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NEJM and Acupuncture: Even the best can publish nonsense.

I realize that the New England Journal of Medicine (NEJM) review of acupuncture has already been covered by Drs. Gorski and Novella. But my ego knows no bounds; so I thought I would add my two cents, especially since this review, more than any paper I have read, generates a deep sense on betrayal.

There was a time when I believed my betters. Then the Annals of Internal Medicine had their absolutely ghastly series on SCAMS, the publication of which was partly responsible for interest in the topic. Since that series of articles, I have doubt whenever I read an Annals article. When a previously respected journal panders completely to woo, they lose all respectability. Sure, the editors that were responsible for that travesty are long gone, but the taint remains. I tell my kids that once a trust has been violated, it is difficult to get it back. The Annals has permanently lost my trust, I am afraid.

But we will always have Paris. I mean the NEJM. The NEJM is the premier medical journal. Just because an article is published in the NEJM doesn’t mean it’s right; the results of clinical trials are always being superseded by new information. But the article has supposedly been rigorously peer reviewed. Its like Harvard and… Oops, Bad example. Harvard, as we have seen, has feet of clay, and so, evidently, does the The New England Journal of Medicine.

Goodness, gracious, great balls of fire, the editors of the NEJM have fallen into the depths of nonsense with this one.

Let’s go through it, shall we.

First up, the authors:

Brian M. Berman, M.D., Helene H. Langevin, M.D., Claudia M. Witt, M.D., M.B.A., and Ronald Dubner, D.D.S., Ph.D.

From the Center for Integrative Medicine, University of Maryland School of Medicine (B.M.B.), and the University of Maryland Dental School (R.D.) — both in Baltimore; the Department of Neurology and the Program in Integrative Health, University of Vermont College of Medicine, Burlington (H.H.L.); and the Institute for Social Medicine, Epidemiology, and Health Economics, Charité University Medical Center, Berlin (C.M.W.).

You always want acknowledged experts in a field to write your review. If you want a review of Lyme disease, you ask a Lyme expert (The Connecticut Attorney General not withstanding), and if you want a review of heart attacks, you ask a cardiologist.

So in that spirit, if you want a review of prescientific magic, you want someone well-versed in the practice of prescientific magic. Fortunately, these authors seem well qualified. Dr. Berman founded the Center for Integrative Medicine at University of Maryland and has a long history of research into acupuncture. The center has on its staff a reflexologist/reiki master. Really. And the center offers:

Physician Consultations, Acupuncture, Nutrition, Massage, Homeopathy, Mindfulness-based Stress Reduction, Shiatsu, Reflexology, Yoga, Qi Gong, Tai Chi, Osteopathic Manipulation.

The University of Maryland proudly offer both acupuncture and reiki to their trauma patients.

Reiki is a Japanese technique of relaxation that works similarly to acupuncture, in that you are releasing and moving energy,” explains Donna Audia, R.N., a nurse on Shock Trauma’s pain management team and a certified Reiki master. “By using Reiki with trauma patients, we are not only helping them to relax, we’re also making them active participants in their own healing, and that can be very empowering.

Reaction from trauma patients has been positive, with most requesting follow-up treatments. In fact, many family members ask to be a part of the Reiki session. A group of volunteers trained in Reiki now visits Shock Trauma regularly. The University of Maryland Medical Center is the only facility in the country offering Reiki to trauma patients, although it has also been used to treat people with cancer and other illnesses.

Seriously. Your body has been shattered in a car accident and your health care providers think they can improve your condition by moving and releasing your energy by waving their hands over you.

If, god forbid, you have trauma in Maryland, get transferred. Fast.

Dr. Berman has published extensively on acupuncture and Dr. Witt has published multiple articles on homeopathy, including one using homeopathy for low back pain.

So two of the authors are well grounded in magical thinking: who better to write a NEJM review on acupuncture? They found a Dumbledore, a Gandalf, to write the article, which explains the content as the editors of the NEJM were evidently hit with the confundus charm. As I think about it, that is not the best metaphor, since in the fantasy world, magic is real, but in the real world, magic is fantasy, as well as a review article in the NEJM.

The authors start with a case of chronic low back pain with mild degenerative disease but no anatomical or physiologic reason for the pain. The vignette ends with:

The patient wonders whether acupuncture would be beneficial and asks for a referral to a licensed acupuncturist.

Nope. Simple enough. Acupuncture is nonsense. Oh wait. There’s more.

They review the epidemiology, physiology and anatomy of chronic low back pain and note that the understanding of the disease is a long way from satisfactory and conclude with:

In addition, psychological and behavioral factors, including fear of movement, appear to play an important role in patients with chronic low back pain. Such patients have been shown to have altered brain-activation patterns at subcortical and cortical sites associated with emotion and postural control. Studies comparing psychosocial variables with anatomical findings have shown the former to have greater predictive value than the latter.

In other words, with low back pain there is a big psychological overlay. It is the psychological overlay of pain that makes it difficult to determine the effectiveness of a therapy meant to decrease the pain. When treating a condition in medicine, most interventions attempt to alter the underlying pathophysiology: block a receptor with a drug, alter anatomy with a procedure as examples. If the intervention has no effect on the underlying pathophysiology, then there is little reason to expect benefit beyond a placebo effect, which is almost no effect.

Then they jump into acupuncture.

Acupuncture is a therapeutic intervention…

It is an intervention, yes, but therapeutic? Therapeutic means relating to healing of disease. So they are front loading the language, saying at the beginning that acupuncture is effective rather than proving the case. I would have used ‘useless magical’ instead of ‘therapeutic,’ but that’s me.

Although a number of different techniques or schools of acupuncture practice have arisen, the approach used in traditional Chinese medicine appears to be the most widely practiced in the United States.

Why? Is Chinese acupuncture better? Or is popularity the criteria we use for determining appropriate medical care? There is Chinese and Japanese and tongue and foot and ear and the German head acupuncture. Is there any justification offered for using one over the other? Which is the correct style? As I have said before, it is a trick question, like asking which is the real astrology: European, Indian or Mayan. It makes no difference.

Then they delve into real nonsense.

Traditional Chinese medicine espouses an ancient physiological system (not based on Western scientific empiricism) in which health is seen as the result of harmony among bodily functions and between body and nature. Internal disharmony is believed to cause blockage of the body’s vital energy, known as qi, which flows along 12 primary and 8 secondary meridians. Blockage of qi is thought to be manifested as tenderness on palpation. The insertion of acupuncture needles at specific points along the meridians is supposed to restore the proper flow of qi.

I hate to point out that the physiologic system I use, based on so-called “Western scientific empiricism,” is also based on anatomy, chemistry, biochemistry, histology etc. All based on physical structures that can be isolated and examined.

Meridians and qi blockage is based on what? Nothing. Meridians and qi do not exist. Here is the NEJM offering up, complete with a picture, the idea of meridians and qi as if they are a meaningful construct. Next up in the NEJM will be:

Traditional European medicine espouses an ancient physiological system (not based on Western scientific empiricism) in which health is seen as the result of harmony among bodily functions and between body and nature. Internal disharmony is believed to cause blockage of the body’s vital energy, known as humors: black bile, yellow bile, phlegm, and blood which flows in the body. Blockage of humors is thought to be manifested as illness. Bleeding and purging is supposed to restore the proper flow of balance of humors.

If anyone sees a conceptual difference between the two paragraphs, let the editors of the NEJM know after they accept my review on therapeutic bleeding. Being published in the NEJM is the medical equivalent of being on the cover of the Rolling Stone, and I think I have my opportunity.

Efforts have been made to characterize the effects of acupuncture in terms of the established principles of medical physiology on which Western medicine is based.

Why? Isn’t an ancient physiological system enough upon which to base a therapeutic intervention?

These efforts remain inconclusive, for several reasons. First, the majority of studies have been conducted in animals, and it is difficult to relate findings from such studies to effects in humans. Second, acupuncture has been shown to activate peripheral-nerve fibers of all sizes, rendering a systematic study of responses complex. Third, the acupuncture experience is dominated by a strong psychosocial context, including expectations, beliefs, and the therapeutic milieu.

And fourth, having no basis in reality, acupuncture can’t work any more than homeopathy or reiki. It is tooth fairy science, published in the NEJM.

Then they delve into the physiology of acupuncture and the basic science studies. Fine. You stick people with needles, you will get a variety of physiologic responses, both locally and in the brain. The question is whether these effects are specific to acupuncture or nonspecific results of poking people with a sharp object. Like all acupuncture apologists, they lack a certain precision in what they consider acupuncture, and offer electroacupuncture as evidence.

In the rat, electroacupuncture has been shown to induce pituitary secretion of adrenocorticotropic hormone and cortisol, leading to systemic antiinflammatory effects.

Ah yes, electroacupuncture. I remember when they discovered those ancient Chinese Duracell’s and alligator clips that allowed the Chinese to shock their patients.

I quote from the electroacupuncture article, referenced above:

While the EA frequency was held constant, intensity was adjusted slowly over the period of approximately 2 min to the designated level of 3 mA, which is the maximum EA current intensity that a conscious animal can tolerate. Mild muscle twitching was observed… For sham treatment control, acupuncture needles were inserted bilaterally into GB30 without electrical stimulation or manual needle manipulation.

And when shocked, the rabbits released ACTH and cortisol, as any animal would if electrocuted. Release of ACTH and cortisol is part of the response to stress. I can just see the poor rat, “placed under an inverted clear plastic chamber” for observation saying,” don’t tase me bro, don’t tase me bro.” Wait. It’s not a taser. It’s a projectile electroacupuncture remote deliver system, and if I use it on you, you are going to release some cortisol and ACTH as well, bro.

Did the NEJM editors look at the references? They seriously need some new reviewers.

But I will grant them that sticking needles in people has physiologic effects and shocking a rat makes it squirt cortisol.

However, acupuncture is about putting needles in specific sites. In the animal models and human studies they attempt to needle specific sites that correlate with treating a disease. Most acupuncture studies use the traditional sites associated with whatever illness they are not really treating; acupuncture is about putting the needle just so.

The basic science concerns, as I read it, the effects of needling people. If you are going to recommend acupuncture, and they will, then you need to justify the use of needles in specific sites by people trained in acupuncture, and the literature doesn’t support that. It doesn’t matter where you put the needles, or even if you use needles at all, as we have mentioned, since twirling a toothpick has better effects on knee pain than needling. And I will ask again: whose style of acupuncture are you going to use? Ear, tongue, foot, Japanese or German or Chinese?

Then they move on to the clinical trials and my gaster is flabbered.

… real acupuncture treatments were no more effective than sham acupuncture treatments. There was nevertheless evidence that both real acupuncture and sham acupuncture were more effective than no treatment and that acupuncture can be a useful supplement to other forms of conventional therapy for low back pain.

Lets take a trip back in time.

There was procedure for the treatment of angina where they ligated the internal mammary artery. The theory was that by tying off the artery the back-pressure forced blood down the coronary arteries and relieved cardiac pain.

Angina improved and there are about 40 plus papers in the 50s and 60s on the benefit of the procedure as well as the underlying physiology of the procedure. Mammary artery ligation ‘worked’ and was popular in the early 60s. Until the procedure was compared to a sham operation. That’s right. They opened people up and did nothing.

The result?

The combined results of two RCTs comparing an earlier surgical procedure for angina — bilateral internal mammary artery ligation (BIMAL) — to a sham surgery clearly show that patients “experienced significant subjective improvement,” with both BIMAL (67% substantial improvement) and the sham procedure (82% substantial improvement). [see Moerman, Meaning, Medicine and the “Placebo Effect”, 2002]

So how would you interpret the study? If a procedure is equal sham, then I would say the procedure does not work. In the case of sham surgery, no underlying change occurred in the blood supply to the ischemic heart. This study is perhaps the classic clinical trial that demonstrates the difficulty in assessing the results of an intervention for pain. Patients had significant improvement in their angina. Much better than doing nothing (although these studies did not have a ‘usual care’ wing), 2/3 of angina patients do not get significant improvement on their own.

And guess what? Open heart surgery “has been shown to induce pituitary secretion of adrenocorticotropic hormone and cortisol, leading to systemic antiinflammatory effects.” Surgery releases endogenous opioids and I bet it actives both peripheral and central pain fibers.

Hmmmm. Looks like we have a justification for going back to treating angina with internal mammary artery ligation.

The authors of the review justify the recommendation on the two studies that demonstrate the equivalence of sham acupuncture and real acupuncture in treating low back pain, the same number of studies for mammary artery ligation.

Now being an article on back pain, they did not include the article that showed knee pain treated with sham acupuncture (in this case twirling tooth picks on the skin) is superior to real acupuncture. It matters not where the needles are placed or even if needles are used.

So far the authors provide no historical scientific plausibility, non-specific modern pathophysiology, a bit of gratuitous rabbit torture, and two clinical trials that demonstrate no efficacy of acupuncture over placebo. Their level of justification reaches that of mammary artery ligation. I start to wonder if the NEJM editors actually read the review before publishing it. The authors then move on to clinical use.

(Acupuncture) not been established to be superior to sham acupuncture for the relief of symptoms of low back pain [translation: it doesn’t work]. As a result, it is not often regarded as the first choice of therapy [translation: clinicians do not like to use ineffective therapy].

However, since extensive clinical trials [er, since when did two become extensive? Are the authors even reading the manuscript?] have suggested that acupuncture may be more effective than usual care, it is not unreasonable to consider acupuncture before [you mean as first line therapy? when it doesn’t work?] or together with conventional treatments, such as physical therapy, pain medication, and exercise [adding nothing to something does not increase the net effect].

That is some interesting sentence structure, worthy of Animal Farm: even though acupuncture doesn’t work, and isn’t first line therapy for pain, it should be used for first line therapy. Although the qualifiers ‘not been established,’ ‘suggested’, ‘may be,’ and ‘not unreasonable’ muddy the water with their density.

Acupuncture is a regulated discipline, and patients should be referred only to practitioners who are licensed by the state in which they practice.

Why? It’s like Duck’s Breath Mystery Theatre’s Dr. Science. A license to practice ineffective nonsense still results in ineffective nonsense.

In the traditional practice of acupuncture, needle insertion itself may be accompanied by a variety of ancillary procedures, including palpation of the radial artery and other areas of the body, examination of the tongue, and recommendation of herbal medications. All of these steps are based on the application of principles of traditional Chinese medicine, as opposed to Western physiological and medical concepts. To what extent such procedures may contribute to the psychological milieu of acupuncture is unknown, and only a few studies have examined the context in which acupuncture treatment is delivered.

Note, it is not that radial artery palpation and tongue examination increase the diagnostic accuracy, it is to contribute to the psychological milieu. Like a psychic talking to your dead parent, it is important to make the environment conducive to fooling the patient into believing that an actual effect is occurring.

Take the pulse. In TCM they are not looking for tachycardia, but imaginary diseases based on imaginary diagnosis. An example:

Each pulse position can reflect different phenomena in different situations. For example, in a state of health, the left middle pulse (Liver) will be relatively soft and smooth, neither superficial nor deep. Therefore, we can say the liver and gall bladder energies are balanced or that the Yin and Yang within the Liver/Gall Bladder sphere are balanced. If a patient is experiencing migraine headaches and her pulse feels wiry (harder or tighter than normal) and more superficial and pounding, then we may diagnose this as Excessive Liver Fire (Yang) Rising (up the Gall Bladder channel to the head). The pulse reflects the rising energy.”

Or tongue examination, which is another example of prescientific nonsense where the body is represented on the tongue.

The editors of the NEJM seem to think this is reasonable, worthy of unqualified discussion. Of course, there is no reference to demonstrate that these additions increase diagnostic or therapeutic accuracy.

The practitioner may further stimulate the needle with electrical current (electroacupuncture), moxibustion (burning the herb artemisia vulgaris at the end of the acupuncture needle), or heat.

Why? No data given that this nonsense increases efficacy. I keep telling myself this is the NEJM, adding their imprimatur to the respectability of burning a plant on top a needle stuck in the skin to ease chronic pain. Then they note that patients need multiple treatments, a minimum of 12, with boosters, and they need to come in to prophylactically keep their spine aligned — no wait, the last is what chiropractors do. It seems, at 65 to 125 dollars a pop, that acupuncturists have recognized the financial wisdom of D.D. Palmer’s descendants. The NEJM is suggesting that people pay around 1200 bucks for what is, at best, a placebo.

The authors go on to the adverse effects. “8.6% reported at least one adverse event, and 2.2% reported one that required treatment.” Pretty impressive complication rate for an expensive, ineffective therapy! They do not mention that in the acupuncture/toothpick for knee pain study, toothpicks had the same effect as acupuncture and zero side effects, nor do they mention the well-reported cases of infection from sloppy aseptic technique.

I will ask you. If you have two procedures of equal efficacy and one has zero side effects, are you not ethically bound to suggest the procedure with no complications? If you are going to suggest acupuncture, ethically you have to offer sham acupuncture with twirled toothpicks, especially when what you offer is no better than a placebo effect.

Then, in the areas of uncertainty section of the review, they note that the effects of acupuncture are mostly explained by elaborate placebo effects. Benefit from acupuncture is

mostly attributable to contextual and psychosocial factors, such as patients’ beliefs and expectations, attention from the acupuncturist, and highly focused, spatially directed attention on the part of the patient. These studies also seem to indicate that needles do not need to stimulate the traditionally identified acupuncture points or actually penetrate the skin to produce the anticipated effect.

It does nothing, and you do not need to do acupuncture to get the effect. Acupuncture has complications and ethically can one recommend and charge for an elaborate placebo? I do not think so. Not the authors.

The patient in the vignette has chronic back pain that has not responded to a number of medical treatments.

So instead, we will go with the unethical, expensive, useless placebo.

He has specifically requested a referral for acupuncture, and we would suggest a course of 10 to 12 treatments over a period of 8 weeks from a licensed acupuncturist or a physician trained in medical acupuncture.

Can you believe this? From the NEJM! Such total tripe. I rely on the NEJM to provide reviews of relevant medical topics as, outside of ID and quackery, I do not have the time to read the primary literature. If this is the best NEJM can do on a topic upon which I have some background, then I suppose I cannot trust them in the future. As I tell my kids, you can judge a person by the company they keep.

The NEJM has lost some of its credibility. I doubt they will ever get it back.

Posted in: Acupuncture

Leave a Comment (106) ↓

106 thoughts on “NEJM and Acupuncture: Even the best can publish nonsense.

  1. sirreal says:

    Marvelous, brilliant, QED!

    Conservatively speaking, you and your esteemed colleagues at SBM have put 1000 nails in the acupuncture coffin. Of course the influential Integrators of Woo and their enablers at formerly respectable institutions will find a way to exhume the rotting corpse, dress it up, and do their best “Weekend at Bernie’s” routine for the oblivious partyers, aka “the American public.”

    That said, I have a recurring, not-so-minor quibble. Speaking as a former editor at a national magazine, I am not particularly distraught by the precipitous decline of print media. But I often have occasion to lament the abandonment of copy editing, because almost all blogs are riddled with typos — never mind grammatical errors, which I can usually overlook with equanimity.

    As I read your devastating critique of the NEJM and acupuncture, I couldn’t help noticing numerous typos, a few of which altered or obscured the points you were making. One of them actually made the OPPOSITE point that you intended. You, and SBM, need to do something about this. Really. And that is my only criticism of SBM, my all-time favorite web site.

    I will forward your post to everyone on my email list; but first I will copy and paste and then edit out some of the most egregious typos. So PLEASE, in the future, find someone to copy edit these essays before you post them. If you can’t find someone, I will volunteer, with the caveat that I was never a stellar copy editor.

    Thanks again, Mark. I have listened to, and applauded, every episode of QuackCast. I just wish there were more people I know who would appreciate it. We win battles but seem to be losing the war.

  2. Steve S says:

    Very good article. Yes, I think there is a organized or what seems to be an organized effort of integrative medicine to gain entry into academic medicine to gain legitimacy. One of the strategies is if you cannot overwhelm them with quality, then overwhelm them with numbers. Something is bound to lead through. I teach at a Family Medicine residency and one of my “colleagues” did the integrative medicine fellowship at Arizona and is trying to get it in our residency, indeed our medical school. I have countered by teaching a course in evolutionary medicine and specifically teach on how woo works, or don’t work. The residents I know, I have been told, like my lectures better. And they come to me for advice, not my “colleague”.

  3. David Gorski says:

    There was procedure for the treatment of angina where they ligated the internal mammary artery. The theory was that by tying off the artery the back pressure forced blood down the coronary arteries and relieved cardiac pain.

    Angina improved and there are about 40 plus papers in the 50’s and 60’s on the benefit of the procedure as well as the underlying physiology of the procedure. Mammary artery ligation ‘worked’ and was popular in the early 60’s. Until the procedure was compared to a sham operation. That’s right. The opened people up and did nothing.

    There were all sorts of procedures like this in the 1930s through 1960s, before the advent on coronary artery bypass surgery. My favorite was called poudrage, which was popular in the 1930s and 1940s. Basically, poudrage involved opening up the chest via a median sternotomy, opening up the pericardial sac and sprinkling sterile talcum powder on the muscle of the heart. The idea was that the inflammatory reaction caused by the powder would result in angiogenesis (i.e., the ingrowth of new blood vessels) into the heart muscle. Advocates of poudrage produced very similar seemingly impressive results in patients with angina; that is, until a randomized trial was done versus sham surgery.

    Actually, the placebo effect from surgery alone has confounded trials of coronary artery bypass, leading to the questioning of whether it is as effective as we have traditionally believed.

  4. baldape says:

    Not to derail this discussion – but could SBM consider a new function… something managed as an “open thread”, but for the express purpose of allowing the “little people” to propose subjects that may be of interest to the general SBM readership, but may have escaped the attention of the SBM authorship. The “open thread” format would allow other little people to speak out for/against proposed ideas, so the SBM authorship can get a pulse on whether a given topic is of widespread instrest before vesting substantial time/energy into it.

    Not to get too meta, but such a thread would be perfect for submitting the idea about a “proposed topics thread” without derailing unrelated discussions :-).

    Some advantages:
    1) With this function in place, SBM authors would have a quick and easy recourse to those who flood them with proposals – a quick redirect to the proposal thread. In addition, it may offer reprieve from what I’m sure is dozens of notifications that arrive after articles such as the NEJM accupuncture article is published.
    2) It would allow meek readers such as myself to submit ideas without the sense that we’re bothering very busy people with what might be incredibly inane topics (or, as the case may be, that we’re derailing ongoing discussions with unrelated topics).

    If this suggestion alone seems too arduous, perhaps a simple mailing address “proposals@sciencebasedmedicine.org” would be a worthy middle-ground idea.

  5. squirrelelite says:

    @baldape,

    Dr Novella has such a thread on his Neurologica blog.

    http://www.theness.com/neurologicablog/?page_id=355

    I don’t remember if one was started for this blog.

    Accessing it when it’s been dormant for a while can be a bit of a nuisance.

    I noticed on Neurologica, it’s linked to in the “pages” section at the upper right hand corner of the home page.

    Perhaps something similar could be done at SBM like adding a link under Categories or, more obscurely, linking to it on the Contact Us page.

  6. Hey NEJM: thanks a lot. Really. Thanks to you, NEJM, I will get more hate mail.

    Because I criticize acupuncture on my website, PainScience.com (link), I can now look forward to many more years of daft acupuncturists sending me cranky email and citing this goofy frackin’ paper as if it vindicates them and incriminates all of acupuncture’s critics. Some of them will even accuse me of being “anti-scientific” because I don’t heed the words of the mighty NEJM!

    It won’t matter that that the authors, biased as they were, still had to admit that acupuncture cannot actually beat a placebo. It won’t matter that acupuncture has already been beaten silly by quite a few excellent RCTs now. Nope, acupuncture apologists will still cite it anyway, fanning the flames of manufactroversy, every single one of them positively tripping over themselves to benefit from the NEJM’s apparent endorsement, to get a bit of warmth from the fire of science … even as they hypocritically attack “Western empiricism” in the next breath, of course.

    I will not answer most of those emails, of course, because I have much better things to do than argue with cranks and ideologues who can’t define a single logical fallacy. But, NEJM, every time I get one of those emails, I will think of you, and how you used your reputation to breathe life back into a dead, stupid horse.

    Yeah. Thanks a lot. Good work, NEJM. Slow clap.

  7. Kausik Datta says:

    What’s with the hate on Dumbledore and Gandalf? :(

    At SBM, we can separate fact from fiction. It’s a disappointment that NEJM appears to have difficulty in doing so. And not just NEJM; several other journals have been guilty of shoddy peer review and passing off magical thinking as legitimate – the recent Virology Journal affair and last year’s Proteomics affair jump to mind.

    It should be a concern for all rational individuals.

  8. Jann Bellamy says:

    That’s not all the Terrapins are doing for acupuncture:

    “The AAAOM [the American Association of Acupuncture and Oriental Medicine] is pleased to announce the “The World Conference on Integrative Medicine and Patient-Centered Care-2011 – Bridging and Defining AOM-CAM and Allopathic Medicine in U.S. Healthcare Delivery.” This historic event, to be held in Baltimore, Maryland, May 13-15, 2011, is co-sponsored by the AAAOM and the University of Maryland, School of Medicine, Center for Integrative Medicine. Read about our exciting preliminary program overview. This event brings together the diverse disciplines of AOM-CAM and allopathic medicine to formulate a foundation for integrative medicine and patient-centered care.”

    http://aaaom.affiniscape.com/index.cfm

  9. Jann Bellamy says:

    P.S. I wonder if Dr. Briggs will make this one.

  10. CarolM says:

    I like baldape’s idea, but the problem I see is that the popular subjects may lie outside the authors’ various specialties, and if there is one thing we can be sure of at SBM it’s that the writers will stick to their fields of expertise. So maybe it’s better that they pick their own topics.

    Anyway, great takedown, but I agree with sirreal that boners like “they loose all respectability” cause me to lose my respect for the literacy of the author. (And posting a link at my own blog would cause my readers to lose respect for my literacy.)

  11. Mark Crislip says:

    To paraphrase Bones Macoy, I’m a doctor, not a writer.

    But for those who are sensitive to typo’s, wait 48 hours after posting to read my entries. We have an editor who fixes all the typos that I seem unable to notice.

    That way you do not have to worry about all my deranged apostroph’e's’ and speling eroors/

  12. Ian says:

    Does anyone else find the term “Western medicine” offensive on behalf of all the medical research and science-based medicine which happens all over Asia?

  13. David Gorski says:

    P.S. I wonder if Dr. Briggs will make this one.

    It’s in Baltimore, which is so close to Bethesda, I don’t see how she could refuse an invitation.

  14. Chris says:

    Ian, yes I do find “Western medicine” offensive for so many reasons. One is the claim that homeopathy is not “western” standard snark question is “did Germany leave Europe?”. Other snark question is to ask is the DTaP and varicella vaccines okay dokay because they were both developed in Japan.

  15. daijiyobu says:

    Great post, great justifiable swagger as well.

    -r.c.

  16. WilliamLawrenceUtridge says:

    Every time someone says “western medicine” I immediately, aggressively and loudly proclaim that “western medicine” is about as accurate as “Jewish medicine”. I freak the eff out. The only thing that gets me more worked up is when someone mentions “toxins”. Unless they’re talking about poisonous levels of lead in the water, shut up. Just shut up you ignorant wanker.

  17. Chris says:

    Unless they’re talking about poisonous levels of lead in the water, shut up. Just shut up you ignorant wanker.

    Or the toxins created by bacteria, like botulism and tetanus!

  18. Maz says:

    It adds insult to injury that, in their most recent issue, the NEJM failed to print any letters critical of the acupuncture review. If you’re going to publish a crackpot study in a “controversial” field, the very least you can do is publish a well-written retort.

    The fact that the editors felt compelled to publish the study AND ignore the many letters (which I am sure they received) slamming it brings them so much lower in my book. I don’t think I’ll be renewing my subscription.

  19. David Gorski says:

    @Maz

    This is not unusual, nor is it slow for the NEJM. The NEJM is not a blog, and it still functions as a regular medical journal.

    In any case we at SBM submitted a letter to the editor about the acupuncture review. According to the NEJM guidelines, you have three weeks after the issue in which an article appears to submit letter to the editor. The acupuncture review appeared in the July 29 issue, meaning that the deadline to write a letter to the editor over the acupuncture review is August 19, still nearly a week away. I don’t expect to see any letters to the editor about the acupuncture review to appear before an NEJM issue due out September. After all, in the August 12 issue (which was just released), there are letters to the editor discussing a study in the April 29 issue.

    In other words, hold your horses. The letters will appear eventually. The NEJM isn’t the blogosphere.

  20. Wolfy says:

    @Ian

    I have always found the term “western medicine” irritating precisely for that reason.

  21. art malernee dvm says:

    To paraphrase Bones Macoy, I’m a doctor, not a writer.>>>

    Mark, I think its MaCoy not Macoy.

  22. Samantha says:

    Actually, you’re both wrong. It’s McCoy. Leonard “Bones” McCoy.

    /star trek geek

  23. JMB says:

    Maybe NEJM would designate someone as an SBM editor for the publication to regain credibility. Dr Crislip would be perfect for that position.

  24. gretemike says:

    A while back in another thread when I was comparing Reiki practitioners to Jedi Knights, dg said that “if a Reiki practitioner gets a light saber . . . then I’m signing up!” I wonder if he’d settle for a lot of tiny needles?

    I can understand why uneducated folks believe in this stuff, but it’s really perplexing to see this stuff gain so much traction among the (presumably) well educated.

    A recent response to a previous post asserted that you folks at SBM are spending too much time focusing on patently ludicrous practices like . . . alchemy, I think it was. This NEJM article strongly rebuts that assertion.

  25. Pman says:

    The NEJM has long been short on credibility, dating back to some of their bisphosphonates studies published earlier in the decade.

  26. Dr Benway says:

    NEJM, where peer review= spell check.

    Hat tip to The Last Psychiatrist.

  27. Yeah, read that Last Psychiatrist quip about the NEJM. Ouch. But …

    A question for those more familiar with NEJM than I am: does it really have such a reputation, or did this recent acupuncture debacle come out of left field?

  28. The Blind Watchmaker says:

    Why is it becoming so politically correct for rationally thinking physicians, scientists and people in general to act as if nonsense deserves such special pleading?

  29. MOI says:

    Excellent. Simply excellent.

  30. pmoran says:

    “Why is it becoming so politically correct for rationally thinking physicians, scientists and people in general to act as if nonsense deserves such special pleading?”

    I am uncomfortable about some of the material in the NEJM paper, too, but I believe the differences which lead some to be more tolerant of CAM than others are more subtle than is being suggested here.

    The starting point is different– a preoccupation with the pressures of patient care, rather than with the purist, highly restrictive, “working better than placebo” scientific model that quite correctly dominates most of medicine. Everything in medicine is context dependent.

    Consider this-

    Chronic back pain is a condition for which the mainstream has no satisfactory solution. Who here has that anywhere near the forefront of their thinking?

    Non-randomised studies show significant benefit from acupuncture in this condition, with reasonable cost-effectiveness in terms of QALYs in some populations.

    I think everyone knows on some level, even most acupuncturists, that the apparent benefits stem from non-specific influences, and not from the workings of untenable old Chinese medical theories. Whenever I have challenged acupuncturists it is clear that their certainties lie with that it “works”, not how it works.

    It is possible, of course, that the oriental mystique favours placebo responses for some patients. Less obviously placebo-related influences may be operative: the enforced relaxation, the additional socio-medical interactions, distractant or counterirritant effects, or endorphin release (?).

    Our SBM authors have to minimise such influences. Some possible mechanisms of benefit are ignored and true placebo “effects” are held to be too small to be worth worrying about. I worry, partly from my own introspection, that the main concern is an unwillingness to give an inch to “woo”. These stances are certainly opinion, and not based upon conclusive science.

    SBM has a fall-back position – ethical problems with the use of placebo – but they are also a matter of opinion, and also often based upon a complete mischaracterisation of how such treatments come to be used in practice. It is also not a science-based judgement .

    We may with acupuncture be being handed a moderately useful and reasonably safe, publically acceptable semi-placebo on a platter, yet we reject it because we think it contains large placebo elements (like anti-depressants?) . We should not do this lightly, in my opinion.

    I am well aware of all the stumbling blocks for the incorporation of such treatments into the mainstream, but this is partly about where we set our thresholds for opposing, endorsing or being permissive of what distressed patients might like to try when we have failed to solve their problems, also whether we can relax a bit about the science when it doesn’t much matter and may benefit our patient.

    The above should be read along with the understanding that medicine has probably always been thus (a complex mixture of influences), and is likely to be so for a long time yet. Over possibly millions of years, humanoids seem to have developed a beneficial collusion with their healers so as to repsond positively to any kind of healing ritual, some more than others, and, importantly for the present shape of medicine, to feel deprived and possibly worsened when no remedies are forthcoming.

    I expect the usual slippery slope arguments but can point towards intensive use of acupuncture in various countries without celestial catastrophe for either science or for the mainstream. I believe the public is also more discriminating than we like to think.

  31. “He has specifically requested a referral for acupuncture, and we would suggest a course of 10 to 12 treatments over a period of 8 weeks from a licensed acupuncturist or a physician trained in medical acupuncture.”

    Whatever your opinions about placebo, the fact is that nothing in the article supports these specific recommendations.

    Why 8 to 12 treatments? Nothing in the article supports that 8 to 12 placebo treatments offer higher value than 4 to 6 or 30 to 45.

    Why over a period of 8 weeks? What do we know about the natural course of low back pain that suggests that the nonspecific effects of a placebo intervention would provide most perception relief in this time period?

    Why a licensed acupuncturist? What is medical acupuncture? What is the benefit (to the patient, to medicine, to the public) of having a doctor offer a treatment they know to be a fraud? None of these questions are answered in the article, so the conclusion drawn is entirely unsupported.

    My understanding is that the usual formula is like so: “Acupuncture is not a medical treatment, so I can’t give you a referral. But some people do say it helps them, so you could try it. If you do, please let me know how it goes.”

    What is the rationale for the doctor referring the patient to a magician instead of providing the usual, professional response? This is not addressed in the article either.

    It would be perfectly fine to discuss the ethics and realities of medical doctors referring patients to practitioners of magic. But that is not what this article does.

  32. gretemike says:

    pmoran wrote that he “expect[s] the usual slippery slope arguments but can point towards intensive use of acupuncture in various countries without celestial catastrophe for either science or for the mainstream.”

    Reiki is in widespread use in hospitals, and I’ve heard that homeopathy is fairly common too. NCCAM . . . I think invoking the name says enough. Additionally you have shoddy (fraudulent) research conducted or proposed for things like the MMR/autism link, chelation therapy and others. Was Wakefield not a catastrophe?

    Slippery slope argument? No, I’m beyond arguing whether there is a slippery slope in the future. Right now all you’re hearing from me is my screams as we continue to hurtle full-speed downhill.

  33. pmoran says:

    Gretemike, I can argue as strongly as you that neither Reiki nor acupuncture should be used in hospitals in most of the likely contexts. But my argument will work. It will say that even if these methods bring comfort to some, there will usually be better ways to employ the resources.

    This reduces the tendency for debate to get bogged down in bitterness, and scientific considerations that only a well-informed elite finds sufficiently conclusive when set against the impressive anecdotes that make most lay people want to give such methods the benefit of the doubt.

    In fact all of my argument is based upon strict cost/risk/benefit grounds, merely adding the dimension that we are as yet not certain as to the potential benefits of non-specific medical attentions when centred upon dubious central precepts.

    For example studies are in progress to determine if “acupuncture” reduces the need for opiates in cancer patients. I have neutral expectations of that, but this is a fairly objective outcome that SBM might have to seriously think about if the results are positive. Other studies strongly suggest that both acupuncture and its sham have a useful effect in preventing migraine.

  34. Dr Benway says:

    pmoran,

    Traditional Chinese Medicine is driving the rhino to extinction.

    It should be banned.

  35. David Gorski says:

    SBM has a fall-back position – ethical problems with the use of placebo – but they are also a matter of opinion, and also often based upon a complete mischaracterisation of how such treatments come to be used in practice.

    Really? “Completely mischaracterized”? Please, Dr. Moran, educate us regarding how any, some, or all of us have “completely mischaracterized” how such treatments come to be used in practice, thus undermining the argument that it is ethically dodgy to use placebo medicine like acupuncture. We are, of course, dedicated to accuracy; so naturally I want to know if I or any of our bloggers here are misrepresenting anything. Otherwise, how are we to learn to do better and come to correct our mistakes? Please be specific, because the times our bloggers have argued that placebo medicine is ethically problematic, I generally recall careful, considered discussions that take into account that the question is not black and white. Perhaps you didn’t read the same discussions I did.

    It is also not a science-based judgement.

    Where have we ever said that it was? And, given that we have never claimed that it was, why mention this? Personally, I simply assume that ethics are so incredibly important in medicine that it is seldom necessary even to say it explicitly. Science-based medicine is paramount, certainly, but ethics must also play a role. Otherwise, we could easily justify a number of highly unethical practices based solely on science, particularly in the realm of research.

  36. gretemike says:

    Dr. Moran,

    You correctly predicted the slippery slope argument and tried to defuse it by pointing to a lack of celestial catastrophe where acupuncture is practiced. I don’t think the slippery slope argument should be so easily dismissed.

    Aside from my original point about how serious and widespread woo and fraud has become, If you refer a patient as suggested in the article’s limited vignette are you not necessarily at least implying approval of acupuncture’s broader claims?

    “The conditions claimed to respond to acupuncture include chronic pain (neck and back pain, migraine headaches), acute injury-related pain (strains, muscle and ligament tears), gastrointestinal problems (indigestion, ulcers, constipation, diarrhea), cardiovascular conditions (high and low blood pressure), genitourinary problems (menstrual irregularity, frigidity, impotence), muscle and nerve conditions (paralysis, deafness), and behavioral problems (overeating, drug dependence, smoking).” – http://www.quackwatch.org/01QuackeryRelatedTopics/acu.html

  37. Calli Arcale says:

    Dr Benway, pmoran:

    It’s not just the rhino that’s being driven to extinction by TCM (though I will note that banning TCM probably won’t save the rhino; the horn is desired also for traditional Arab daggers and other decorative purposes, and some populations may already beyond the point of no return given that captive breeding is extremely difficult, making it harder to envision the sort of recovery plan that got the Bald Eagle off the endangered species list).

    Other species prized for medicinal purposes:
    * bears
    * seahorses
    * pangolins
    * sea turtles
    * musk deer
    * tigers
    * sharks
    * coral (and anything that lives on and around it, which is a hell of a lot)
    * wild American ginseng (it can be and is cultivated, but is still poached in dangerous quantities)
    * snow lotus

    Not all of these are endangered yet, but some are facing extinction, and for the rest, it is probably only a matter of time, especially since TCM is hardly the only threat these animals face. Many are eaten in unsustainable quantities, often prized as either cultural icons or status symbols when eaten, and/or taken for decorative purposes (either as pets or taxidermy or because their parts can be used to make other things), their habitats are eroded by human development, and conflicts with humans cause more and more to be put down for human safety.

    It is very sad indeed that in China, where a growing upper class is driving ever more consumption of these species, hardly anyone is seriously considering abandoning use of these species. Instead, the solution offered is to farm the animals. The likely outcome, if that route is pursued indefinitely, is that the animals will ultimately live nowhere except in farms and zoos. Those which breed very rapidly may sustain wild populations (alligators, for instance, have done fine since alligator farming began), but the slow-breeding ones (e.g. rhinos) will remain costly and this will be more than enough to drive poaching. Especially since farming of rhinos is probably not possible — it’s extremely difficult to breed them in captivity.

  38. David Gorski says:

    One of your best posts, IMHO.

  39. pmoran says:

    David, again, I was not thinking only of this blog.

    Nevertheless, I performed an SBM blog search on “placebo”. I quickly found “placebo medicine is a sham”, which is to me a bit simplistic, but it was clearly going to take the rest of my life to go through the innumerable finds and assess every mention of placebo use in the way you suggest.

    I remember reacting to placebo use being characterised as “lying to the patient”, but that may have been said in a comment.

    Anyhow, I still suggest, and anyone here can argue against me if they wish, that the pronouncement that ” placebo use is unethical” usually has in mind the simplest possible instance, wherein the ethical issues are clearest and there is no redeeming context, i.e. MDs prescribing frank placebos with no expectation of worthwhile benefit.

    Now I am sure that sometimes happens, with lazy doctors wanting to get on to the next patient. But most use of the medicines we regard as placebos, or mainly placebo, is by practitioners who believe that they work, who have some grounds for believing that they may work, or who are responding to a patient enquiry – a situation requiring separate consideration.

    Placebo medicines are also mostly used by doctors when there are no obviously superior conventional methods, and there is the potential for adverse outcomes if the practitioner does not seem interested enough to explore available options.

    Then there are the many doctors, for example Andrew Weil and probably also Ted Kaptchuk who believe that placebo responses are strong enough as to rival many drugs. There is some evidence that this is so, especially if placebo responses are deliberately enhanced. If accurate, this suggests that the ethical objections to placebo use are based upon a preciousness concerning HOW a treatment is being represented as working rather than WHETHER it works and that the ethical objections can be legitimately avoided by the right wording.

    At least one medical ethicist has allowed that placebo use is ethical if the practitioner believes that placebos work — to which I would add that there are also no better options.

    So, as you say, it’s not black and white.

    I am now not even sure myself what I meant by “not a science-based judgement”. I think I had in mind certain opinions upon which the ethical position depends, for example that any true benefits from placebo are feeble enough to be readily forgone, or that they can be easily mimicked within strictly science-based, fully informed consent, conventional medicine.

  40. pmoran says:

    Focus, chaps! Even the longest bow cannot connect anything I said about acupuncture with TCM herbalism. Or is this another version of the slippery slope argument?

  41. weing says:

    “Now I am sure that sometimes happens, with lazy doctors wanting to get on to the next patient. But most use of the medicines we regard as placebos, or mainly placebo, is by practitioners who believe that they work, who have some grounds for believing that they may work, or who are responding to a patient enquiry – a situation requiring separate consideration.”

    I disagree. Historically, I thought that placebos were prescribed at the request of the patient. Hence the name. They did not expect it to do anything, they prescribed it to simply please the patient. So, if a patient wants me to prescribe an inert substance that he thinks will help him and I do so, I am prescribing a placebo. If I prescribe an active substance, that is something else. If I prescribe an inert substance and tell the patient it will help him, that is not placebo in the original sense.

  42. halincoh says:

    My son and I created two goofy little videos to convey the message of this NEJM article.

  43. Dr Benway says:

    pmoran,

    Professional acupuncture is a guild with colleges, degrees to the doctorate level, licensing, lobbying, etc. That guild also practices TCM.

    That guild also tends to be anti-pharma and pro-dodgy supplements-t0-kids-with-autism.

  44. JMB says:

    The publication of such an article in NEJM just exposes some of the weaknesses of the peer review system. Editors know which reviewers are difficult and which are easy. An editor can do a favor to a submitting author by sending the paper to easy reviewers. When I was starting in academic medicine, I was instructed on the importance of getting introduced to the editors of the prestigious journals at the national meetings. The social network of academic medicine was just as important for getting an article published in a peer reviewed journal as the scientific rigor. Needless to say, the editors risk considerable loss of prestige when such poor papers are published. However, the most important prestige to them is still that in the community of senior academic medical scientists that they socialize with at the meetings. Hammering them with the fact that their scientific standards have been compromised may still have an effect. Good luck to the faculty of SBM at hammering them with their failing.

    I remember in the guidelines for publication of a scientific paper that the author was given a certain amount of leeway in the discussion of the results to speculate about some of the possible consequences of the results of the study. Statements could pass in the discussion that were speculative. However, statements in the paper under question are so far beyond the bounds of what may be speculated based on the results that it could be argued that the paper should be retracted.

  45. pmoran says:

    Gretemike: “Aside from my original point about how serious and widespread woo and fraud has become, If you refer a patient as suggested in the article’s limited vignette are you not necessarily at least implying approval of acupuncture’s broader claims?

    “The conditions claimed to respond to acupuncture include chronic pain (neck and back pain, migraine headaches), acute injury-related pain (strains, muscle and ligament tears), gastrointestinal problems (indigestion, ulcers, constipation, diarrhea), cardiovascular conditions (high and low blood pressure), genitourinary problems (menstrual irregularity, frigidity, impotence), muscle and nerve conditions (paralysis, deafness), and behavioral problems (overeating, drug dependence, smoking).” – http://www.quackwatch.org/01QuackeryRelatedTopics/acu.html
    ___________________

    PM Think of it this way — people can respond positively, in subjective ways, to any treatment whatsoever.

    This is why historically there is virtually no substance or human activity that has NOT been credited with healing powers — everything from animal dung in the ears to spending the night in the appropriate Greek temple. It is also why we now have CAM, aided by unmet medical needs that lead folk to be constantly trying out this treatment and that and inevitably stirring up belief in them.

    This generic medical activity is so pervasive that we have had to develop extraordinarily sophisticated placebo- controlled RCTs to answer some kinds of scientific question.

    Of course, the “benefits” are only partly real, and part illusion. Some is from spontaneous improvements in symptoms, for many possible reasons. Some, we believe, is due to reporting bias, such as patients trying to please their doctor by giving the right answer. That happens a lot.

    The 64 million dollar question is “what is left?” after taking out the spurious? I am trying to say in various ways that we are not as scientists entitled to assume, on no sound evidential basis, that there is nothing left, or nothing worth taking into account when tuning up our reactions to the availability of these methods, their use by our patients and how others behave tpowards them. We know that people can be very suggestible, and there is no reason why this should not extend to the perceptions that define and measure illness.

    A few responders to the posts were expressing dismay and disbelief at the tolerance of CAM by some, and it was to this that I was responding, trying to point out that it is mainly outlandish if you can find no positive side at all to it and cannot see it as a possibly inevitable phase in the evolution of medicine.

    More bothersome to me is when supposedly science-oriented practitioners cannot grasp on at least some level that the pseudoscience is merely CAM’s “schtick”. It does not in any way demand serious scientific attention. From the excerpts I have seen the NEJM article may not have sent a clear enough message in this regard .

    My views regarding the possible non-specific benefits of what Harriet has called “comfort medicines” will change in a flash when or if the science firms up against it. I hate being thought to be encouraging pseudoscience. I simply think patient needs should always be our first priority.

  46. pmoran says:

    Weing, actually modern use of the term placebo has a less than savoury history. Everyone refers to “Beecher’s seminal paper” on the subject published back in the 60s where he describes among other matters how with severe post-operative pain a saline injection can appear to work as well as 20mgm morpine.

    I have a copy of that paper and it would give most of us the horrors today. He believed that responsiveness to placebos was part of a neurotic tendency. The attitudes of those times may be partly responsible for alt.med supporters today reacting so negatively whenever it is suggested that their testimonials may indicate a placebo response.

    You are right that it is difficult to define exactly what a placebo is especially in the light of evidence that it may have limited physiological effects. It is so easy to get as tangled up in the semantics that I usually chicken out .

    When I was referring to “placebo use” or “placebo medicine” I I had in mind any use of remedies that SBM would regard as placebos. But you are right that what the prescriber is thinking is a more usual determinant.

  47. daedalus2u says:

    pmoran, do you have a reference for the animal dung in the ears treatment? That is very interesting to me because animal dung is often a very strong source of NO/NOx due to the nitrifying bacteria converting ammonia into nitrite. Crocodile dung was used as a pessary by ancient Egyptian women (I think as a sexual stimulant) and I have measured very large NO fluxes from composted chicken manure (a crocodile dung simulant). The ears would be a good application point because they are well vascularized and the skin is thin.

    I think the scalp is the main physiological site for these bacteria, and the NO/NOx they produce is the reason emissary veins drain through the skull, to better supply the NO/NOx they produce to the brain.

    I think that dung in the ears would trigger the physiology of the placebo effect pharmacologically.

    I agree with you that many people do get hung up in the semantics of what a “placebo” actually is. They acknowledge that people seem to derive therapeutic physiological effects from placebo treatments, but then don’t acknowledge that those effects must be due to physiology. This is a disconnect between the usual SBM approach. If there is “something” happening therapeutically through the placebo effect, that “something” must be happening via physiology. We may not understand the mechanism(s) of the physiology of the placebo effect, but we know that it isn’t mediated via magic or chi, or prana or spirits, but via chemistry and physics mediated through evolved physiology.

  48. Dr Benway says:

    A few responders to the posts were expressing dismay and disbelief at the tolerance of CAM by some, and it was to this that I was responding, trying to point out that it is mainly outlandish if you can find no positive side at all to it and cannot see it as a possibly inevitable phase in the evolution of medicine.

    Individual doctors may prescribe placebos from time to time for valid reasons. That doesn’t alter the general rule against misleading patients.

    An analogy: we have a rule against killing other people. However, sometimes we forgive a homicide, for example as in self defense when escape is impossible. But we usually want to understand the details of a particular case before we offer our forgiveness. We make our decision to acquit on a case-by-case basis rather than according to a general rule of thumb.

    pmoran, when you challenge the rule against knowingly prescribing an unproven or disproven therapy, I get the feeling you have in mind particular patients or situations where using a placebo might prove useful. I don’t doubt those situations exist. Human relationships, including the doctor-patient relationship, are unique and usually rather messy.

    If I say that we need a rule against knowingly saying or doing things to mislead patients, yet we also must allow exceptions to that rule on a case-by-case basis, will you and I agree?

    “CAM” is a hungry coalition of politically connected wealthy individuals and corporations. Some want to make money. Others, such as the Scientologists, want to “clear the planet.”

    Opposition to organized, evangelical CAM invading our medical schools and hospitals doesn’t mean an individual doctor is going to get spanked for telling a half-truth to an anxious patient for perfectly understandable reasons.

  49. Harriet Hall says:

    Dr. Benway said “Individual doctors may prescribe placebos from time to time for valid reasons. That doesn’t alter the general rule against misleading patients.”

    I think this is the key. We have ideal, universal rules: no murder, no deception of patients with placebos. In some situations we don’t live up to those ideals because there are individual cases where we think breaking that rule is justifiable because there is some higher principle that over-rides it. But we think very carefully about those individual cases, we don’t make the decision lightly, and our consciences suffer as we wonder whether we were really justified. It’s like lying: lying is “always” wrong, but there are cases where telling a little white lie is the kind, humane thing to do. If we have the sense that we are breaking a rule, we will be selective and will break the rule judiciously.

  50. pmoran, I would still like you to discuss the issue of doctors prescribing acupuncture, given the following assumptions:

    1) The placebo effect is a genuine entity that goes beyond a bias in self-report.

    2) Doctors know that acupuncture has only non-specific placebo effects.

    3) Bigger placebos generate more positive effects on the body. A “bigger” placebo may be one with more manipulation of the body, a more detailed background story, or a higher price. Acupuncture can meet these criteria easily, especially with a background story that involves a life force to be protected by keeping the body free of toxins. A routine doctor’s visit with cognitive services may not meet all of these criteria, especially if it is short.

    Ok, so we have made all these nice assumptions. Questions:

    What is the benefit to having the doctor actively prescribe acupuncture, rather than simply allowing the patient to seek it out themselves?

    If “bigger” placebos have bigger effects, is there evidence to weigh the costs and benefits?
    · More manipulation of the body means more risk. Chiropractors can cause stroke; acupuncturists can cause infection and pierce lungs.
    · A more detailed background story may also carry risk. If acupuncture works best if the acupuncturist can induct the patient into an alternative culture in which vaccines are toxic, is the benefit worth it?
    · A more costly intervention carries a risk too. What if the acupuncturist prescribes thousands of dollars worth of treatment which the patient could have used for something else?

    In the absence of evidence to balance the risks and benefits of placebo, do you feel confident enough to actively prescribe it?

    A related hypothetical: If you thought your patients would get more pain relief if you told them that vaccines would kill their children, would you?

  51. Interesting discussion on the use of placebo. I think I gather from the discussion that the use of placebo would rarely be recommended in SBM, yet years ago I came across an article in the NYT that suggests it may be quite common in the mainstream medical practice (internists and rheumtologists).

    I’ll skip the NYT article link and just give the PubMed to the paper… I’d be interested to hear folks observations on the quality of the survey. I remember at the time that I read the NYT article that I was quite disconcerted at the use of anti-inflammatory, antibiotics and sedatives in particular.

    “Prescribing “placebo treatments”: results of national survey of US internists and rheumatologists.”

    http://www.ncbi.nlm.nih.gov/pubmed/18948346

    “679 physicians (57%) responded to the survey. About half of the surveyed internists and rheumatologists reported prescribing placebo treatments on a regular basis (46-58%, depending on how the question was phrased). Most physicians (399, 62%) believed the practice to be ethically permissible. Few reported using saline (18, 3%) or sugar pills (12, 2%) as placebo treatments, while large proportions reported using over the counter analgesics (267, 41%) and vitamins (243, 38%) as placebo treatments within the past year. A small but notable proportion of physicians reported using antibiotics (86, 13%) and sedatives (86, 13%) as placebo treatments during the same period. Furthermore, physicians who use placebo treatments most commonly describe them to patients as a potentially beneficial medicine or treatment not typically used for their condition (241, 68%); only rarely do they explicitly describe them as placebos (18, 5%).”

  52. David Gorski says:

    Individual doctors may prescribe placebos from time to time for valid reasons. That doesn’t alter the general rule against misleading patients.

    Indeed. There are always specific exceptions to general rules. The problem is that, for example, acupuncture as currently practiced is nothing but one huge exception to the general rule that you don’t prescribe placebos that the only way to justify it as a practice is to rewrite the rules and say that it’s OK to prescribe placebos. Given the deception of both patient and practitioner inherent in the prescribing of placebos in “alt-med,” I’m uncomfortable with that idea.

  53. daedalus2u says:

    Using acupuncture as a medical treatment violates Feynman’s first principle of being a scientist.

    “The first principle is that you must not fool yourself and you are the easiest person to fool.”

  54. pmoran says:

    Alison: “In the absence of evidence to balance the risks and benefits of placebo, do you feel confident enough to actively prescribe it?”
    ___________________________________

    I think I have the drift of the several questions you ask and they do go to the heart of the matter. I have basically been saying that CAM should be assessed along the same cost/risk/benefit lines as conventional methods, even if they are mainly placebo. That raises methodological problems but they may be solvable.

    That is my overall answer, along with the opinion that the present evidence is compatible with a range of possible solutions to the relevant equations with very different implications for how we view placebo medicine and CAM.

    Thus, if you fear unintended consequences , such as an explosion of pseudoscience, from the cautious use of CAM in selected clinical settings, they must be weighed against any benefits.

    But you do need evidence. You are not entitled to ASSUME there is insufficient benefit to justify the hypothetical risks, or that any realistic expectations regarding the expansion of pseudoscience are necessarily going stop people seeking proper medical attentions. I think those risks are overstated, anyway. Despite the upsurge of CAM in the last few decades very, very few rely on CAM alone, even yet,, and proper medical science proceeds as usual.

    Yes, acupuncture has rare serious risks, probably with the poorly trained (wow! — there are reasons for training acupuncturists!). Yet we tolerate equivalent risk from NSAIDs because they also do some good things.

    So we must be consistent. The risks of acupuncture programs loom largest only when we assume there are no benefits at all. That might eventually be shown to be close to the truth for many clinical settings, but we are NOT entitled to assume so on the present evidence, only that the benefits are not related to the needling in any direct sense.

    In answer to your last question (above), in most settings the risks of placebo use are obviously minimal, and any benefits will swing the balance to the plus side.

    A classic example: Non-specific tiredness and lack of energy is/was a common complaint in family practice. After looking into it a little the doctor may know that there is not a lot that can be done about the problem until the unruly kids leave home and the financial problems are resolved. Yet the patient is still sitting there needing help. Sixty years ago such a patient would have invariably been prescribed a “tonic”, often containing iron and vitamins. A frank placebo, but at least some of those patients would have felt better for that simple attention.

    Tonics are probably too old-hat to appeal to the present generation, and I am now out of touch, not sure what present day doctors would do. I hope it does not involve the overuse of antidepressants or stimulants.

    Why not a bit of CAM, in patients amenable to it? This is why doctors are drawn to CAM; it is the pressures of everyday medical practice, not any attraction of the pseudoscience. They may well suspect that it is all placebo but they have no great reason to care.

    Does that help?

  55. JMB says:

    Science Based Medicine. Use of placebo in the art of medicine does not affect the science we use as our basis. Acceptance of pseudoscience cripples our scientific basis.

  56. pmoran says:

    David, it is easier for those of us in specialist practice to be pure and placebo- free in our prescribing. We can direct patients to their family doctor whenever they have complaints for which there is no clear SBM- endorsed answer.

    I think family doctors are the salt of the earth, that they nearly all want to practice ethical medicine, and that they are highly dependent upon maintaining the trust of their patients. Yet they will almost certainly be using a lot more placebo or semi-placebo medicine (and probably also CAM methods) than the internists and rheumatologists in the study Michele quoted.

    I can’t say that I feel wholly comfortable about that, just as you don’t. But it is one of the factors contributing to my interest in the non-specific elements of medical interactions. It is something that we need to understand. I suspect there is still a lot to be understood about medicine at its fringes.

    CAM practitioners sense it too. They are constantly trying to alert us to “healing outside the modern scientific paradigm”, but their pretentiousness, their tendency to drift off with their own fairies and especially their appearing to accept extreme “woo” makes it hard for us to take them seriously.

    Nevertheless, I keep being drawn to certain questions that I am sure can be examined within the conventional “paradigm” (it’s the only one, really). It is not easy. There is not yet even a wholly satisfactory vocabulary for the field — not within my capacity, anyway.

  57. pmoran says:

    daedalus2u: ” pmoran, do you have a reference for the animal dung in the ears treatment? .”That is very interesting to me because animal dung is often a very strong source of NO/NOx due to the nitrifying bacteria converting ammonia into nitrite. Crocodile dung was used as a pessary by ancient Egyptian women (I think as a sexual stimulant) and I have measured very large NO fluxes from composted chicken manure (a crocodile dung simulant). The ears would be a good application point because they are well vascularized and the skin is thin”

    ______________________________

    PM On checking, I may be conflating a couple of paragraphs on page 4 of “The Powerful Placebo” by Shapiro and Shapiro, although I think I have encountered such usage somewhere else.

    On page 4, they describe how Egyptian healers were “fond of dung” using human excrement, as well as that of “eighteen other creatures”, including the cat, crocodile, pig, dog. They also scraped fly specks off the wall for medical use.

    In the next paragraph they describe how medications were inserted into bodily orifices and spread over “all parts of the body”.

    However they only specifically mention inserting dung into the rectum. That suits my purposes as well the ear, and probably also yours, although I remain dubious that placebo influences have anything to do with NO physiology. I think they are due to malleable human perceptions and preoccupations.

    They don’t supply a primary source for that specific piece of information although there are references in other contexts on the same page.

  58. David Gorski says:

    But you do need evidence. You are not entitled to ASSUME there is insufficient benefit to justify the hypothetical risks, or that any realistic expectations regarding the expansion of pseudoscience are necessarily going stop people seeking proper medical attentions. I think those risks are overstated, anyway.

    You “think” those risks are “overstated”? One could equally point out that neither are you entitled to ASSUME (sorry, couldn’t resist) there is sufficient benefit to justify the risks or that any realistic expectations regarding the expansion of pseudoscience are not going to stop some people from seeking proper medical attentions. That does not go along with your “thinking” those risks are “overstated.”

  59. daedalus2u says:

    pmoran, thanks. I have a primary source for the use of crocodile dung as a pessary, in the earliest medical text, a papyrus on gynecological treatments from 1825 BCE (Kahun Gynecological Papyrus). Unfortunately there is a hole in the papyrus so exactly what condition was treated by crocodile dung remains unknown.

    I have another reference for using manure and soil on the umbilical cord to prevent tetanus. The clostridia are exquisitely sensitive to NO/NOx, so a NO connection is plausible.

    Crocodiles are uricotelic organisms, the same as chickens. They both excrete uric acid which ends up as the white solid in their excrement. It was the uric acid in guano which was oxidized to nitrate which resulted in the massive deposits of nitrates in Chile. As I mentioned, I have data where I took composted chicken manure and simply by adding water it produced a large quantity of NO for an extended period of time. Levels that would be physiologically active.

    Dr Novella has a recent post over at Neurologica on wacky medical treatments, a number of which comprised coating the body with mud from various sources which are used to treat things like rheumatism. It is extremely likely that ammonia oxidizing bacteria are present in those natural muds and that individuals would inoculate their skin by applying mud to it. If so, that represents a plausible physiological effect of the wacky treatment independent of any placebo effect.

    I understand your reluctance to impute any physiological effects to placebos, but I think the data is pretty clear, that some people do experience actual physiological therapeutic effects from placebos. Those effects have to be mediated through physiology in some way, even if the individuals are especially suggestible and malleable; their physiology has to couple to their psychological state. NO is a plausible coupling pathway. If NO is the coupling pathway, then increasing NO levels should improve the coupling and at some NO level the pathways should “saturate”; that is the patient would derive no more physiological benefit from a placebo.

    If you are going to prescribe an agent that triggers the placebo effect, that is where you want the patient to end up, with the placebo effect maximized and saturated from the treatment you have prescribed.

  60. Dr Benway says:

    I have basically been saying that CAM should be assessed along the same cost/risk/benefit lines as conventional methods, even if they are mainly placebo.

    Isn’t that what SBM says also? Aren’t we advocating for one standard for all proposed therapies?

    “CAM” is a category that makes marketing sense but is not rational. The set is arbitrary. Why TCM, acupuncture, reiki, yoga, homeopathy, chelation, and vitamins? Where is the voodoo and the snake handling?

    I might group a few things together: aluminum, large breasted women, platform shoes, lasers, and alligators, for example. I might name my category, “visionary.” Then I might create a a pro-visionary political movement to insure visionists “have a voice” or whatever.

    CAM, like cults, is defined not by what it includes but by what it excludes. It is the enemy, the “suppressive person” who defines a cult.

    I didn’t ask for a fight with CAM. It was only after pro-CAM doctors told my patients that the scientific consensus I represented was a BigPharma scam that I got sucked into this struggle.

  61. The old “western medicine” / “eastern medicine” issue: “oh, here in the ‘west,’ we are too short-sighted to appreciate the wisdom of the ‘east.’ ” CAM partly is formed into a single “thing” by its “eastern” origin.

    Why don’t more people from the “east” speak out against this slap in the face? Or would al-Razi and other remarkable Persian physicians consider themselves part of the “western” world?

    Plus: nowadays, we know our “cradle” of the western world, ancient Greece/Rome, was in heavy contact with non-”western” intellectual currents – from the ancient near east, the middle east, Africa and beyond.

    Some make the case that we “westerners” co-opted a great deal of this knowledge from the “east.”

    In the “east,” it can be argued that the Hindu culture had a formal line of intellectual thought in logic and reason and epistemology – the Nyaya-Vaisyasika – that progressed ahead of our “western” equivalent. They had an atomic theory of matter, developed through reasoning, the same as Democritus is credited with. They even had a nihilistic, atheistic line of thought, the Carvacas.

    At the same time, here in the “west,” we have always had interventions that should properly be recognized as “eastern.” There are plenty of breast cancer patients who believe, natively, not for some CAM-inspired rasons, that the disease is a result of guilt, or sin, and that corresponding psychic actions or superstitious rituals, can bring about cures.

    Maybe we should call this “east/west” argumentative fallacy the “appeal to esotericism.”

  62. Mark Crislip says:

    I guess I do not need an editor after all

    Olny srmat poelpe can raed this.
    I cdnuolt blveiee that I cluod aulaclty   uesdnatnrd what I was rdanieg.. The phaonmneal pweor of the hmuan mnid, aoccdrnig   to a rscheearch at Cmabrigde Uinervtisy, it deosn’t mttaer in what oredr the ltteers in a word are, the olny iprmoatnt tihng is that the first and last ltteer be in the rghit pclae. The rset can be a taotl mses and you can still raed it wouthit a porbelm. This is bcuseae the huamn mnid deos not raed ervey lteter by istlef, but the word as a wlohe. Amzanig huh? Yaeh and I awlyas tghuhot slpeling was ipmorantt! If you can raed this psas it on   !!

  63. David Gorski says:

    Speaking of woo in the NEJM, there’s an editorial in the Aug. 19 issue that, while not as bad as the acupuncture article, is pretty bad.

  64. pmoran says:

    Daedalus2: “I understand your reluctance to impute any physiological effects to placebos, but I think the data is pretty clear, that some people do experience actual physiological therapeutic effects from placebos.”

    That’s not what I said. I think, specifically, that the NO theory of placebo is weak, in part through not having seen any evidence that placebos change NO levels, or that benefits from placebo are correlated with NO levels, or evidence that placebos in general have effects that might favour “healing” at the level of basic biochemical and physiological processes.

    In my view it is, in a way, “all in the mind” but in a good sense. Even if there is transient endorphn release that could only favour placebo responses through secondary psychological processes “gee — this is helping!” or “it’s not so bad, now”.

    If I understand NO physiology correctly ( and I admit to being weak in that), we have a model for cerebral (psychological) control of NO release within sexual arousal, but is there evidence for any mechanism whereby the psychological factors upon which placebo responses wholly depend could influence NO activity? Where is the necessary neural control of overall NO activity. For that matter, why might not placebos induce erections in non-sexual contexts?

  65. pmoran says:

    David Gorski: “You “think” those risks are “overstated”? One could equally point out that neither are you entitled to ASSUME (sorry, couldn’t resist) there is sufficient benefit to justify the risks or that any realistic expectations regarding the expansion of pseudoscience are not going to stop some people from seeking proper medical attenti,ons. That does not go along with your “thinking” those risks are “overstated.”

    ==================================
    Thanks for still talking to me. I stated why I think the risks are overstated — we have had three decades of rampant “woo”, and there is very little evidence that it is taking over from conventional medicine or science.

    In fact I think I can already see signs of a reaction to AM, in the local press and current affairs programs, and also on newsgroups and mailing lists (even the horrible cancer ones). Remember that AM was once prone to make such extravagant claims that they can by now be seen to be false even within the public’s own communal anecdotal experiences.

    So, whence the mind-set that has so little confidence in the logic of science, and the innate sense that most of the public is already displaying in relation to CAM (look at the data as to how it is used), as to consider that scientific medicine is under serious threat? (You may have to put aside confirmation bias that focuses upon heart-rending outcomes that are not necessarily always avoidable, anyway.)

    That may be the fairly reasonable basis for the despised “shruggie” position and behind the relaxed attitudes of some of our institutions.

    But I admit I only began to think differently once I was able to think past my personal offence at the pseudoscience, so as to see that the scientific considerations were MY obsession — they matter very little to the average patient and not much more to the alternative practitioner who “just knows it works” and will often admit that it could be mainly placebo when pressed.

    As I have indicated, the pseudoscience is merely the “schtick”, a hook upon which to justify the methodogy, preferably also providing some mystique and an affectation of being privy to arcane knowledge – a powerful brew that we doctors once had with those mysterious prescriptions written in illegible abbreviated Latin (mostly translating into placebo.)

    We have also seen how resilient and malleable the pseudoscience is, able to morph into something else altogether when under challenge. It’s like punching porridge, it spatters this way and that and the mop-up is endless.

    Taking into account all of the above, the surest way to scuttle threats from pseudoscience might be to be more accepting of the METHODOLOGY, as some already do, to our disgust. It removes the elements of “we versus they”, “what the doctors don’t want you to know” and “different medical paradigms” upon which “alternative” medicine thrives and tries to justify itself.

    That’s a thought. Might the surest way to counter any threats from CAM be to make it part of the ORDINARY? Does our fire and brimstone merely serve to make it look more important than it really is?

  66. wales says:

    Thanks MC, amazing indeed.

    “This is bcuseae the huamn mnid deos not raed ervey lteter by istlef, but the word as a wlohe.”

    Just another example of the whole being greater than the sum of its parts. At least in our minds.

  67. daedalus2u says:

    pmoran, there is much more to NO physiology than erections.

    All vascular tone is regulated by NO. The vasodilatation observed in BOLD fMRI is due to neurogenic NO. Meditation does increase NO levels (measured instrumentally). The relaxation response increases NO levels. That is what relaxation does and why relaxation has stress-relief properties.

    Stress is a low NO state. The regulation of O2 consumption by mitochondria is via NO. NO inhibits cytochrome c oxidase and so allows O2 to diffuse farther into tissues away from the vessels. Lowering the NO level is a generic stress response. The fight or flight state is a low NO state. Low NO can be triggered very rapidly through the generation of superoxide. Low NO is the main mechanism by which superoxide has physiological effects. Virtually all superoxide is confined to vesicles because it is an anion. NO is uncharged so it can diffuse into those vesicles and react with superoxide which it does at diffusion limited kinetics.

    Ischemic preconditioning is triggered by low NO which regulates ATP lower, which turns off less time critical pathways (that is what ischemic preconditioning is). That is what stress does, it turns off less time critical pathways to free up more ATP for dealing with the stress. Healing is a less time critical pathway, something to put off until after the stress is over, until after the fight or flight state is over. The fight or flight state has hysteresis, it takes a higher NO level to reverse the hysteresis of the fight or flight state.

    This link discusses low NO in the context of the bacteria I am working with and the hygiene hypothesis.

    http://books.google.com/books?id=a3mwmXzpsjkC&lpg=PP1&pg=PA103#v=onepage&q&f=false

    I think the main difference in disease incidence between the developed world and the rural undeveloped world is due to low NO in the developed world. NO is not a panacea, but it should help just about everything.

  68. Dr Benway says:

    Taking into account all of the above, the surest way to scuttle threats from pseudoscience might be to be more accepting of the METHODOLOGY, as some already do, to our disgust. It removes the elements of “we versus they”, “what the doctors don’t want you to know” and “different medical paradigms” upon which “alternative” medicine thrives and tries to justify itself.

    I wish you would pepper your vague generalizations with some concrete examples.

    When you say, “CAM” or “methodology,” I don’t think you have in mind the awkward clinical problems that I face.

    In my world, CAM is already on the inside. It’s rich and powerful and calling the shots. It wears white coats and orders lots of lab tests. It’s even tenured at Harvard Medical School.

    Dr. CAM, who shares a patient with me, sells supplements from his office. He’s a “too many too soon” anti-vaccinationist. He could crush me like a bug with his piles of money if I were to make trouble for him.

    CAM wants to chelate my kids. For that, I say CAM is a right bastard what can f*ck off.

  69. David Gorski says:

    Taking into account all of the above, the surest way to scuttle threats from pseudoscience might be to be more accepting of the METHODOLOGY, as some already do, to our disgust. It removes the elements of “we versus they”, “what the doctors don’t want you to know” and “different medical paradigms” upon which “alternative” medicine thrives and tries to justify itself.

    If you really think that that’s what would happen, you’re more naive than I thought. If there’s one thing I’ve seen in my time examining CAM is that being more “accepting” of the methodology only invites more outrageous forms of woo. That’s how we got into the mess with quackademic medicine infiltrating academia to begin with.

  70. pmoran says:

    daedalus2u, I don’t doubt what you say about NO physiology, your placebo theory requires the direct connections I requested if it is to be taken seriously. At present you have mere conjecture.

  71. pmoran says:

    Yes, Dr Benway, and also Dr Gorski, every medical discussion ends up being plagued by over-generalisation and over-simplification at some point.

    I firstly would ask you, David, and Steve ,and others, how well are present approaches working for you, if we still face the prospect of a collapse of medical science from CAM intrusion? It is not as though there can be many people left of any persuasion who are not familiar with sceptical stances on pseudoscience, and who also give a fig.

    Dr Benway, what I have in mind, still tentatively, is a selective approach.

    If we are tolerant of our patients use of CAM where it doesn’t much matter, where they want to try it anyway, AND where it may also help them (which it seems no one here is prepared to seriously debate), they may be more receptive to our more serious message, the one that we MUST emphasise, the one that I have previously suggested should be SBM’s mantra i.e. some simple version of : “that seems reasonably safe, so go ahead and try it if you wish. You may feel better for it but understand that it is has never been shown to favourably affect any serious disease and is most unlikely to do so”.

    That happens to have the advantage of being wholly consistent with the available science. “It doesn’t work” isn’t, unless you specify a restricted meaning of “works” or have a very one-eyed view of the available evidence regarding placebo and other non-specific infuences.

    It has the advantage of providing a clear divide in when we tolerate CAM i.e. the methods must be safe, and used for subjective effect in responsive complaints, not as a cure of cancer or whatever. We also have an easier scientific case to present in disputes over conditions that are objective and objectively measurable.

    “It doesn’t work” probably instantly alienates a large population that either thinks they may work or is not clear how we can be so sure of that without Big Pharm lurking in the background.

    We are more or less condemned to a purely patient advisory role, so why not think for a while about the message we wish to deliver and how we deliver it?

    Dr Benway: “It was only after pro-CAM doctors told my patients that the scientific consensus I represented was a BigPharma scam that I got sucked into this struggle.”

    Infuriating isn’t it? I got sucked in because my cancer patients were being enticed into all kinds of nonsense. But even that is almost impossible to prevail against. The best we can do is make sure patients get diagnosed properly and are fully informed as to the treatment possibilities.

  72. pmoran, you are defending this:
    “He has specifically requested a referral for acupuncture, and we would suggest a course of 10 to 12 treatments over a period of 8 weeks from a licensed acupuncturist or a physician trained in medical acupuncture.”

    as being equivalent to this:
    “that seems reasonably safe, so go ahead and try it if you wish. You may feel better for it but understand that it is has never been shown to favourably affect any serious disease and is most unlikely to do so.”

    They are not the same.

  73. pmoran says:

    I am not sure of your point, Allison.

    I am also not defending Berman’s paper in all respects. I do note that he is essentially admitting that acupuncture is mostly placebo, in response to the now compelling science, but he still gets blasted in every possible way for his pains.

    His journey of discovery cannot have been at all easy, and he can be forgiven for still being somewhat confused about where TCM theory fits in.

  74. pmoran,

    The point is that I keep asking you what the benefit is of a doctor referring a patient for a specific course of acupuncture, or even “medical acupuncture,” as opposed to simply keeping communication with the patient open while the patient pursues acupuncture on their own. You keep not answering.

    And now you propose that we accept the idea that maybe doctors should keep the lines of communication open while patients pursue acupuncture on their own. Well, isn’t that what doctors have always done?

    Has anyone here suggested that patients be discouraged from discussing possible alternative treatments (vitamins, herbal “supplements,” acupuncture) with their doctors? Or that doctors be dismissive of patients’ silly ideas? Even if you don’t believe in an independent placebo effect, presumably you want your patients to trust you to listen so that they tell you what they’re doing and you can warn them away from the truly dangerous stuff. (Acupuncture to help you with the side effects of chemo? Sure, whatever, if you want to and you aren’t spending too much money on it and you let me know how it’s going. Bioidentical hormones to help you feel better while you’re taking tamoxifen? Um, no, that’s really not a good idea.)

    The NEJM article proposes that doctors refer patients to a specific course of “medical acupuncture.” That is the article you are defending. If you do not approve of this active participation in the promotion of acupuncture, why haven’t you said so? And if you do think that doctors should actively refer patients to acupuncturists – or even perform acupuncture themselves – why don’t you make that really clear? I have repeatedly asked you why you think active promotion of woo by doctors is better than the traditional keeping of an eye on the woo, and you repeatedly haven’t answered.

    Can you really not see the difference?

  75. David Gorski says:

    The NEJM article proposes that doctors refer patients to a specific course of “medical acupuncture.” That is the article you are defending.

    Exactly. The article doesn’t just recommend that we “keep the lines of communication open” with a patient who’s going to pursue woo anyway no matter what we say. Rather, it explicitly recommends that the physician refer the patient for a specific course of woo. By doing so, it endorses that woo. The authors recommend that physicians, rather than trying to talk the patient out of it or simply say what we know, namely that there’s no evidence that acupuncture is more than placebo, and let the decision be on the patient, actually prescribe placebo medicine to the patient.

  76. Dr Benway says:

    pmoran,

    The patients aren’t the problem. The board-certified MDs are the problem.

    I don’t feel sorry for Dr. Brian Berman. He is well compensated for his trouble by his wealthy benefactors.

    Were it not for the Bravewell collaborative and people like Dr. Berman, so-called “traditional Chinese medicine” would have died a natural death. And the rhino might have been saved.

  77. I guess the whole discussion just make me think, if come doctors within the broad scope of CAM using chelation therapies means “CAM wants to chelate my children” then…

    Consider that 13% of survey respondent doctors admitted to using sedatives as a placebo. Also numerous state reports seem to admit that pediatricians caring for foster children are prescribing psychotropic medications that are not FDA approved for use in children without a thorough psychiatric evaluation or support.

    Does this mean that mainstream medicine wants to sedate my children?*

    I genuinely like SBM, but I am not completely sure that the emphasis on CAM opposition is not done at the cost of ignoring scientifically questionable practices that abound within the mainstream medical community.

    As a layman and reader I sometimes get this picture… antidepressants as placebo**, regrettable but “oh well” acupuncture as placebo “What a quackadelic scam! It is a plague on responsible medicine! I will destroy society etc, etc!” Although, of course, with more knowledge and wit.

    I do acknowledge that there are sometimes articles critical of mainstream approaches, but the frequency and vigor are no where near those of addressing CAM.

    I would love to see more discussion of mainstream medicine’s flaws…and not only when they are adopting CAM methods.

    Not only could this possibly correct an impression of bias, it would also be helpful to those of us who pursue solely mainstream medical therapies and want to be informed of questionable practices there.

    *I don’t think it does, but I think there’s a problem with lack of oversight.

    **I am not suggesting that antidepressant or other psychotropic drug are not effective when prescribed and supervised appropriately or that they work entirely as placebo.

  78. whoops “It will destroy society!” not “I will destroy society!” My subconscious ego with arch-villianal delusions is escaping from the box, I guess.

  79. Zoe237 says:

    You know, this came up when I was discussing this with some friends who swear by chiropractic care and all have positive anecdotes. They pointed out that I’ve never had any chronic problems. I admitted that if I were in constant pain and had tried everything else, I couldn’t guarantee that I wouldn’t spend $50 bucks and an hour of my time trying chiropractic care or acupuncture, just to see if it would work. I think I probably won’t get to that point in my lifetime, but never say never. I could start going to church too.

    Until then, my judgement remains that it’s a waste of money.

  80. Zoe237 says:

    “I would love to see more discussion of mainstream medicine’s flaws…and not only when they are adopting CAM methods.”

    Agreed. There was a show today on NPR about the breast cancer drug avastin. Would be interesting to hear Gorski’s opinion.

    http://thedianerehmshow.org/shows/2010-08-19/fda-drug-approval-process

  81. Harriet Hall says:

    Mainstream medicine certainly does have flaws, and several SBM posts have addressed them. But we don’t need a lot of emphasis on these, because the scientific medical community is self-critiquing and practices change in response to new evidence. CAM begs for more of our attention because it has no tradition of critiquing itself and it never rejects any treatment even when the evidence argues against it.

  82. Zoe237 says:

    Well, there’s a story on avandia now up on sbm, something I requested months ago (coincidence I’m sure, but I still appreciate it), so I figure it can’t hurt to at least ask. One doesn’t have to get rid of the CAM stuff to also pay attention to real medicine.

  83. “But we don’t need a lot of emphasis on these, because the scientific medical community is self-critiquing and practices change in response to new evidence. CAM begs for more of our attention because it has no tradition of critiquing itself and it never rejects any treatment even when the evidence argues against it.”

    Harriet, I do get your point and I agree to a certain extent, but it also begs the question, if practices change in response to evidence, why the sedative placebos? Why the unexpectedly high level of use of psychotropic medications (many of which aren’t approved for use in children) in foster children? Why the increase in prescription drug abuse in this country? Is there a SBM way to improve any of these situations? These issues are not trivial threats and I know they are difficult questions. But, I believe they are questions that the SBM writers may have some interesting insights into if they chose to struggle with them.

  84. pmoran says:

    David: “Exactly. The article doesn’t just recommend that we “keep the lines of communication open” with a patient who’s going to pursue woo anyway no matter what we say. Rather, it explicitly recommends that the physician refer the patient for a specific course of woo. By doing so, it endorses that woo.”
    ———————————————————–
    Oh, this is also what Allison is getting at? Sorry for being obtuse, but there was never any doubt in my mind why the course was so specific and it has no direct connection with ancient Chinese superstitions.

    1. Even if we regard acupuncture as a wholly bland placebo it must “look” like an authentic program of treatment if placebo effects are to be best evoked. In practice acupuncture does impose elements that can reasonably be expected to provide benefit in non-”woo” ways.

    2. It is similar programs that are known to “work” (no better than sham, of course) in the clinical trials.

    I have no doubt that a good actor could perform the same as a highly trained acupuncturist, so I will give you that point.

    If the concern is doctors playing a more active role in advising patients who are not being helped much by mainstream methods (why else would they?) that surely is mainly culpable to the extent that the doctor regards the method as pure placebo, if so, how useful such clinical effects may be for the individual patient, and how we view the ethics of it in that individual case.

    I suggest that we need a very strong argument before we withold possible benefits from any individual patient and that we don’t yet have that in the case of “acupuncture-like” programs for certain conditions.

    The “woo” aspect is virtually irrelevant. As I keep saying, that is OUR obsession. Patients will be happy with “we are not sure why it works”,

  85. pmoran,

    As a patient, I need to be able to trust my doctor. If I think that she is going to happily lie to me about anything she thinks I want to hear then I can’t trust her and there’s no point in seeing her.

    I don’t see a doctor to be patted patronizingly on the head. I go for a medical perspective. I have lots of friends who will promote acupuncture and Bach’s Rescue Remedy and homeopathy and gluten-free diets and crocodile dung pessaries and whatever else to me if I’m interested. There’s a whole social network ready to plug me in as soon as I say the word. I don’t need my doctor for that.

    I go to the doctor for information and support that my friends and neighbours aren’t in a position to give me. If my social group believes in acupuncture then I don’t need my doctor’s signature for acupuncture to have a placebo effect.

    My understanding is that the placebo effects of acupuncture are quite small even in these Very Serious Clinical Trials. In reality acupuncture is only going to “help” in the sense that it gives me a ritual to keep me busy; it’s not actually going to relieve my pain, or not by enough to matter. I’m having a great deal of trouble understanding why you are arguing so hard for trading away your professionalism for a tiny clinical benefit that can be had without you. I know you believe that your white coat and signature are key to the placebo effect, but you haven’t cited any evidence to support your belief. If I need a white coat to feel good about my “treatment,” then I can just see an acupuncturist who wears a lab jacket. Most people’s world is bigger than your office.

    Yes, when a patient comes in with a list of things they want to try it does usually mean that whatever they are doing now isn’t working for them. I believe most doctors see that as a cue for some probing, counselling and tweaking. Maybe medicine has more it can offer; maybe it doesn’t. That can be very sad and frustrating. But I fear that you are trying to rationalize making yourself feel better at the expense of your professionalism.

    pmoran, please stay away from my doctors. My “very strong argument” is that I need my doctors to be doctors and I need them to be honest with me.

  86. JMB says:

    The authors recommend that physicians, rather than trying to talk the patient out of it or simply say what we know, namely that there’s no evidence that acupuncture is more than placebo, and let the decision be on the patient, actually prescribe placebo medicine to the patient.

    I would suggest that the doctor also warn the patient:
    1. What a reasonable price for treatment should be.
    2. If the first treatment is ineffective, there is no reason to return for additional treatments (tell me if I’m wrong, but if first treatment with placebo fails, there is no reason to argue that more treatments are necessary to produce an effect).
    3. While some may get relief of symptoms from placebo treatment, placebo treatments have never been show to prevent relapses.

    These are some common ploys to fleece the patient seeking relief.

    Is there a SBM way to improve any of these situations?

    I think this blog is most effective when it is directed at policymakers and medical educators. Monitoring of behavior of physicians in private practice is the responsibility of state boards of health. Patients may learn to recognize dubious behavior in physicians, and report it to state boards of health.

    The issue of SBM in private practice has limitations. In many situations, a clear diagnosis can not be made. If no clear diagnosis can be made, then does the physician decline to treat the patient, give symptomatic treatment, or take a chance and treat for a possible disease? If the private practitioner decides to try a treatment to be effective without sound scientific basis, that is still different than prescribing homeopathy. For example, we may estimate that a properly done test for strep throat fails to be positive in 15% of patients who actually have strep infections. A patient with a negative test may still have a strep infection. Does the physician stick to experimental results that show that in patients with a negative swab test, there is no statistically significant difference in outcome by treating with antibiotics. Or does the physician use physical exam findings to identify patients who are more likely to have a strep throat even though the lab test is negative? By treating those patients with more positive physical exam findings (or risks by history) with antibiotics, there is likely to be a small fraction of patients who will actually benefit. When the physician sees a larger fraction of patients benefiting from the antibiotic therapy than expected, then they will recognize the placebo effect in action. They may not be able to tell which patient experienced the placebo effect, and which experienced the suppression of the strep infection effects by antibiotics. If homeopathy is prescribed, then every patient who benefits is experiencing a placebo effect.

    Of course there is the problem with indiscriminate prescription of antibiotics contributing to the development of antibiotic resistant bacteria. Most will not criticize the physician if they are selective about who they prescribe the antibiotic for (basing the selection on history and physical findings as opposed to giving it to every patient with a sore throat).

    Those issues in the art of the practice of medicine is why most of the faculty of this blog will agree with Dr Gorski that,

    There are always specific exceptions to general rules.

    There is also a gradient of certainty in any individual case as to whether we are many a decision clearly within the confines of available scientific evidence (the patient fits the selection criteria specified in a randomized clinical trial) or not (some variations that might effect the outcome).

  87. JMB says:

    Sorry, I need an eoitdr, too.

    “treatment to be effective” should be “treatment know to be effective for some disease”.

    “we are many a decision clearly within the confines” should be, “we are making a decision clearly within the confines”

    I would also agree with Dr Gorski that the trend of integrative medicine is a more serious development. It will erode the scientific foundation if new quasi statistical methods are introduced to support the decision to use woo. Medical science already has a problem with the validity of statistical methods and experimental design. We need to move forward to figures don’t lie, not backward to liars can figure.

    The acceptance of a class of treatments that can be sold by doctors offices is also a step backward in patient protection, and a step away from the goal of curtailing unnecessary healthcare expenditures. How many patients will be walking out of doctors offices with shopping bags full of naturopathic/homeopathic remedies while fattening the doctors wallet? In the 60′s, state governments were effective at stopping doctors from owning the pharmacy to which they sent their patients. Prescriptions noticeably declined in those states that passed the laws. In the 80′s and 90′s government was ineffective at stopping doctors from profiting from the tests they ordered, hence the explosion in use of diagnostic testing. If the government does not stop physicians from selling woo, we will see another explosion in unnecessary healthcare spending.

  88. JMB says:

    “Those issues in the art of the practice of medicine is why most of the faculty of this blog will agree with Dr Gorski that,”

    That is my impression from reading the various blogs. I may not be correctly characterizing their individual opinions.

    I need to proofread my comments more carefully, sorry.

  89. pmoran says:

    Alison: “My understanding is that the placebo effects of acupuncture are quite small even in these Very Serious Clinical Trials. In reality acupuncture is only going to “help” in the sense that it gives me a ritual to keep me busy; it’s not actually going to relieve my pain, or not by enough to matter.”

    Alison, if I thought that we would not be having this debate.

    The differences between “true” and sham acupuncture are invariably trivial, but I cannot recall any study of subjective complaints such as pain that has failed to show highly significant differences between patients receiving acupuncture-like treatment programs and those receiving usual care or on a waiting list for treatment. And that is under the conditions of the usual clinical study, which are not necessarily very conducive to placebo responses.

    http://www.bmj.com/cgi/content/full/336/7651/999 gives some idea of what is possible. Admittedly the key factor there is the additional patient/doctor interaction, but it is not clear to me what kind of a program strictly science-based medicine could come up with that could mimic this. I doubt if patients could be kept coming back just to talk. The opportunity for addiitonal interaction is one of the elements of acupuncture that make it different to a pure placebo such as a sugar pill.

    Sure, some patients will be like you and not wish to dabble in alternative methods and they will be treated accordingly.

    These days it is probably at least as common for a new patient to state, before even sitting down, “I don’t like taking drugs!” .

    I am perhaps coming across as more promotional of CAM than I really am. I think we can be certain about some aspects of the relevant science, but not others, such as what value it is to its users..

  90. JMB – I can see why you as a doctor would be looking for something different from SBM than I would as a patient/patient advocate, so probably our preferences will never mesh completely.

    But, I would say that the prescriptions of active drugs as placebo, psychotropic medication to children and a rise in prescription drug abuse are all good topics for policy makers and educators to consider and discuss. They are certainly not problems that are easily eliminated by individual doctors working independently.

    It seems to me that doctors have traditionally functioned on a very individualistic basis. They practice medicine they way they see fit and leave the other doctor’s to do as they will. If an individual doctor performs badly, then it is up to the patient to find another doctor, report the doctor, etc.

    But if you believe the idea that an individual doctor should not ignore other doctors, that they should discourage other doctor’s from including unscientifically based CAM techniques in their practice, then how can you ignore unscientifically based mainstream techniques? I find it to be an artificial divide.

    As to reporting dubious practices of individual doctors to the state board of health, if that is sufficient action to take in the event that pediatricians in Texas are over prescribing psychotropic medications to foster children, then why wouldn’t it be sufficient action to protect people from doctors practicing chelation therapy?

    But, I think I covered my thought. I should probably leave that poor horse to rest in peace.

  91. Dr Benway says:

    micheleinmichigan,

    Some children are on psychotropics that aren’t helping. Some lack access to psychotropics which would improve their lives. Many studies concerning this issue are politically motivated and require careful interpretation.

    The ultimate authority among physicians is the scientific consensus, which is ever-changing and of varied quality and authority depending upon the topic. Investing more authority in political bodies can have the unintended consequence of undermining the rule of scientific evidence.

    WRT “you pick on CAM more than SBM therapies”:

    From a scientific perspective, “CAM” and “SBM” are not two tribes, parties, schools of thought, or clubs. Science has no sects.

    Notice that there’s no “integrative” physics, chemistry, biology, geology, astronomy, etc.

    “CAM” verses “SBM” is a cargo-cult distinction. It only matters to people who don’t understand how science works. We’re stuck with the terms for the moment, thanks to a few politicians who view science as something akin to politics. One day hopefully CAM will die and the reaction against it known as SBM will also die.

    Controversies within scientific medicine are interesting and worthy of discussion. But they don’t represent a political effort to weaken the rules of evidence within science generally. And they don’t represent an effort to undermine public respect for the authority of a scientific consensus, which is really quite different from a political consensus.

    However imperfect, science is the best trier of fact that we have. There is nothing to take its place, save tyranny.

  92. weing says:

    michelinmichigan,

    I’m not a pediatrician, but I would not immediately assume that psychotropic prescribing for children is inappropriate. If faced with increase in such prescribing, I would wonder what was making these children require such drugs. I think an epidemiology study would be called for. It may find that a drug rep with nice legs is the cause, but it may also find other causes.

  93. Dr. Benway “Some children are on psychotropics that aren’t helping. Some lack access to psychotropics which would improve their lives. Many studies concerning this issue are politically motivated and require careful interpretation.”

    Well, yes, my point exactly. Which is why I would love to be able to read an article on the topic on SBM rather than MSNBC, FOX or even NPR, because those outlets are not cutting it.

    Dr. Benway “WRT “you pick on CAM more than SBM therapies”:

    From a scientific perspective, “CAM” and “SBM” are not two tribes, parties, schools of thought, or clubs. Science has no sects. “

    Point, I did not say CAM vs SBM I said CAM vs mainstream. I am referring to mainstream medical techniques that are NOT science based. By definition there could be no SBM techniques that are not science based, right?

    Also, I learned the name CAM and the “threat of CAM” from ORAC, White Coat Underground and this site, please take it up with them if it’s too cult cargo.

    “However imperfect, science is the best trier of fact that we have. There is nothing to take its place, save tyranny.”

    Ultimately, I guess my question is “When the scientific facts and the best practices of medical science are not used by a significant number of medical practitioners, doesn’t science then ask “Why? or What Gives? What do we do about it?” Doesn’t science and medicine have as good or better a chance of a answering those questions as the politicians and the journalists?

    AND if science is answering those questions, I wish they’d share with the rest of us “people who don’t understand how science works” crowd, so we could understand better.

  94. Just for the record, I’m neither for or against physcotropic drugs for individual children.* From peers, I know there is a reasonable amount of concern about over prescription of drugs for children from Ritalin on up to Risperdal. Some of these concern is certainly NOT well informed, some are.

    But, I generally don’t want to derail the discussion any further with particulars. I was using the issue to illustrate a “mainstream medical” issue.

    *My concern with this issue would have much more to do with appropriate diagnoses, monitoring and record keeping.

  95. Zoe237 says:

    “Controversies within scientific medicine are interesting and worthy of discussion. But they don’t represent a political effort to weaken the rules of evidence within science generally. And they don’t represent an effort to undermine public respect for the authority of a scientific consensus, which is really quite different from a political consensus.”

    I disagree. Clearly, the profit motive in medicine is undermining the rules of evidence under the applied science of medicine. Vioxx being exhibit A. Medicine and science will ALWAYS be political, and it’s dangerous to assume otherwise. The scientitific method is a the best tool we have, but it too is prone to biases and we have to be aware of this, because human beings, not robots, practice it.

    The most important thing is that the business influence on medicine, the quickly changing recommendations before all evidence is in, *IS* underminig the authority of scientific consensus and making people more prone to CAM, especially those who don’t have lots of time to evaluate claims on their own merit. There needs to be more transparency. It’s all related, iow.

    The focus on science or evidenced based medicine in all of its forms will also boost the credibility of the site. I know the information is available elsewhere (i’ve been reading it for years), but I haven’t found it in a blog format.

  96. weing says:

    “I disagree. Clearly, the profit motive in medicine is undermining the rules of evidence under the applied science of medicine. Vioxx being exhibit A.”

    So, the problem with Vioxx was discovered by non-MDs?

  97. Zoe237 says:

    “I disagree. Clearly, the profit motive in medicine is undermining the rules of evidence under the applied science of medicine. Vioxx being exhibit A.”

    So, the problem with Vioxx was discovered by non-MDs?”

    I didn’t say that. But it took way too long and there is evidence of corrupt influences among the FDA. as well as lack of transparency. I see money and lack of transparency as the a much bigger threat to medicine that CAM, which is still outside the system (although that’s changing!).

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