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Fake Treatments for Fake Illnesses

I wrote previously on NeuroLogica blog about Morgellons disease. Both Peter Lipson and Wallace Sampson have also covered this interesting syndrome here on SBM. Briefly, sufferers of this dubious syndrome believe they have foreign material exuding from their skin, causing chronic itching and sores. The evidence suggests that in truth they suffer from something akin to delusional parasitosis – the false belief of foreign parasites in their skin, leading to chronic itching which causes the sores and also works clothing fibers into the skin, which are later exuded.

Morgellons, in short, is a fake disease, a false and somewhat far-fetched explanation for symptoms that have a much more prosaic, if undesired, explanation.

Those who believe they have Morgellons, however, are legitimately ill and are an extremely vulnerable population. They feel they have a serious and mysterious illness, and worse the medical profession does not understand their illness and so denies that it exists. This is a perfect setup for snake oil-peddling con-artists.

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Posted in: Herbs & Supplements, Science and Medicine

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Another Useless NCCAM-Funded Study

Sometimes I read an article in a medical journal that makes me say, “Well, duh! I could have told you that without a study.” Sometimes I read collected data that make me ask, “So what?” Sometimes I read an article that makes me wonder what kind of pogo stick they used to jump from their data to their conclusions. Sometimes I read a study that is so poorly conceived that you couldn’t hope to get any useful information from it. Sometimes I read a study that reminds me of class projects or term papers where you just thought of something easy to do to fill the squares to get credit. Sometimes I read a study funded by the NCCAM that makes me very angry that they wasted my tax dollars. Sometimes all these things coincide in one article.

“Ophthalmology Patients’ Religious and Spiritual Beliefs: An Opportunity to Build Trust in the Patient-Physician Relationship” is such an article. A questionnaire was anonymously filled out by 124 consecutive return patients in one ophthalmologist’s practice. It asked about their religious and spiritual beliefs and their understanding and level of concern about their eye condition. (more…)

Posted in: Faith Healing & Spirituality, Science and Medicine

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Do physicians really believe in placebos?

ResearchBlogging.orgIn a previous post, I argued that placebo is an artifact of certain clinical interactions, rather than a treatment that we can exploit. Apparently, there are a whole lot of doctors out there who don’t agree with me. Or are there?

A recent study published in the British Medical Journal is getting
a lot of enk (e-ink) in the blogosphere. As a practicing internist, I have some pretty strong opinions (based in fact, of course) about both this study and placebos in general.

The Study

The current BMJ study defines placebo as “positive clinical outcomes caused by a treatment that is not attributable to its known physical properties or mechanism of action.”  I’ve got a lot of problems with this definition, but we’ll get to that later.  It also allowed physiologically active medications to “count” as placebos.  Oops.

The study surveyed internists and rheumatologists practicing in the U.S. They tried to control negative responses to the term “placebo” thusly (from the Methods section):

Because the term “placebo” and behaviours surrounding its use can be contentious, we devised a series of non-judgmental questions beginning with broad questions that avoided the term “placebo” and then gradually gained more specificity, culminating in items whose responses used a clear definition of a “placebo treatment.” By constructing a series of items in this manner we allowed respondents to describe their attitudes and experiences as accurately as possible.

The first set of three items began with a hypothetical scenario in which a dextrose tablet was shown in clinical trials to be superior to a no treatment control group (thus establishing its efficacy as a placebo treatment). To avoid biasing responses these three questions did not use the term “placebo,” “placebo treatment,” or “placebo effect.”

I know a lot of doctors.  They tend to be fairly bright.  I don’t think any of them would be deceived by this scenario.  When you read “dextrose pill”, you think “placebo”.  It might as well be the same word.

Respondents were then asked to indicate which of several treatments they had used within the past year primarily as a placebo treatment, defined as a treatment whose benefits derive from positive patient expectations and not from the physiological mechanism of the treatment itself; and how they typically described placebo treatments to patients. By asking these five questions both without the term “placebo” and then using the term, we aimed to assess physicians’ practices as accurately as possible.

All docs would recognize this as a placebo scenario.  However, the definition above is rather problematic.   Is a placebo “a treatment whose benefits derive from positive patient expectations and not from the physiologic mechanism of the treatment itself”?

The validity of this study hinges on the answer to this question.

Placebo—I do not think it means what you think it means

The concept of placebo, and the way it is used in this study are both problematic.  First, we have an elephant in the exam room.  When we observe a so-called placebo effect, we are very susceptible to the post hoc ergo propter hoc fallacy.  Just because the patient’s condition changes doesn’t mean we have done anything to cause that change.  In fact, due to the remarkably inexact human pattern-recognition software, we are likely to attribute a change in a patient’s condition to something, and if we don’t know what that something is, we may label it “placebo”.  So the very concept of placebo may be an artifact of our way of thinking, a label to place on a co-incidence, rather than a “thing”.  We may have wrongly reified a rather fuzzy concept.

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Posted in: Science and Medicine

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Placebos in the news again

ResearchBlogging.orgTowards the end of last week, I was contemplating what I would be writing about for Monday. No topic had quite floated my boat, but I hated to dip into the archive of topics I’ve written about before to update a post. After all, I like to be topical whenever possible. Then what to my wondering eyes should appear (yes, I know Christmas is still two months away) but a study in the British Medical Journal by a group lead by Jon C. Tiburt at the Department of Bioethics at the National Institutes of Health in collaboration with investigators at the Osler Institute at Harvard University and the McClean Center for Clinical Medical Ethics at the University of Chicago entitled Prescribing “placebo treatments”: results of national survey of US internists and rheumatologists.

Serendipity? Who cares? The study addresses a very important aspect of science-based medicine.
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Posted in: Herbs & Supplements, Science and Medicine, Science and the Media

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Is There a Placebo Effect for Animals?

One of the occasional arguments used in support of “alternative” approaches to human medicine is the observation that since “alternative” medicine is used (with anecdotal success) in animals, and animals don’t know anything about the treatment that they’re getting, then they must work a priori.  Of course, the fallacy of such an observation is pretty obvious to anyone with a logical/skeptical frame of mind, because it assumes that the therapies do work (even though there’s little evidence of that).

Clearly, however, some people perceive that the therapies work, including veterinarians – there are veterinary acupuncturists, chiropractors, homeopaths, etc., etc.  Since there’s very little scientific support for the idea that the therapies actually have any clinically significant effect on biological processes, including the processes that result in disease, questions arise as to whether there are other effects of “alternative” treatments on animals. Specifically, people may wonder whether or not animals can benefit from placebo effects.
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Posted in: Acupuncture, Science and Medicine, Veterinary medicine

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Another new blogger, or SBM is going to the dogs (well, horses, actually)

We at Science-Based Medicine are pleased to announce the recruitment of yet another blogger to add to the discussion of the scientific basis of medicine. We’re especially pleased because he will help us address questions that we were not particularly well-equipped to address before his joining us. So, please welcome to the SBM fold David Ramey, DVM, who will be discussing science- and evidence-based veterinary medicine.

David Ramey, DVM, is a 1983 graduate of Colorado State University. After completing an internship in equine medicine and surgery at Iowa State University, he entered private equine practice in southern California. Dr. Ramey is an author of numerous books on equine health care, and a prominent voice for the application of evidence-based standards to veterinary medicine. He was a member of the task for on “Therapeutic Options” of the American Association of Equine Practitioners, as well as a member of the task force that wrote the current guidelines for the use of “Complementary and Alternative” veterinary medicine for the American Veterinary Association. He has published numerous articles and books pertaining to “alternative” approaches to veterinary medicine, including the 2004 Complementary and Alternative Veterinary Medicine Considered, co-authored with world renowned veterinary ethicist Dr. Bernard Rollin.

We get a fair number of questions about the use of “alternative” medical practices such as homeopathy and acupuncture on animals, particularly from people who ask us how they can appear to work on animals when animals supposedly don’t exhibit placebo effects. Dr. Ramey will be of great value in discussing such issues. Unfortunately, he will only be able to contribute posts around once a month or so. Fortunately, his first post will appear tomorrow. Don’t miss it.

Posted in: Announcements

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51 “Facts” About Homeopathy

Get your facts first, and then you can distort them as much as you please.

—- Mark Twain

I use a Mac, so I know I think different. I also coexist on an alternative parallel world where people live on the same planet as me, but have such a radically different way of thinking that I wonder if we have the same ability to evaluate reality (1).

The best example of different ways of seeing the same thing is homeopathy. Homeopathy is utterly and completely ridiculous with zero plausibility or efficacy. Only therapeutic touch is its rival. Yet homeopath Louise Mclean can suggest there are 50 facts that validate homeopathy (2). These facts were presented as an attempt to counter criticism that homeopathy is only water with no therapeutic effects.

Lets evaluate each fact. There are two parts to the evaluations: whether the fact is true and what, if any, logical fallacy is being used. Deciding on which logical fallacy is being used is not my strong point, feel free to correct me in the comments, and I will add to the text later.
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Posted in: Health Fraud, Homeopathy

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When Further Research Is NOT Warranted: The “Wisdom of Crowds” Fallacy

Most scientific research studies have at least one thing in common: the conclusion section ends with, “further research is warranted.” I’d say it’s about as common as the “talk to your doctor” disclaimer in TV ads for pharmaceutical products. And in a way, they both serve the same purpose. They’re a “CYA” move.

What does “further research is warranted” mean in plain English? I think it can be roughly translated: “My research study is not of the size or scope to fully explain all the phenomena described in this article. Therefore, draw conclusions beyond the data and study methods at your own risk. And yeah, my work is important and cool – so people should study it further.”

Of course, the first two sentences are reasonable – we should always remember not to draw conclusions beyond the information provided by the data we’ve collected (even though that’s about as challenging as getting a beagle not to eat a table scrap in an empty room). The real problem is the third sentence. Is the research promising enough to require further investment? How are we to know if further research is indeed warranted? I would argue that it should not be based solely on the subjective opinions of the researchers nor the popularity of the research topic to the general public. (more…)

Posted in: Clinical Trials, Science and Medicine

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Interpreting the Medical Literature

The science in science-based medicine includes all of science, but relies most heavily on the biomedical literature – published studies that collectively represent our scientific medical knowledge. The scientific basis of medicine is only as good as this body of knowledge and the manner in which it is interpreted and put into practice.

We often discuss on this blog how to evaluate individual studies- the need for blinding, randomization, the importance of study size to meaningful statistical analysis, and other features that distinguish a reliable study from a worthless one. This is important, but only half of the equation. We also at times discuss the medical literature as it relates to a specific medical question or set of related questions – does homeopathy work or are statins beneficial for cholesterol reduction, for example. This requires not only the ability to judge individual studies, but a higher order analysis of the overall pattern of evidence among all relevant studies. Failure to do this, by focusing only on individual studies, results in the failure to see the forest for the trees.

It is this higher order analysis that I wish to discuss in this entry.

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Posted in: Clinical Trials, Science and Medicine

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Puncturing the Acupuncture Myth

Note: This is slightly revised from an article I originally wrote as a “SkepDoc” column for Skeptic magazine. It was pre-released online in eSkeptic and it has already generated a lot of comments, including “a truly amazing piece of peurile pseudo-intellectualism,” “an ad hominem attack on one form of alternative medicine so beset by poor thinking that one must come to the conclusion this woman might just be paid to write such propaganda,” and “twaddle wrapped in swaddling rhetoric.” (I treasure comments like those as evidence that my critics are so bankrupt of real arguments that they have to dip into the insult pouch for ammunition.)  I thought it would be interesting to post it here on the blog and see how much controversy it would stir up among my co-bloggers and readers.  Please keep in mind that it was written for a popular audience and excuse the lack of scholarly citations. You may recognize some of the studies I refer to from previous blog entries.

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“Alternative” medicine is by definition medicine that has not been scientifically proven and has not been accepted into mainstream scientific medicine. The question I keep hearing is, “But what about acupuncture? It’s been proven to work, it’s supported by lots of good research, more and more doctors are using it, and insurance companies even pay for it.”

It’s time the acupuncture myth was punctured – preferably with an acupuncture needle. Almost everything you’ve heard about acupuncture is wrong. (more…)

Posted in: Acupuncture

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