning), if “integrative” were changed to “modern” it would hardly stir the dozing medical students in the back row. That, of course, is exactly why its misleading language is so pernicious: it can’t really mean “based on a sound scientific approach” or “with informed skepticism and scientific evaluation,” because those would preclude what’s really meant by “integrative.” Sure enough, the rest of the article is a paean to Weil’s “Arizona Program,” which the authors intend to emulate at Duke, and to the Consortium of Academic Health Centers for Integrative Medicine, which is also committed to the wooification of modern medicine behind the veil of “scientific studies” (quoted in Snyderman):

Our mission is to help facilitate the transformation of health care through rigorous scientific studies, new models of clinical care, and innovative educational programs that integrate biomedicine, the complexity of human feelings, the intrinsic nature of healing and the rich diversity of therapeutic systems.

There are now 39 medical schools among the members of the consortium, including, in all likelihood, yours. As my colleague Dave Gorski has discussed, there are others that also push woo. Be afraid.

And now for the amusing diversion…

That was depressing, to say the least. As an antidote, I’m proposing a weekly “language distortion” game: the Weekly Waluation of the Weasel Words of Woo (W^5 for short). It’s simple: each week on Friday, I’ll post a passage at the end of my blog. Feel free to comment on its misleading language over the weekend (please stop before Monday and limit yourselves to one submission each, or I’ll get overwhelmed and confused), and I’ll select the really good ones and heap praise upon you the following Friday. Feel free to draw upon “external evidence.” Here’s the first entry, which calls to mind at least two recent SBM posts, here and here (hint, hint):

For people with chronic pain or with other refractory conditions, the chiropractic visit itself can be a source of comfort even without the addition of a demonstrable scientific component. Treatment by a chiropractor can generate a sense of understanding and meaning, an experience of comfort, an expectation of change, and a feeling of empowerment. Chiropractic’s combination of vitalist “innate intelligence” and simple mechanical explanation can give rich vocabulary for just those illnesses conventional medicine remains poorly equipped to address. Research indicates that for many of the illnesses chiropractic treats, precise diagnosis, assurance of recovery, and physician-patient agreement about the nature of a problem hasten recovery.

Chiropractic finds its voice exactly where biomedicine becomes inarticulate. Too often, biomedicine fails to affirm a patient’s chronic pain. Patients think their experience is brushed aside by a physician who treats it as unjustified, unfounded, or annoying, attitudes that heighten a patient’s anguish and intensify suffering. Chiropractors never have to put a patient’s pain in the category of the “mind.” They never fail to find a problem. By rooting pain in a clear physical cause, chiropractic validates the patient’s experience.

Happy Waluating!

Post-post addendum

At least two studies in recent years, both published in Academic Medicine, have shown that “CAM” courses in medical schools are overwhelmingly uncritical and promotional. One of these was done by our colleague Wally Sampson; the abstract is here. The abstract of the other is here.

A recent issue of Academic Medicine was once again devoted to the teaching of “CAM” in medical schools. A perusal of the table of contents and the available abstracts confirms that “CAM” advocacy is, more than ever, the norm for such ventures.

The Misleading Language and Weekly Waluation of the Weasel Words of Woo series:

  1. Lies, Damned Lies, and ‘Integrative Medicine’
  2. Integrative Medicine: “Patient-Centered Care” is the new Medical Paternalism

Posted in: Medical Academia, Medical Ethics, Science and Medicine

Leave a Comment (34) ↓

34 thoughts on “Misleading Language: the Common Currency of “CAM” Characterizations Part II

  1. Stu says:

    Observe the power of simple substitution:

    For people with chronic pain or with other refractory conditions, the prostitute’s visit itself can be a source of comfort even without the addition of a demonstrable scientific component. Treatment by a prostitute can generate a sense of understanding and meaning, an experience of comfort, an expectation of change, and a feeling of empowerment. Prostitution’s combination of vitalist “innate intelligence” and simple mechanical explanation can give rich vocabulary for just those illnesses conventional medicine remains poorly equipped to address. Research indicates that for many of the illnesses prostitution treats, precise diagnosis, assurance of recovery, and physician-patient agreement about the nature of a problem hasten recovery.

    Prostitution finds its voice exactly where biomedicine becomes inarticulate. Too often, biomedicine fails to affirm a patient’s chronic pain. Patients think their experience is brushed aside by a physician who treats it as unjustified, unfounded, or annoying, attitudes that heighten a patient’s anguish and intensify suffering. Prostitutes never have to put a patient’s pain in the category of the “mind.” They never fail to find a problem. By rooting pain in a clear physical cause, prostitution validates the patient’s experience.

    “vitalist innate intelligence”, indeed.

  2. sashen says:

    I think Stu is pointing out that Spitzer spent $80k on “chiropractic” adjustments.

  3. Calli Arcale says:

    *hoots at stu’s reply*

    That was good. ;-)

    What struck me about the quoted passage was the persistent use of passive voice. This is common in “CAM”, and deliberate. It allows them to make claims that are beyond what they know they can support by making their claims a little less strong. The intent, of course, is to conceal the weakness of the argument. And most of the time it works. Fact is, the above passage doesn’t actually say that chiropractic is good for anything. It asserts that it *can* do a bunch of things, but doesn’t say that it actually does. Yet most readers will not notice that.

  4. overshoot says:

    Medical Paternalism Returns

    Maybe I’m sensitized by yesterday’s post and “350 dog years” (I have a few more) but this post brought out something that has been bothering me about the woo rhetoric for years: a lot of that semantic smokescreen comes across to me as a disguise for the return of medical paternalism in spades.

    Let us be clear here: I am well past midlife, I have a reasonably good education, I have spent more time than most acquiring an “informed consumer’s” understanding of medicine. I am also a professional in my own field and not fool enough to pay an expert for hir expertise and then ignore it (another way of saying I’m a carefully compliant patient when the need arises.)

    However, when I pay an organic mechanic for repair or maintenance services, I am *not* looking for someone to take that as license for care of my soul (or whichever euphemism is currently being disguised by linguistic tricks.)

    Yes, I know it’s a bit off-topic, but I hope not too much so.

  5. David Gorski says:

    However, when I pay an organic mechanic for repair or maintenance services, I am *not* looking for someone to take that as license for care of my soul (or whichever euphemism is currently being disguised by linguistic tricks.)

    I actually agree with you here, although I definitely disagree with your assessment of Kimball’s description of the deceptive terminology of CAM as evidence of medical “paternalism.”The problem is, there is a large movement in medicine to fuse religion and medicine. It’s very disturbing. Personally, I view the entire “CAM” movement as an aspect of the very same movement, the desire to inject “spirituality” (a.k.a. religion) into medicine, given how many CAM modalities are based on religious and spiritual beliefs, rather than science.

    I may do a post about this in the future.

  6. Sastra says:

    Excellent post. I always notice these subtle little red flags; it’s good to see them dissected bit by bit.

    Here is my entry for the Weekly Waluation of the Weasel Words of Woo. It is a (rough) translation:

    For people with chronic pain or with other refractory conditions, just thinking the chiropractor might help should be enough. If the chiropractor makes soothing, flattering noises at you, you’re supposed to feel better, and even a temporary and superficial psychological “lift” ought to leave you satisfied. Nothing empowers a patient like being treated like a child come to mommy.

    If they throw around a bunch of religious, “spiritual” language and images, you will be totally charmed and disarmed, because you’re not supposed to question faith or expect any real scientific evidence for it. Even so, it’s nice to find a ‘science-y’ confirmation that God exists and the universe is on your side. If it sounds like religion, then the best test is deciding if it feels true in your heart. You want to be that kind of person.

    Research indicates that for many of the illnesses chiropractic treats, nothing substantial related to your body’s health actually has to change at all. Being told you are better will make you think you are better, because you fall for it. Being told you are as sick as you think you are will make you feel so validated that you’ll never notice or care that you’re being mislead.

    Chiropractic is able to lie in ways which biomedicine can’t, because it isn’t hampered by either honesty or real respect for the patient, as an adult. As long as they tell you what they think you want to hear, you’ll enjoy your visit and be none the wiser.

  7. Will TS says:

    I’m not sure the things that jumped out at me in the chiropractic passage were as misleading as they were ridiculous:

    “…without the addition of a demonstrable scientific component.”

    To me that means without a demonstrable effect. Do they seriously expect to attract patients when they admit that their treatment has no demonstrable effect?

    Better was:

    “They never fail to find a problem.”

    I can imagine the clinical trial to support this statement. One hundred healthy volunteers are examined by chiropractors and every one of them is diagnosed with a subluxation of the vital energy flux and prescribed a 26 week course of mechanical manipulation. Seven percent experience irreversible damage to the phrenic nerve and subsequent paralysis of the hemidiaphragm, but ninety percent reported a ‘validating experience’.

  8. daedalus2u says:

    I can’t force myself to read it carefully enough to make a reply.

  9. pmoran says:

    (Pssst! Just between us! :-)) Is it just possible that some of this pretentious and misleading language, from people who should know better, is code for “perhaps we need to bring back placebo-based medicine, but in a way that no one will notice”? Andrew Weill, for example, is on record as saying “placebos are the meat of medicine”. “Mind-body medicine” is mostly used in a way that makes it interchangeable with “placebo medicine”.

    The science of placebo reactivity seems to be maturing, but it may need a descriptor with fewer negative connotations if it is to intrude into serious scientific discussions such as occur here.

    Whatever one’s view of the “power of the placebo”, and the ethics of its intentional employment, the fact that 40-50% of medical practitioners in Australia and the UK are using alternative methods needs some explanation. This is presumed placebo medicine — especially all that homeopathy used by UK practitioners.

    Also needing explanation are the high rates of satisfaction that both practitioners and patients express with these methods.

    All this “voting with the feet” does suggest that “biomedicine” (methods having intrinsic medical activity) cannot yet satisfactorily meet all the demands that are placed upon modern medical systems and that science, as defined by the limits so far applied to it on this blog, is not always necessary for the success of medical interactions.

    I agree we don’t need to be invoking an “art” of medicine in any mystical sense but do we really yet fully understand the “alternative” medicine phenomenon and what light it may throw on some of the complexities of day-to-day medical practice, as well as ever-present DIY medicine?.

  10. DVMKurmes says:

    My entry or “translation’;

    If your bedside manner is better than the MD’s, and you act confident and assured, you can make the patient believe anything you choose to make up. The patient might even feel better and be happier with your treatment than the more realistic, but possibly less apparently sympathetic treatment from the MD.

    In response to pmoran, yes, most CAM treatments rely on the placebo effect, or the fact that people usually get better no matter what treatment they receive for things like viral infections, mild musculoskeletal injuries, etc. Does that mean we as a society should spend money on placebo’s? Also, some people will not have important diagnoses made in time to be cured of more serious disease. As long as people age and die, there will be some who will try anything, no matter how improbable, to save themselves. I am sure many CAM practitioners are satisfied with their results, and the money they recieve from their patients who are convinced they were helped, but that does not mean it was an appropriate thing to do. Apparently more expensive placebo’s work better-what price would you consider “appropriate”.

  11. overshoot says:

    I actually agree with you here, although I definitely disagree with your assessment of Kimball’s description of the deceptive terminology of CAM as evidence of medical “paternalism.”

    Not so much evidence of paternalism as a push towards restoring it.

    Further deponent sayeth naught; this was already OT enough.

  12. David Gorski says:

    Not so much evidence of paternalism as a push towards restoring it.

    I also disagree that it represents a push towards restoring paternalism.

  13. Fifi says:

    Interesting, I’d suggest that CAM actually offers a more “maternal” vibe most of the time (depending on the practitioner, of course). It’s kind of a “big mommy” syndrome – let’s look at what people are getting for the money given to big mommy (which is really Big Money)…

    1-unconditional acceptance of self diagnosis usually (so unconditional affirmation), and maybe even a couple of gold stars (yes, you were very famous in your past life and that’s why you now have lower back pain)

    2-lots of touching, listening and attention, maybe even a hug and a kiss for your boo boo

    3-lots of emphasis on eating your vegetables

    4-goddesses, goddesses, and more goddesses (rub the belly, such the teat, and you’ll feel better)

    5-lots of indulgences from Big Momney because she wants you coming back for more, and/or the use of guilt about being a “bad person” or illness being a result of karma or whatever to serve the CAMmers purpose.

    Angry because science based (which can be paternalistic depending on the doctor or institution) Big Daddy medicine won’t grant your indulgence or can’t make everything bad go away? Get a hug from Big Momney.

  14. Skeptico says:

    It’s shooting fish in a barrel, but I’ll go anyway:

    For people with chronic pain or with other refractory conditions, the chiropractic visit itself can be a source of comfort even without the addition of a demonstrable scientific component.

    It doesn’t work but we’ll make you think it does.

    Treatment by a chiropractor can generate a sense of understanding and meaning, an experience of comfort, an expectation of change, and a feeling of empowerment.

    The drivel we’ll feed you will make you come back for more adjustments. Even though you won’t need them.

    Chiropractic’s combination of vitalist “innate intelligence” and simple mechanical explanation can give rich vocabulary for just those illnesses conventional medicine remains poorly equipped to address.

    Real doctors won’t know what’s wrong with you; we’ll make something up.

    Research indicates that for many of the illnesses chiropractic treats, precise diagnosis, assurance of recovery, and physician-patient agreement about the nature of a problem hasten recovery.

    The more confident we appear that we can cure you, the better you’ll feel.

    Chiropractic finds its voice exactly where biomedicine becomes inarticulate.

    Real doctors won’t know what’s wrong with you; we’ll make something up.

    Too often, biomedicine fails to affirm a patient’s chronic pain. Patients think their experience is brushed aside by a physician who treats it as unjustified, unfounded, or annoying, attitudes that heighten a patient’s anguish and intensify suffering.

    Real doctors won’t know what’s wrong with you; we’ll make something up. The more confident we appear that we can cure you, the better you’ll feel.

    Chiropractors never have to put a patient’s pain in the category of the “mind.”

    We don’t care where it is; we’ll charge you anyway.

    They never fail to find a problem.

    Even when one doesn’t exist. And the solution is always “crack your back”.

    By rooting pain in a clear physical cause, chiropractic validates the patient’s experience.

    The more confident we appear that we know what your problem is, the better you’ll feel.

  15. daedalus2u says:

    As I point out in my blog on the placebo effect (which is mediated by NO), the archetypal placebo is the mommy’s “kiss it and make it better” message which tells the child they can relax, stand down from the “fight or flight” state and resume normal metabolic functions which include healing and growing.

    The paternalistic equivalent (which I associate with high school football coaches not my father), is the “suck it up and go” message. I consider that to be the opposite of the placebo effect, a message which drives you farther into the “fight or flight” state. That is where you want to be in preparation for a battle, or a football game.

  16. Michelle B says:

    The woo language was so soothing that I nodded off, muttering to myself about how prostitution would be an effective substitute for Chiropractic. Upon waking up, I saw that Stu expounded excellently regarding that angle.

    @pmoran, For a placebo to work it has to be prescribed by someone with authority. If some practitioners of evidence-based medicine want to outsource the placebo effect, then it would be better not to diss the non-evidence based practices–it would be like cutting their noses off to spite their faces.

    Lack of belief in God(s) is often challenged by believers as not delivering what belief in God can. And no way can it, because lack of belief cuts through the delectable magic of eternal life and having a hot-line to the God of the particular brand of religion in question. And that is what evidence-based medicine does for Woo. Evidence-based practitioners who do the Woo dance, are like religious apologists who encourage religious belief because they have decided that belief in belief is good.

    I do not consider honing the skills to ferret out the tricky and sneaky approaches used by Woo practitioners and apologists to be encouraging deference to a paternal figure. It is the opposite, really, where the individual is given a bull-shit detection kit (per Carl Sagan) and can used the ‘tools’ whenever needed by his/her own self with no reliance whatsoever on a father figure.

  17. overshoot says:

    Forehead slap (mea culpa):

    I actually agree with you here, although I definitely disagree with your assessment of Kimball’s description of the deceptive terminology of CAM as evidence of medical “paternalism.”

    I should have been clearer: I see the woo merchants as being paternalistic. Facts and evidence are the antithesis precisely because they are accessible to all, and semantic analysis of woo marketing is just that — a technique based on the claccical rhetoric or even on formal semantics, for showing sleight of word.

    If I read you correctly, this is actually quite ironic because we’re both victims of English ambiguity. My paragraph could (I now see) be thought of as accusing the deconstruction of woo marketing of being “paternalistic.” Likewise I mistook yours (it was a mistake, wasn’t it?) as:

    I definitely disagree with your assessment of
    {Kimball’s description of
    {the deceptive terminology of CAM as evidence of medical “paternalism.”
    }
    }

    Which actually is rather a strained reading of your words. Sorry ’bout that.

  18. Antono says:

    @Michelle B: I completely agree with you in finding no justification for embracing woo medicine with full knowledge it’s BS, just for its potential to mediate a small placebo effect.

    What I’ve told my patients and colleagues who rationalize using CAM this way is that real therapy has an inherent placebo effect already since people believe or rather KNOW it works. Add on top of that the actual pharmacologic effect and it becomes superior to woo even in the context of this rather bizarre reasoning.

    However, I can’t help recalling a recommendation I read in a USMLE book. They suggested a doctor should not dispel the patient’s illusions. If the patient is convinced some strange voodoo will cure her, the doc is supposed not to discourage her (provided her CAM treatment is not dangerous) but offer real treatment as a complement instead.

    My concern is that such actions are not only unethical (letting patients be scammed) but could also be perceived as Medicine supporting CAMs (“hey, the doc I went to said I should keep drinking energized water and also take these pills for more effect; see, even doctors accept it).

  19. pmoran says:

    Antonio: “What I’ve told my patients and colleagues who rationalize using CAM this way is that real therapy has an inherent placebo effect already since people believe or rather KNOW it works. Add on top of that the actual pharmacologic effect and it becomes superior to woo even in the context of this rather bizarre reasoning.”

    Think some more about this. You are making at least three assumptions: that there are completely safe and 100% effective pharmacological answers to all of mankind’s ills, that there is a generally favourable public attitude towards pharmaceuticals, that the beneficial pharmacological effects of pharmaceuticals such as NSAIDs, antidepressants, and antibiotics are always sufficient to outweigh the risk of serious ill-effects when dealing with very common minor or self-limiting conditions.

    I am also confident that most doctors use CAM with discimination (as, indeed, do most patients). They will not deny their patients pharmaceuticals when needed.

    We have even just heard how the benefits beyond placebo of common antidepressants may well not exceed the potential for ill effects, or even nocebo effects, if a patient is already suspicious of drugs, as many are. An FDA approved drug for IBS worked better than placebo by 3% but also caused diarrhoea in 3%, in the largest trial performed. What niceties certain interpretations of SBM impose upon us!

    I am not saying what is right or wrong. I am adding to the matters that need to be thought about and trying to understand them in a way that does not carry the implication that everyone who does not share certain views is an ignorant fool. It is for me, so far, very arguable as to who has the true interests of patients at heart in what is an extremely complex environment, one that does not always match well the medical model that SBM has evolved to deal upon.

    I don’t buy any of the slippery slope arguments. Find me a proper doctor using “energised water”. Science will win out in the long run.

  20. Antono says:

    pmoran: “You are making at least three assumptions: that there are completely safe and 100% effective pharmacological answers to all of mankind’s ills, that there is a generally favourable public attitude towards pharmaceuticals, that the beneficial pharmacological effects of pharmaceuticals such as NSAIDs, antidepressants, and antibiotics are always sufficient to outweigh the risk of serious ill-effects when dealing with very common minor or self-limiting conditions.”

    Indeed, I didn’t want to go into much detail along this trail of thought for fear of over-analyzing a dull point.

    Of course I don’t believe medicines or any other form of real treatment are 100% safe (it’s been proven they aren’t) but neither is any CAM. Furthermore, CAM’s side effects are poorly explored and thus have the potential to be even more dangerous.

    You are quite right in pointing out that only a non-CAM-believer would trigger a placebo effect from real treatment. Regardless of the prevalence of each belief in the general population, the point is that one doesn’t need to be a “believer” to benefit, unlike with religion where one “has” to believe in order to get a placebo effect. Instead, skeptic patients “believe” (for lack of a better word) in Medicine. That was the aim of my argument.
    But if I had to elaborate further on this: 1) When a patient visits my hospital there’s a pretty good chance she believes there’s a good probability of getting a cure from us; if she were a CAM believer she’d go see an alternative doc, 2) The problem with triggering an effect with CAM is you need to hit the exact belief that your patient holds: if you suggest acupuncture but she really just accepts homeopathy, you’ve ruined it for her; giving her real therapy is more probable to be compatible with her beliefs because this belief is more uniform.
    It’s like the trouble with believing in a God so that you don’t run any risks of Him actually existing and sending you to Hell: if you’ve picked the wrong God to believe in, you’re just going to make him more angry!

    As to the issue of weighting the harm vs. good of any given treatment, this is already computed before suggesting it to the patient. Note that alternative medicine cannot reliably compute this ratio due to lack of data so it has the potential to be more harmful.

    Now, on top all all that, add the real efficacy of the medical treatment and you’ll see why it’s superior even when appealing to alternative medicine’s placebo triggering potential.

    I can’t speak of my colleagues about whether they use CAM with discrimination as you suggest or not but the placebo effect is not so hard to trigger: showing genuine interest for your patient, adequately discussing their disease, explaining what they can expect, offering general advice to follow, simple things like this can build a healer-patient relationship without any prescription taking place.

    The question is what to do when the patient believes in inefficient or dubious treatments: let her keep on following them and offer your treatment as complement or try to dispel her illusions? Personally, I follow the latter course of action, if only for ethical matters. A lower efficacy due to lower “placebo level” is probable (at least for subjective symptoms) but I believe not remarkably so if you establish the proper relationship and inspire a belief in the efficacy of the treatment you’re offering.

  21. BlazingDragon says:

    pmoran is right. The medical profession needs to understand WHY so many people are susceptible to this kind of crap. Until one understands the enemy, one will not be able to fight it. Railing about the fact that the enemy is winning (while doing nothing to understand why they are winning) is a formula for defeat.

    I’ve got a pretty good idea of why modern medicine is being poached by these nutjobs. It has to do with the fact that people who don’t fit into clinical trials find themselves adrift in a sea of uncaring (or outright hostile) medical professionals.

    Most clinical trials are done with carefully selected groups of patients (neither too sick nor too well, with some effort made to weed out those who would screw up the data by being oddballs). For those of us who are actually medical oddballs, we get screwed. Taking the results of a clinical trial and applying to medical oddballs is no longer a direct logical connection, but an inference. Quite often, the inference works and everyone is happy. Fairly often, however, the inference fails and the patient is left being told they are “making themselves sick with worry,” or some other equally ludicrous and damaging “diagnosis.”

    People affected by being an oddball will often be treated with anti-depressants or anti-anxiolytics, then when those don’t work, they are told they are “head cases.” Is it any wonder why the people affected in this way are susceptible to a “big mommy” telling them that everything is going to be OK?

    Also remember, a “normal distribution” only covers 95.6% of patients with +/- 2 sigma. That means that roughly one out of twenty patients a physician sees will be well outside of what is considered “normal.”

    Until physicians understand this and begin to treat patients who have refractory conditions with respect, these people will be very susceptible to woo. Even if these patients are only 1% of the population, they will create an ocean of testimonials that woo-based frauds will use to sell their wares to an unsuspecting public. Even patients whose conditions are “psychosomatic” need to be treated with respect or they will flee the disapproval (and even outright abusive tone) to woo-based “therapies.”

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