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President Obama – Defund the NCCAM

As part of President Obama’s new approach to politics, with the promise of making it more transparent, his transition team solicited ideas from the public at change.gov. On this site anyone could post an idea and everyone could vote proposals up or down. Apparently the most popular ideas will be given some consideration. It’s an interesting blend of democracy and representative government. Whether is has any utility remains to be seen – but it’s just electrons and therefore it’s easy to experiment.

There are numerous suggestions under the health care category, but one in particular that might be of interest to readers of this blog. The author, Professor S, sent me the link to his suggestion that the new Administration defund the National Center for Complementary and Alternative Medicine (NCCAM).

What a great idea.

The NCCAM has been under considerable criticism by scientists (including here at SBM) since it was created in 1992 (as the Office of Alternative Medicine, converted to NCCAM in 1998) by an act of Congress. The NCCAM is a part of the NIH and it’s mission is to fund studies of so-called complementary and alternative medicine. It’s total budget through 2008 has been 1 billion 85.2 million dollars, and its most recent budget for 2008 was $121.5 million. The real cost is much higher, as the listed budgets do not include studies that are co-sponsored with other centers at the NIH.)

Of course, a billion dollars isn’t what it used to be, but what has the American public and the world received for its billion plus dollars? Exactly nothing. Proponents of unscientific and fraudulent medical claims, however, have received the best PR campaign they could have hoped for.

The measure of success of medical research is the impact it has on medical practice. Studies don’t have to be positive to be useful – showing that a treatment does not work is also highly valuable. Medicine that is science-based changes in response to new research. The more important the question researched, the more relevant the clinical implications, the bigger and better the study, and the more definitive the outcome – the greater the impact of the study.

The problem with CAM is that it is not science-based. It has therefore always been an inherent contradiction to carve out special funding for scientific research into claims that are not based upon science in the first place, and that are used by practitioners who are generally not science-based. That is a guaranteed waste of resources.

Any question or modality worth studying scientifically can be funded through other departments in the NIH. They don’t need special funding. And any claim that cannot justify funding for scientific research through the normal means likely does not deserve to be funded, and the proponents of such claims likely don’t care what the research says anyway.

As a result more than a billion dollars of taxpayer money spent has not changed the practice of CAM one bit. No CAM modality has been abandoned because research showed a lack of efficacy. Neither has any CAM modality been shown to be effective with research of sufficient quality that it has become accepted by mainstream practice. Nothing added or taken away.

Much of the research coming out of the NCCAM isn’t even designed to test safety and efficacy of a specific treatment. Here’s a good example, a look at the effects of “true” vs sham acupuncture on brain activity using fMRI and PET scanning. This is a worthless study for many reasons. First, clinical studies, taken as a whole, have not demonstrated any difference between true and sham acupuncture. Second, this study included only 12 subjects – far too few to pull any signal out of the noise using fMRI or even PET. And further, there is no way to know how to interpret the results – it’s little more than anomaly hunting.

But this kind of research makes acupuncture seem scientific and legitimate. It is worthless scientifically, and doesn’t even address the only important question at this point: does it work – but is great for marketing.

The only worthwhile studies coming out of the NCCAM are those looking at specific herbal remedies for specific conditions. But these kinds of trials do not need the NCCAM. They can be funded through other departments. These studies have largely been negative, but that is useful as there is already a large market for many supplements, and they are almost completely unregulated (which is a separate issue).

Defunding the NCCAM will save money at a time when it is critical to do so. But even more importantly, the NCCAM has not fulfilled its mission. It serves no legitimate function. It only serves to legitimize unscientific medical practices.

President Obama wants more transparent government. I agree, and part of that means we should have one transparent and honest standard. The NCCAM’s true purpose is to create an opaque double-standard based upon distortion of language and misleading claims. I think 17 years of the experiment is enough – end it.

On a side note – I know that the NCCAM is a creation of the Congress, not the Administrative branch of the Federal government. And therefore only Congress can kill the beast it created. However,  a popular president can have great power to set policy and agenda, especially when his own party is in the majority in the House and Senate. Further – I am not just calling to Obama, but also to Congress to end the NCCAM.

Readers can go to this link to support the proposal to defund NCCAM. While you are there, take a look at all the pro-CAM suggestions and take the time to make your opinions heard.

Posted in: Politics and Regulation, Science and Medicine

Leave a Comment (45) ↓

45 thoughts on “President Obama – Defund the NCCAM

  1. DevoutCatalyst says:

    Richard Feynman said that science demands an unusually high level of honesty — utter honesty. Barrack Obama said it’s time to set aside childish things. NCCAM is a childish thing, and utter honesty requires that it be done away with.

  2. Dacks says:

    Much as I would look forward to this, can you honestly see it happening? The conspiracy theorists would be in seventh heaven: “Big Pharma suppresses alternative medicine!” It’s probably better to push for more rigorous studies and let them continue NOT producing results.

  3. qetzal says:

    I’m not sure the Change.gov site is still active. I tried voting “up” on defunding NCCAM, and “down” on several pro-altie suggestions, but the point values didn’t change. Also, I couldn’t find any way to add a comment.

    Lastly, if you go to the change.gov home page, you see the message:

    Thank you for visiting Change.gov. The transition has ended and the new administration has begun. Please join President Barack Obama at Whitehouse.gov.

    I tried searching for a similar Citizen’s Briefing Book at Whitehouse.gov, without success.

    Is anyone else able to successfully vote or comment at Change.gov?

  4. yep, they seem to have changed over the website just today – good timing :)

    If they move the change.gov function over I will post an updated link. If anyone finds it before I do pleas post it.

  5. Fredeliot2 says:

    Glad I voted last week. There were plenty of woo ideas but I didn’t have time to go through all of them.

  6. maus says:

    “Much as I would look forward to this, can you honestly see it happening? The conspiracy theorists would be in seventh heaven: “Big Pharma suppresses alternative medicine!” It’s probably better to push for more rigorous studies and let them continue NOT producing results.”

    Is there a manner to better require results for funding?

  7. salzberg says:

    The Obama transition team closed the site for comments Sunday night. They say that the best ideas will be presented to the President in a “briefing book,” but it is unclear how they will choose which ideas to present.

    Thanks to the support of this blog, to PZ Myers (Pharyngula blog), and to Orac, the proposal to de-fund NCCAM got a huge burst of support, with its vote total rising to > 11,000 by Saturday. (Yes votes counted +10, No votes counted -10.)

    However, the CAM community got wind of it, and through at least 3 blogs they called on their minions to vote it down. Here is the most zealous of the three:
    http://theintegratorblog.com/site/index.php?option=com_content&task=view&id=527&Itemid=189
    This pseudoscience blog calls on its readers to “Act now!” to vote down the proposal. If you read it, you’ll see that proponents of CAM were mobilizing via email and blogs to vote it down. Here is a quote from an email sent by a naturopath that was being sent around: “One of the largest number of comments on the Obama administration’s Change.gov website involves the issue of defunding of the NIH¹s National Center for Complementary and Alternative Medicine (NCCAM), with a net support for defunding of over 1100 people (11240 points as of the time of this writing, 10 points/person) and 113 written comments . This is compared to other issues such as the general state of healthcare and the war in Iraq, which only have 80-90 comments and net support of a few hundred people. Clearly, someone has energized the population to defund the NCCAM, which would be a huge setback to our profession.”

    So the energy of the skeptical community was effective. The pseudoscience crowd then flooded the Change.gov proposal with as many pro-CAM comments as they could, but they only got the vote down to 8,940 before it closed on Sunday.

  8. RickK says:

    I’ve browsed the NCCAM website. Is there any summary of studies that actually reached conclusions? Or is there a way to search PubMed for completed studies that were funded by NCCAM?

    I found a couple that demonstrated “no apparent effect”. But it took a lot of searching because most of the studies are “in progress” or have no results.

    It would be very useful to have a list of the NCCAM studies that found CAM treatments equivalent to placebo.

  9. pec says:

    “This is a worthless study for many reasons. First, clinical studies, taken as a whole, have not demonstrated any difference between true and sham acupuncture. Second, this study included only 12 subjects – far too few to pull any signal out of the noise using fMRI or even PET.”

    So you’re saying that “Behavioural Brain Research” published it even though it was worthless? Do you realize that the number of subjects is not relevant if you don’t know the effect size or the variance? The positive results could only be published if the effect was statistically reliable, and this cannot be determined only by the number of subjects.

    Is it scientific to dismiss research that has been reviewed and published in a mainstream journal, just because you don’t like the result?

    I certainly hope Obama’s advisors can see how political and unscientific your motivations are.

  10. Karl Withakay says:

    pec,
    12 subject is a pretty small sample for any study. Consider that one subject accounts for 8.3% of the study group. That’s a huge effect for any anomaly or error.

  11. wertys says:

    Now pec, we know you do science a bit differently to the rest of the scientific community, but even you would have to see that a study like that is essentially worthless. It’s not because we don’t like the result, it’s that without even knowing the result you can conclude that such a study is only worth publishing as an exercise in hypothesis generation or a pilot study.

    Again, as we have pointed out a number of times, it is futile to do further pilot studies on acupuncture as the big studies with good blinding and good definition of the hypothesis being tested have in fact been done. They were negative, for every condition tested. We therefore conclude that as a treatment acupuncture has no specific effects, as its adherents claim, but merely nonspecific effects which cannot be distinguished from placebo responses.

    Once the evidence is in, proponents of acupuncture now have to account for the mass of negative evidence as well as producing a coherent explanation for the ‘effectiveness’ of acupuncture which does not violate the known facts of biology and physics.

  12. Wholly Father says:

    After over 1 billion dollars spent hunting for unicorns, its time to put our tax dollars to better use.

    Proposals for CAM therapies should not have a separate pathway to funding. They should be evaluated and prioritized on their own merits, among all other proposals (within the existing Institutes), and let the chips fall where they may. It is a tragedy if proposals with genuine potential to impact our health get passed over to fund the implausible and impossible.

    How would people feel if a portion of dollars alloted to solving our current financial mess was set aside to study alchemy?

  13. Wallace Sampson says:

    Deja vue again? encore? Wieder? Otra vez? Anyone is still listening, reading, …

    With apologies for self-serving again (otra vez, etc.) I coined the expression “defund the NCCAM” in calling for the same in several articles back in the early 2000s,
    one being in Sampson W, Dancing with a dream: the folly of pursuing alternative medicine. Acad Med. 2001 Apr;76(4):301-3. in an exchange with the NCCAM director Steve Straus. I’ve stated the same “defund” thing several mre times.
    Arthur Grollman and Robert Marcus pusued the same tack in an article in Science 2-3 years ago, using the same wording.
    I don’t know who Professor S is, but it was not I. If anyone knows, feel free to pass this on.

  14. wertys says:

    As a secondary topic relating to Obama, does anyone know whether the open letter he supposedly sent to the American Chiropractic Association was real ? I have read it and I have to say it does not read like he wrote it. He is very articulate and the wording of that letter seemed quite clumsy.

    If it is correct however, and he has big plans to increase the Government funded participation of chiropractors in his proposed national health reforms, then I think the gloss may wear off the 44th president very quickly..

  15. weing says:

    “Is it scientific to dismiss research that has been reviewed and published in a mainstream journal, just because you don’t like the result?”

    Of course not. But, is it scientific to accept research just because it has been reviewed and published in a mainstream journal?

  16. Ditto to Dr. Sampson.

    I will post something about this tomorrow. I haven’t decided exactly what, yet, but I think it ought to include information not much discussed in recent posts and comments, on various blogs, regarding Professor S’s modest proposal. Perhaps it will include an annotated bibliography of the many articles that have called for the abolition of the NCCAM (or its predecessor, the OAM). It will definitely include a discussion of the Marcus/Grollman article in Science, summer of 2006, and the disingenuous responses to that article by the NCCAM leadership and by conspicuous Quackademics (which “segues” with Dr. Sampson’s post of today).

    I do know who Professor S is; I don’t know if he wants to reveal his identity here, so I won’t do it for him. I can assure readers that he is well-qualified to write what he writes, if anyone is wondering. Not that this really matters, because his arguments speak for themselves.

  17. salzberg says:

    hi,
    I don’t mind revealing that I’m Professor S. I very much appreciate the support my proposal got at Change.gov.
    If anyone has the patience for it, it’s interesting (although frustrating) to read the swarm of last-minute negative comments on my proposal, posted by pro-NCCAM people. They repeat a laundry list of logical fallacies that could be used to construct a lesson in logical thinking and skepticism – a lesson on what not to do, that is. E.g., they argue that “CAM is used by over half the population,” and “let’s only research what we already know or think we know,” and “the majority of what allopaths [i.e. doctors] do daily is unsupported by evidence.” It goes on and on.

    Dr. Sampson is correct that he coined the expression “defund the NCCAM” – that’s why I cited his Quackwatch article in my proposal.
    -Steven Salzberg (“Professor S”)
    http://genefinding.blogspot.com

  18. David Gorski says:

    Yeah, I was going to tweak Dr. Sampson for being a little too sensitive about not being attributed when in fact he has been. ;-)

  19. Prometheus says:

    “pec” says:

    Do you realize that the number of subjects is not relevant if you don’t know the effect size or the variance? The positive results could only be published if the effect was statistically reliable, and this cannot be determined only by the number of subjects.

    Has “pec” actually read this study? Here are a few “highlights”:

    [1] They started with 22 subjects – 8 were eliminated because they did not experience pain relief with “real” acupuncture.

    [2] The “sham” acupuncture was done with a blunt-tipped retractable needle. Although the authors asserted that this technique had been “validated”, the authors showed that the subjects could tell the difference between the “sham” and “real” acupuncture:

    “As expected, we found significantly lower SASS [Subjective Acupuncture Sensation Scale] ratings for the sham acupuncture treatment than for the verum acupuncture treatment in both fMRI and PET sessions.”

    So, after weeding out the subjects who were less responsive to suggestion, the authors confirmed – by questionaire, fMRI and PET scan – that the subjects could tell the difference between the “sham” and “real” acupuncture techniques.

    Not exactly earth-shattering results, that. As a friend from the South likes to say, it was “a long run for a short slide”.

    Of course, the authors come to a different conclusion.

    The fact that this study was published is irrelevant, expecially when you consider the various reasons an editor might have for publishing an obviously flawed study. The study’s conclusions are not supported by the data presented.

    In reality, this wasn’t a study of 12 subjects – it was a study of 20 subjects. Eight (8) of the twenty (40%) could detect no difference in the “analgesia” of “sham” and “real” acupuncture and were “eliminated”. I wonder what the statistics would have looked like if they had been left in the analyses.

    In the end, this study is – as Dr. Novella said – an excellent example of why the NCCAM should not be allowed to waste tax money on worthless research.

    Prometheus

  20. pmoran says:

    “The study’s conclusions are not supported by the data presented. ”

    Can you explain further? It is not clear from the abstract that any major conclusions were drawn or that the research is “worthless”.

    I think many acupuncture researchers (e.g. Linde) reject Chinese superstitions and understand that it “works”, to the extent that it works, through placebo and other non-specific effeccts of the needling sessions (e.g. enforced relaxation and distraction).

    Such research might help elucidate the nature and extent of these non-specific influences, and confirm the validity of sham procedures. It might also help eventually answer the vexed question as to how much of any apparent benefits to patients are “real”, or merely due to reporting biases (patients giving the answers expected of them).

    I wholeheartedly agree that research that has the sole aim of vindicating adequately disproved theories should be stopped.

    Nevertheless, there are still practical medical and political questions to be answered concerning public access to and and the control of presumed placebo medicines. These require a somewhat different focus to the the usual “working better than placebo” one of science-based medicine. They may also not be easily funded through normal channels.

  21. dsrileymd says:

    I believe there was a positive study on acupuncture for osteoarthritis of the knee published in the Annals of Internal Medicine in 2004 (Ann Intern Med. 2004 Dec 21;141(12):901-10). There were 570 patients, a bit more than 12.

  22. wertys says:

    @dsrileymd

    Your belief is correct. That particular trial has a huge problem with credibility however, as to quote from the abstract

    “At 26 weeks, 43% of the participants in the education group and 25% in each of the true and sham acupuncture groups were not available for analysis. ”

    ie nearly half the non-intervention control arm dropped out, and a quarter of the intervention groups dropped as well. if an intention-to-treat analysis was to be performed the results are likely to be unreliable whether positive or negative.

    This paper also illustrates a major feature of acupuncture literature, which is that it is likely that people who participate in the trial have high expectations of the treatment, and do better accordingly. The high dropout rate in the education grouip is probably reflective of the disappointment and lack of motivation of those who thought they would get a ‘real; treatment instead of a ‘lame’ control intervention.

    There have also been heaps of studies published since then, many with better methodology. I wonder why you would cite that particular one ?

    Oh..that’s right. All the other ones with better methodology are negative.

  23. pmoran says:

    http://www.cochrane.org/reviews/en/ab001218.html

    This kind of material has been looming for some time. I have been trying to warn of it. We should have stopped engaging ancient superstitions on their own turf a long time ago and tried to understand just what placebo and other non-specific influences of medical attentions are capable of doing for our patients (or not, as the matter is not yet conclusively settled). Instead, we gave in to prejudice. We embraced weak evidence that such influences could be ignored, or found dubious ethical reasons as why they should not concern us.

    Wally, the slope just got slipperier, in terms of the healthfraud debate, if not yet conclusively as to where or if placebo methods may still have some place in medicine. Or are we to be the dog in the manger about methods that we see no use for?

  24. Fifi says:

    pmoran – I couldn’t agree more, well said! (Excuse me sir, is that my bee in your bonnet?) There’s something going on and, since it may help patients, it’s worth understanding. I think one reason there’s less curiosity about the placebo effect (and a sort of dismissive attitude of “just a placebo effect) is that it starts to integrate psychology with physical medicine. (Not to mention that it has an association with hypochondria or “faking” in some people’s minds. “It’s all in your head” tends to be an insult or dismissal, which entirely ignores the fact that indeed it is all – and I mean all each and every one of us experience – in our head.) Obviously there’s more openness in chronic pain research since it’s generally accept that there is a mental/psychological/experiential aspect to the issue of chronic pain but pain researchers are already often considered “fringe” – like many who deal with the mind as well as the brain. In some (perhaps small not large) ways it’s that old hard/soft science prejudice that some people hold coming to bite medicine in the butt.

  25. Prometheus says:

    pmoran asks:

    Can you explain further? It is not clear from the abstract that any major conclusions were drawn or that the research is “worthless”.

    True, the abstract doesn’t state any conclusions, which is why it is important to read the actual article. In it, the authors make two conclusions:

    [1] Their subjects experienced pain relief (averaging 1 “point” on a 20 “point” scale) with acupuncture. However, since they had already pre-selected a population that reported pain relief with “real” and not “sham” acupuncture, this finding is rather circular – they found what they had selected for.

    [2] Their subjects had different fMRI and PET scan changes with “real” and “sham” acupuncture. See above.

    I am not arguing that acupuncture doesn’t “work” in some people; my argument is that there is nothing behind the idea of “meridians”, “chi” or “acupuncture points”. I think that it is perfectly reasonable that if someone thinks that sticking needles in their body will relieve pain, that they will experience pain relief when stuck with needles. I would be more impressed if being stuck with needles had an effect on blood glucose in diabetics or other more objective finding.

    I also don’t think that there is some sort of “resistance” to the idea that a patient’s mental state can affect their health or subjective experiences. Again, the issue is not whether this happens – it does – but whether we need to accept all of the magical mumbo-jumbo that goes along with “therapies” exploiting this effect.

    My objection to this particular study is that they set it up in such a way that the data was meaningless. There is no way of knowing if the fMRI and PET changes the authors saw were specific to sticking a needle in a specific spot or if they are generalizable to sticking needles anywhere (which is what I suspect is the fact).

    Likewise, there is no way to tell if the 12 subjects eventually chosen were “special” in their ability to discriminate between the sham needle and the real one or if they were “special” in their response to being stuck with needles.

    In the end, it was a waste of time and money – their time, our money.

    Prometheus

  26. pmoran says:

    Fifi: “There’s something going on and, since it may help patients, it’s worth understanding. ”

    Couldn’t have put it better.

    The “something” is (obviously) to do with the human mind’s perceptions concerning illness, but in a nice way, and as an inescapable component of medical interactions. It is NOT the same as the exaggerated imaginings of the mind-body crowd, or that exercise in futility, the New Age, as certain “alternative” identities have tried to portray it.

  27. pmoran says:

    “I would be more impressed if being stuck with needles had an effect on blood glucose in diabetics or other more objective finding.”

    Thanks for the further comments.

    I agree about the limitations upon placebo influences. The placebo medicines of CAM are, however, often employed when conventional medicine has no entirely satisfactory answers. If patients are deriving even minor benefits from them, should our default position be one of total condemnation?

  28. Harriet Hall says:

    Our default position should be one of total condemnation of false claims. We should not condemn patients who choose to try an irrational or placebo treatment. We should only condemn those tho lie to them.

    To give an example: I condemn the chiropractor who says he will improve the patient’s nerve flow by correcting a subluxation; I don’t condemn the one who says he wants to try a treatment has seemed to help other people with the same symptoms, even though there is no good scientific evidence to support it.

  29. David Gorski says:

    I would be more impressed if being stuck with needles had an effect on blood glucose in diabetics or other more objective finding.

    Indeed. As a cancer surgeon, I’d be more impressed if it resulted in the shrinkage of tumors or could measurably prolong the life of cancer patients.

  30. pmoran says:

    David: “Indeed. As a cancer surgeon, I’d be more impressed if it resulted in the shrinkage of tumors or could measurably prolong the life of cancer patients.

    So would I, but we are already certain that acupuncture won’t do that. Respectable acupuncturists make no such claims. Even the Chinese have not attempted such studies, or if they have, they have not obtained results worthy of general publication.

    However acupuncture might help with cancer pain. Concurrent opiate requirements could be used as a very clinically relevant semi-objective end point in studies that would not necessarily need a sham control. Quality of life measures are also probably sufficiently sophisticated as to be meaningful even within non-placebo controlled studies.

    We have been so confined by the “working better than placebo” model of medical practice that we have only a very limited idea as to what various complicated treatment rituals and the associated medical attentions can do for our patients. I have pointed out before the inconsistency of a position that allows us to dismiss them as insignificant, while at the same time having to obsessively exclude their influence within those studies designed to reveal the intrinsic efficacy of treatments.

  31. Dr Benway says:

    We have been so confined by the “working better than placebo” model of medical practice that we have only a very limited idea as to what various complicated treatment rituals and the associated medical attentions can do for our patients.

    Positive transference. Easy to induce; easy to manipulate.

    If accupuncture is no better than placebo it can be safely ignored, which is convenient because all those needles are a hassle. Instead, we can use some other trick to induce a feeling in patients that a powerful, idealized, caring person is making a bad thing go away.

    Or –even better– we can help patients understand that humans are social animals. When suffering, humans instinctively seek out someone smart and caring for help. Simply finding such a person can reduce the sense of suffering.

  32. Harriet Hall says:

    As for those needles, one prominent acupuncture researcher(Ulett) is convinced that no needles are necessary and that the same effect can be obtained by transdermal electrical stimulation at a single location on the wrist. He covers this in The Biology of Acupuncture co-written with Han.

  33. Fifi says:

    pmoran – “The “something” is (obviously) to do with the human mind’s perceptions concerning illness, but in a nice way, and as an inescapable component of medical interactions. It is NOT the same as the exaggerated imaginings of the mind-body crowd, or that exercise in futility, the New Age, as certain “alternative” identities have tried to portray it.”

    Dr Benway – “Or –even better– we can help patients understand that humans are social animals. When suffering, humans instinctively seek out someone smart and caring for help. Simply finding such a person can reduce the sense of suffering.”

    Exactly! I suspect most of it is a psychotherapeutic effect but I don’t dismiss the potential physical influence of loving touch for some people (no, not some magical lasers shooting from the hands kind of thing, just the basic kind of gentle, loving touch that’s also responsible for proper neurobiological development in infants…it seems reasonable to consider if this outside of the woo claims and to wonder whether accepting/loving/gentle/caring touch has importance for social animals). People also have very different levels of suggestability (which seems to be linked to the placebo effect). I would think that, for instance, people on the autistic spectrum who tend to be very literal probably aren’t prone to suggestion in the same way that someone with a borderline personality disorder. For me these are very exciting and interesting questions because I suspect that there’ll be a cascade effect as we start to unravel these mysteries of the brain and our experiences.

  34. pmoran says:

    “If acupuncture is no better than placebo it can be safely ignored — ”

    And how well is this working for the aims of healthfraud skeptics (whatever those are — will we one day work out some priorities?)?

    What spin can magically evaporate the latest evidence from Cochrane as to the potential of one of the placebo medicines of CAM? I will be talking to persons who will thrust this data down my throat, but fortunately I have already aired the opinion that methods like acupuncture may still have some place within medicine at large at this stage of its evolution, and that some of the clinical claims for it probably are based upon substance, if mainly through placebo and other non-specific influences.

    I should say that my main concern is not how or whether we medicos should go out of our way to exploit placebo methods (mostly meaning CAM because of prior credibility with some of the public). I am mainly concerned about how we should talk about such methods. We have become accustomed to talking in absolutes and generalizations and “can’t possibly work”s that clash violently and to some extent unnecessarily with public experience and perceptions and increasingly and more damagingly with what the latest science actually shows.

    This may be partly why we are not having the influence we crave. While we are perceived as wanting to deny even possible benefits to suffering people we will be seen as the lunatic fringe of medical skepticism, in unfortunate symmetry with the one that that we are trying to protect people from and that probably drew most of us into becoming critics of health fraud and quackery in the first place. I know that most of us don’t want to deny people anything, but we are involved in a PR battle here. as much as an evidence-based one — we need to be looking at what IMRESSIONS our rhetoric is conveying. It certainly must cohere with every aspect of the relevant science.

    My sallies into this subject are triggered by the smugness of some of the attacks upon “believers” and even upon those who hold more moderate views . I think many people are groping away in semi-darkness, trying to make sense of an impossibly complex field of human activity. Those who don’t find themselves bemused by some of it have probably merely not yet looked closely enough at it. Let’s not leave normal scientific cautions and temperate modes of expression behind.

  35. Prometheus says:

    The problem I have with using “CAM” modalities to exploit the “placebo effect” is all the baggage they bring with them.

    I understand that the ritual and pseudo-scientific (neo-magical) utterances are part of the way “CAM” treatments exploit the “placebo effect”, but is it really necessary to talk to the patient about “chi flow” and “meridians” and “acupunture points” or can we simply stick needles wherever convenience and modesty dictate and get the same “results”? So far, the data suggest the latter.

    The same has also been shown for chiropractic – their “manipulation” of the spine only “works” for lower back pain (about as well as mundane physiotherapy). Do we have to swallow the rest of the chiropractic catechism to get back physiotherapy to “work”? Studies comparing chiropractic to physiotherapy say “no”.

    And how about homeopathy, which is no better than placebo because it is placebo. Do we have to tell the patient the patently ridiculous story of “like cures like” and “the law of infinitesimals” to make a placebo “work”? I hope not.

    I guess this is where I part company with pmoran – I still hold to the outdated idea that it is wrong to deliberately deceive a patient, even if the doctor thinks it will “help”. And let’s be brutally honest – the explanations usually given to explain acupuncture, chiropractic and homeopathy (to name just three) are lies.

    The only mitigating factor is the most of the “CAM” practitioners don’t realize they are telling lies, which makes them innocent of deliberate deception but guilty of gross stupidity.

    The rest of us all know that there is no such thing as “chi”, “meridians” and we all know that the only thing acupuncture “redirects” is the flow of money (from the patient to the practitioner). To pretend otherwise is a lie.

    How about this for an idea: tell the patient that the needles produce a response in their brain that alters their perception of pain (or nausea). That is honest and allows the patient to give an informed consent.

    Prometheus

  36. Fifi says:

    Prometheus – For me, the point of understand what is actually going on with a CAM treatment – is it the ritual, or in the case of homeopathy is it the intent listening that has a psychotherapeutic effect, or is there a hypnotic effect that makes people open to suggestion or perhaps the healer/client relationship which is ongoing and weekly, or is it NO or something we don’t expect but wouldn’t notice if we don’t look more closely? If we don’t isolate the effective aspect of the treatment, we can’t know what is actually going on and then apply it without unnecessary woo.

    What you suggest telling patients seems much more misleading to me than just being honest with a patient. Doctors don’t need to con patients about placebos – which seems to indicate that the simple belief that “something” is being done (some action is being taken) provides temporary relief from pain even if one is consciously aware that the treatment is inactive/ineffective. Ritual and habit aren’t entirely conscious affairs, we all tend to salivate when our bell is rung!

  37. Dr Benway says:

    pmoran

    I should say that my main concern is not how or whether we medicos should go out of our way to exploit placebo methods (mostly meaning CAM because of prior credibility with some of the public). I am mainly concerned about how we should talk about such methods.

    My effort to be honest makes it difficult to prescribe placebos. The cognitive dissonance is a killer.

    Lucky for my placebo-loving patients, a lot of what they want is OTC.

    Last conversation I had about this topic with a patient went something like this: “Hey, I’m a human being. I know what it’s like to be sick and afraid and desperate. If there’s some slim chance Vitamin X might help and it’s pretty safe, a lot of people will want to try it. I’ve no problem with that. I just think we shouldn’t kid ourselves. If there’s no good evidence to support Vitamin X as a treatment, let’s not pretend otherwise. Whatever we decide to do, let’s do it with our eyes open.”

  38. Prometheus says:

    I am encouraged to hear that Dr. Benway feels uncomfortable with the idea of lying to patients (i.e. giving them a placebo).

    As a patient, I am extremely uncomfortable with the idea that my doctor might be giving me a medication that he/she knows is ineffective simply to evoke a “placebo response”. I’d find it very difficult to ever again trust a physician who lied to me that way.

    Now, I realize that many treatments that were (and are) thought to be “real” are, in fact, ineffective and all we are seeing is the “placebo effect”. That’s why we have to do rigorous clinical testing before treatments become “standard of care” (and thus more difficult to test).

    In clinical research, we give patients placebos, but only after informing them (“informed consent” – it’s not just a good idea, it’s the law) that there is a possibility they might receive a placebo. It’s right in the consent form. We aren’t lying to them at all – they know there is a chance (and they know the odds) they will get a placebo.

    And one of the other “facts” about placebos is that they don’t “work” if the patient knows (or even strongly suspects) that they are receiving a placebo. That’s why we work so hard to make the placebo indistinguishable from the “real” treatment.

    I know that this is “old hat” to people like Dr. Moran, but I wanted to make it absolutely clear that when we say “placebo effect”, it isn’t an effect of the placebo, it is an effect the placebo has on the mind of the patient (that’s why they don’t “work” on unconscious patients).

    As a result, the “placebo effect” has greater impact on subjective symptoms (e.g. pain) and less impact on objective signs (e.g. cancer, infection, blood glucose).

    Even with pain – arguably the symptom most susceptible to the “placebo effect” – placebos are not able to affect more severe pain (try doing surgery under acupuncture) and generally tend to have a shorter duration of effect. The same is seen in treatment of nausea.

    Studies looking at placebo for treatment of depression and anxiety have shown less effect, while studies of placebo “treatment” of blood pressure (which is at least partially related to mood and mental state) show even less effect.

    The point is, with effective non-placebo treatments for pain, nausea, anxiety, depression, etc. at our disposal, is it really worth the loss of patient trust to start deliberately lying to patients about their treatment? And make no mistake about it – placebo “treatments” won’t “work” unless the patient thinks that they are (or have a good chance of) receiving a “real” treatment.

    So, is there a groundswell of interest in lying to patients among the medical community? I sincerely hope there is not. Even the “alternative” quacktitioners are at least being honest in the sense that they believe the nonsense they are telling their patients. Are we to have real practitioners sink below that standard?

    Prometheus

  39. Fifi says:

    Promethius – In an experimental context obviously it’s important for the subjects not to be able to distinguish between the placebo and real treatment (so as to avoid a double placebo effect? ;-) I’m joking, kind of…). In clinical practice, when treating chronic pain patients in partcular, it’s not uncommon for a patient to be told that a certain treatment has been experimentally shown to have no real effect and they will STILL insist on the treatment and that it makes a difference for them (which the ritual of the treament obviously does provide some sense of relief, if only psychological). In these cases the patient has been clearly told and knows that it’s only a placebo effect but it doesn’t change their belief or experience. Of course, chronic pain tends to accerbate superstious/ritual behavior since it gives people a sense of control or agency in a very difficult situation (that is often treated as a weakness by people who don’t or haven’t suffered from illness or severe pain so have little understanding of what suffering really is – luckily for them, of course!)

  40. Fifi says:

    “I know that this is “old hat” to people like Dr. Moran, but I wanted to make it absolutely clear that when we say “placebo effect”, it isn’t an effect of the placebo, it is an effect the placebo has on the mind of the patient (that’s why they don’t “work” on unconscious patients).”

    Well explained Prometheus :-)

  41. pmoran says:

    “As a patient, I am extremely uncomfortable with the idea that my doctor might be giving me a medication that he/she knows is ineffective simply to evoke a “placebo response”. I’d find it very difficult to ever again trust a physician who lied to me that way.”

    An artificial scenario. Doctors would use placebos because they think that it would help and they see doing nothing as a worse option, having its own adverse effects.

    The proper place for placebo methods would be as something to try when there is no entirely satisfactory “working better than placebo” EBM-endorsed method or such methods have been exhausted.

    Being prepared to try anything that *might* help, even methods that the practitioner is dubious about, can only enhance patient trust. It will also almost always be better for a proper doctor have some overall control than for the patient to end up in the hands of a complete woo-merchant.

    I am not pushing such a viewpoint, although I suggest that there will be occasions in any doctor’s experience where it is the right approach. Honest doctors will admit that.

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