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Spin City: Using placebos to evaluate objective and subjective responses in asthma

As I type this, I’m on an airplane flying home from The Amazing Meeting 9 in Las Vegas. Sadly, I couldn’t stay for Sunday; my day job calls as I’ll be hosting a visiting professor. However, I can say—and with considerable justification, I believe—that out little portion of TAM mirrored the bigger picture in that it was a big success. Attendance at both our workshop on Thursday and our panel discussion on placebos on Saturday was fantastic, beyond our most optimistic expectations. There was also a bit of truly amazing serendipity that helped make our panel discussion on placebo medicine an even bigger success.

If there’s one thing about going away to a meeting, be it TAM or a professional meeting, it’s that it suddenly becomes very difficult for me to keep track of all the medical and blog stuff that I normally keep track of and nearly impossible to keep up with the medical literature. This is the likely explanation for why I had been unaware of a study published in the New England Journal of Medicine (NEJM) on Thursday that was so relevant to our discussion and illustrated out points so perfectly that it was hard to believe that some divine force didn’t give it to us in order to make our panel a total success.

Just kidding. It was TAM, after all. It was, however, embarrassing that I didn’t see the study until the morning of our panel, when Kimball Atwood showed it to me.

Before I get to the meat of this study and why it fit into our nefarious plans for world domination, (or at least the domination of medicine by science-based treatments), a brief recap of the panel discussion would seem to be in order. First, for the most part, we all more or less agreed that the term “placebo effect” is a misnomer and somewhat deceptive because it implies that there is a true physiologic effect caused by an inert intervention. “Placebo response” or “placebo responses” seemed to us a better term because what we are observing with a placebo is in reality a patient’s subjective response to thinking that he is having something active done having something done. In general, we do not see placebo responses resulting improvement in objective outcomes; i.e., prolonged survival in cancer. The relative contributions of components of this response, be they expectancy effects (if you expect to feel better you likely will feel better), conditioning, or one that is frequently dismissed or downplayed, namely artifacts of the design of randomized clinical trials and even subtle (or even not-so-subtle) biases in trial design. This issue of placebo responses being observed only in subjective patient-reported clinical outcomes (pain, anxiety, and the like) and not in objectively measured outcomes is an important one, and it is one that goes to the heart of the NEJM study that so serendipitously manifested itself to us. As Mark Crislip so humorously pointed out, the placebo response is the beer goggles of medicine (this is not a spoiler or stealing Mark’s line; several TAM attendees have already tweeted Mark’s line), and much of what is being observed are changes in the patient’s perception of his symptoms rather than true changes in the underlying pathophysiology. This study drove the point home better than we could.

Another point discussed by the panel is also quite relevant. As more and more studies demonstrate very convincingly that “complementary and alternative medicine” (CAM) or “integrative medicine” (IM) therapies do not produce improvements in symptoms greater than placebo. Moreover, multiple studies, including a famous NEJM meta-analysis and a recently updated Cochrane review, demonstrate, placebo responses probably do not constitute meaningful responses. In light of these findings, CAM apologists, driven by ideology rather than science and masters of spin, have begun to admit grudgingly that, yes, in essence their treatments are elaborate placebos. Not to be deterred, instead of simply concluding that their CAM interventions do not work, they’ve moved the goal posts and started to try to argue that it doesn’t matter that CAM effects are placebo effects because placebos are “powerful” and good and—oh, yes, by the way—there are a lot of treatments in science-based medicine that do little better than placebos. In other words, CAM advocates elevate the subjective above the objective and sell the subjective, and that’s exactly what they are doing with this study.

Perception versus physiology

The study under question was performed at Harvard, with Michael E. Wechsler as its first author and Ted Kaptchuk as its senior author. Studies done by groups including Ted Kaptchuk have actually presented us here at SBM with copious blog fodder before, all designed to promote placebo medicine, either through making an argumentum ad populum, claiming in a truly Humpty Dumpty moment that it is possible to have placebo effects without deceiving the patient, and or rebranding of exercise as “alternative” in the New England Journal of Medicine (NEJM) last year.

The current study is entitled, Active Albuterol or Placebo, Sham Acupuncture, or No Intervention in Asthma. Personally, I like this title. It’s a fine title, as it tells the reader in essence what the trial design is in only a few words. And it’s actually a reasonably good pilot study. Of course, it’s not so much the trial design that goes disastrously awry. Rather, it’s the interpretation of the results of the RCT that devolves into propaganda for quackademic medicine in which subjective improvement is used to argue that placebo medicine is good, even when no objective improvement is observed in a disease for which we have good drugs that produce objective improvements as well as subjective improvements.

This study basically compared four different interventions

  • Treatment with Albuterol
  • Sham acupuncture using the classic retractable needle (note that this was only single-blinded)
  • Placebo inhaler
  • No treatment at all

Inclusion criteria were as follows:

  • Men and women age>or= 18 with a diagnosis of asthma
  • Meet American Thoracic Society diagnostic criteria for asthma
  • Currently using a stable asthma regimen (no med. changes for 4 weeks)
  • Ability to withhold short-acting bronchodilators for 6 hours prior to each visit (see Spirometry description)
  • Ability to withhold long-acting bronchodilators for 48 hours prior to each visit (see Spirometry description)
  • Presence of reversible airflow obstruction as demonstrated by an improvement in FEV1 of at least 12 % following the inhalation of a β-agonist after 10 am. at screening visit.

Exclusion criteria were straightforward:

  • Lung disease other than asthma
  • Respiratory tract infection within the last month
  • Active tobacco use
  • Asthma exacerbation requiring the use of systemic
  • corticosteroids within the past 6 weeks
  • Prior experience with acupuncture

These criterial guaranteed that the patients selected have only mild to moderate asthma with no complications from the asthma, such as pneumonia or pulmonary fibrosis. Of course, it would be highly unethical to take people with severe asthma off of their bronchodilators; so medical ethics pretty much prevents testing placebos on people with more severe disease. Still, I can’t help but wonder whether the results reported would have been different in more severe asthma and if the subjective improvement would have been nearly as great. In any case, this study ended up including 39 patients, after 79 were screened, 46 underwent randomization, and 7 dropped out during the protocol. Patients who completed the protocol underwent the following procedure:

These patients returned within a week and were assigned to a randomly ordered series of four interventions — active albuterol inhaler, placebo inhaler, sham acupuncture, or no-intervention control — administered on four separate occasions, 3 to 7 days apart (block 1) (Figure 2). This procedure was repeated in two more blocks of four visits each (blocks 2 and 3), during which the interventions were again randomly ordered and administered. Thus, each subject received a total of 12 interventions. Albuterol and the placebo inhaler were administered in a double-blind fashion and sham acupuncture in a single-blind fashion, and the no-intervention control was not blinded. As before, short-acting and long-acting bronchodilator therapy was withheld for 8 hours and 24 hours, respectively, before each intervention. The no-intervention control condition differs from the natural history of asthma, since it controls for nonspecific factors such as attention from study staff, responses to repeated spirometry, regression to the mean, natural physiological variation, and any effects arising from the hospital setting. Nonetheless, no-intervention controls are the best approximation of no treatment in an experimental design. The study was conducted in accordance with the protocol (available at NEJM.org).

I’m not entirely sure why Kaptchuk thought he had to place a comment in there about no-intervention controls being only an approximation of no treatment in an experimental design. After all, that’s the sort of thing that clinicians and clinical researchers simply know; it does not need to be pointed out to them, much as it shouldn’t need to be pointed out that an RCT is an intentionally artificial method designed to remove as many biases as possible. Be that as it may, one thing that is clear is that these patients could not have truly severe asthma. Ruling out anyone requiring steroids for an acute exacerbation in the recent past and only including patients who could be off their long-acting bronchodilators for 48 hours and their short-acting bronchodilators for 6 hours pretty much guaranteed that.

Everyone’s heard the old cliche that a picture is worth a thousand words, and this is exactly the sort of situation where that’s true. All I need to do is to show you two graphs, and instead of one of my usual 5,000 word blog posts, you can have a 4,000 word post. Funny how that works. In any case, for your edification, here a graph of the objective results of this study, namely the FEV1 for the four groups:


(Click to embiggen)

Not surprisingly, a known, effective bronchodilator had a very strong effect on the actual, objectively measured lung function of these patients. However, it should be noted that all groups improved, even the no-treatment group; it just improved much less than the albuterol group, and the sham acupuncture and placebo albuterol groups were indistinguishable from the no-treatment arm. In fact, in the supplemental data, there is also a table showing that in 32 of the patients exhaled nitric oxide (FENO) was measured, with identical results. Immediately after treatment, FENO increased in patients treated with double-blind albuterol by 5.9%, in contrast to patients treated with placebo inhaler, placebo acupuncture, and no treatment, all of whom demonstrated no significant change in FENO. This graph is about as clear and compelling evidence as there can be within the limits of a relatively small trial, that placebo responses do not change the underlying physiology of the disease of asthma or produce any objectively measurable improvements in lung function the way that real medicine does.

Now, for your edification and comparison, here is a graph of the self-reported subjective improvements.


(Click to embiggen.)

The results are pretty striking, aren’t they? They were so striking that Steve couldn’t resist flipping back and forth between these two graphs for several seconds in order to drive home the point to the audience. The albuterol, sham acupuncture, and placebo albuterol groups all demonstrated a significant improvement in symptoms, while the no-intervention control did not. However, here’s an important point. The scale used was a visual analog scale from 0 to 10 in which 0 means no improvement and 10 means complete resolution. So, again, even though the albuterol, sham acupuncture, and placebo albuterol groups all demonstrated subjective improvement, so did the no-treatment control arm, just less. In other words, all groups reported improvement, even those who received no treatment.

There’s another graph buried in the back of the supplemental data that I now wish we had also shown. Basically, it’s a look at how many patients responded objectively to treatment, as defined by an improvement in FEV1 of 12% or more, at each of the three sessions they did. The results and pattern are striking


(Click to embiggen.)

Notice that, as expected, the vast majority of the patients responded at each session to the albuterol (3/3 sessions). In contrast, only 3% of patients responded 3/3 times to placebo, sham acupuncture, or no treatment. In fact, what’s striking is how similar the three graphs look and how different they look from the graph of patient responses to albuterol. Again, the message is very clear: Real medicine produces real, objectively measurable changes in physiology towards a more normally functioning state. Placebo medicine does not. In any rational, science-based discussion, this would be the end of the story. Placebos don’t work in asthma.

But that’s not the message that was being spread about this story, and here’s where the NEJM, less than a year after its massive fail in publishing a credulous Michael Berman acupuncture article and a clever bait-and-switch article looking at Tai Chi in fibromyalgia, allowed quackademic language to try to make left right, up down, and a negative result an indication that placebo medicine is a good thing.

Spin, spin, spin, spin

As I read the discussion of this paper, I could almost hear the cracking of bones as Kaptchuk went into major contortions to try to explain his negative result. Even though nowhere did the authors really explicitly state their real hypothesis, the design of the study made it painfully clear to anyone who understands clinical research that their hypothesis going in was that placebo responses would result in changes in objectively measured lung function in asthma. They were sorely disappointed, and the contortions of language that went into the discussion were plain to see. The authors implied that it might have been their use of a new, not really validated, patient-reported measure of asthma improvement. Or maybe, they argue, FEV1 isn’t a good measure of the severity of constriction of the airways in asthma, even though spirometry has been a reliable, well-validated test for asthma severity for decades. This is especially true in an academic medical center with a lot of pulmonary specialists. While spirometry can be unreliable in primary care settings and other settings where there isn’t a lot of experience performing it, such a description does not apply to Harvard-affiliated hospitals. At least I would hope not.

Overall, the spin on this study is not that placeboes don’t result in objectively measurable improvements, which is the correct conclusion. Rather, the spin is that subjective symptoms are as important or more important than objective measures; so let’s use placeboes. In the paper itself, Kaptchuk doesn’t quite say that. He first makes a perfectly reasonable point that, if subjective and objective findings don’t correlate, go with the objective findings. Then he does some handwaving:

Indeed, although improvement in objective measures of lung function would be expected to correlate with subjective measures, our study suggests that in clinical trials, reliance solely on subjective outcomes may be inherently unreliable, since they may be significantly influenced by placebo effects. However, even though objective physiological measures (e.g., FEV1) are important, other outcomes such as emergency room visits and quality-of-life metrics may be more clinically relevant to patients and physicians.

My jaw dropped when I read this. “Other outcomes” besides objective measures of disease severity may be “more clinically relevant”? The spin goes way beyond that, though. I have to think that the reviewers kept the authors from getting too frisky with their desire to advocate placebo medicine and promote subjective outcomes as being more important than objective outcomes. No such restraint seemed to inhibit the author of the accompanying editorial, Daniel E. Moerman, Ph.D., who, alas, appears to be based practically in my back yard at the University of Michigan-Dearborn. I had never heard of him before; so I did what all bloggers do when they encounter an unknown. I Googled him. His CV is here, and this is what I found:

Daniel E. Moerman is the William E. Stirton Professor of Anthropology at the University of Michigan — Dearborn, so recognized for his distinguished scholarship, teaching, and professional accomplishments. Because of his work in the field of Native American ethnobotany, Professor Moerman often receives calls from the American Indian community, such as an inquiry from the Menominee in Wisconsin, asking him what kinds of plants they should include in the restoration of their indigenous ecosystem. He acknowledges that we are deeply indebted “to those predecessors of ours on the North American continent who, through glacial cold in a world populated by mammoths and saber-toothed tigers, seriously, deliberately, and thoughtfully studied the flora of a new world, learned its secrets, and encouraged the next generations to study closer and to learn more. Their diligence and energy, their insight and creativity, these are the marks of true scientists, dedicated to gaining meaningful and useful knowledge from a complex and confusing world.”

He’s also known for having written a book entitled Medicine, Meaning and the “Placebo Effect,” part of which can be found here, in particular this doozy of a quote:

There is much objection among physicians to the very existence of something called the placebo effect. It often seems to bother doctors enormously that the fact of receiving medical treatment (rather than the content of medical treatment) can initiate a healing process. Why? I think it is because medicine is rich in a particular kind of science. Medical education is filled with science. In the US, all students must score high on the “Medical College Admission Test” in order to be admitted to medical school. Students are allowed a total of 345 minutes to complete the exam. Eight five minutes are devoted to “verbal reasoning,” and 60 minutes to “writing sample.” The remaining 200 minutes (58.5%) are split evenly between “physical sciences” and “biological sciences.” It is apparently important that physicians understand levers, inclined planes, the acceleration of falling bodies, the life cycle of insects, and the process of photosynthesis. The kind of science that doctors have to learn is the simpler sort of science, the mechanical kind. Physicists worked out the mechanics of simple machines (levers, planes) in the seventeenth century. In our times, they have been working on much slipperier subjects: quarks, chaos, the “weak force,” and the oddest of quantum phenomena. Cause and effect are far less easy to detect in these matters than in the study of falling bodies…But it is the latter, not the former, in which physicians are schooled. And there is very little social science in medical education where one must address the complexities and subtleties of, say, emotion, or ritual, or culture.

If you detect shades of Deepak Chopra in there, you are correct, all with a dollop of utter contempt for Newtonian physics, which, I will remind you, are still accurate enough for most real-world purposes here, where few things we do reach relativistic speeds. Instead, Moerman invokes quarks, quantum theory, and other complexities and contrasts it to the “simpler” sciences that physicians apparently learn. One can almost feel the contempt for us poor, deluded physicians. Perhaps if I had known a bit about Professor Moerman, my jaw ouldn’t have dropped so far when I read this in the editorial accompanying the NEJM study:

What do we learn from this study? The authors conclude that the patient reports were “unreliable,” since they reported improvement when there was none — that is, the subjective experiences were simply wrong because they ignored the objective facts as measured by FEV1. But is this the right interpretation? It is the subjective symptoms that brought these patients to medical care in the first place. They came because they were wheezing and felt suffocated, not because they had a reduced FEV1. The fact that they felt improved even when their FEV1 had not increased begs the question, What is the more important outcome in medicine: the objective or the subjective, the doctor’s or the patient’s perception? This distinction is important, since it should direct us as to when patient-centered versus doctor-directed care should take place.

Apparently Moerman thinks that patient-centered care means inducing a patient through placebo responses to think that he feels better when in actuality the disease-impaired function of his organ (in this case, the lungs) puts him at risk for serious complications. He then goes on to write:

For subjective and functional conditions — for example, migraine, schizophrenia, back pain, depression, asthma, post-traumatic stress disorder, neurologic disorders such as Parkinson’s disease, inflammatory bowel disease and many other autoimmune disorders, any condition defined by symptoms, and anything idiopathic — a patient-centered approach requires that patient-preferred outcomes trump the judgment of the physician. Under these conditions, inert pills can be as useful as “real” ones; two inert pills can work better than one; colorful inert pills can work better than plain ones; and injections can work better than pills.

I find it hard not to notice that Moerman has cast a very wide net; virtually any condition outside of trauma could fit into his definition. I can’t help but think that, if I, for instance, had asthma and the severity of my symptoms didn’t correlate well with my objectively measured lung function as estimated by FEV1, then I would want my lung function tuned up. And if I didn’t want my lung function to be improved, I would hope that my doctor would be able to educate me as to why it is important to make my lungs function better, even though I feel OK. Moerman would seem to advocate telling me, “Oh, no, Dr. Gorski, don’t worry about those blue lips you have. That’s just an ‘objective’ finding. You feel OK, and, since I practice ‘patient-centered’ care, which teaches, among other things, that symptoms are the most important thing and the reason why you come to a doctor in the first place, your feeling better is all that matters!”

I’ll give you another example. Consider an epidural hematoma. If you crack your head hard enough, it can sheer or damage one of the epidural arteries. The typical clinical course is that the patient will be knocked unconscious due to head trauma. Later, he will regain consciousness and experience what is known in the biz as a “lucid interval” that can last several hours. What’s happening during that “lucid interval” is that the blood is still accumulating, but the hematoma hasn’t reached a large enough size yet to cause damage, but when it does the patient deteriorates rapidly. Frequently, one of those “objective findings” is a CT scan that shows a little epidural hematoma, which may or may not blossom into a life threatening epidural hematoma that can squash the brain against the inside of the skull. That’s an “objective” finding. Even though the patient feels well; that hematoma could expand and kill him in a few hours.

No doubt Professor Moerman or Ted Kaptchuk would claim that these are ridiculous and unfair examples. No doubt they would say that this is not what they’re talking about, and that’s probably true. I’ll even concede that the example of the epidural hematoma example was a bit over the top, but that was intentional.
However, whether they realize it or not, by elevating the subjective beyond the objective, and then offering placebo medicine for the subjective, these are exactly the sort of arguments they are making, when you strip them to their essence. No doubt Moerman or Kaptchuk would like to think that they would never, ever use such an approach for diseases with such potentially bad outcomes, but where do they draw the line? When, exactly, do we decide that subjective improvement is more important than objective improvement and by what criteria?Moerman makes a great show of saying, “First, do no harm”:

Do we need to control for all meaning in order to show that a treatment is specifically effective? Maybe it is sufficient simply to show that a treatment yields significant improvement for the patients, has reasonable cost, and has no negative effects over the short or long term. This is, after all, the first tenet of medicine: “Do no harm.”

Clearly implicit in Moerman’s statement is the assumption that not intervening in the abnormal physiology of some diseases (for instance, asthma) doesn’t do harm. He’s wrong. Sometimes doing nothing is harmful, as it allows the disease to continue unchecked, possibly resulting in permanent end organ damage or even the death of the patient, and placebo medicine does nothing to prevent that.

Let’s return to asthma, since that is the disease that this study examined. Even if a person with asthma seems to feel fine with a lowered FEV1, there is a price to be paid for leaving asthma untreated, which, let’s face it, is what placebo medicine is, leaving the functional disorder untreated. For instance, there is evidence that early treatment after the diagnosis is made can prevent the airway remodeling that occurs in chronic asthma, in which airway constriction and inflammation lead to further narrowing of the airway and further functional decline. Moreover, if a case of asthma’s severe enough, a patient could be walking on the proverbial tightrope, where all it would take is a small insult to push him over into a life-threatening asthma exacerbation or pneumonia, whereas if lung function in an asthmatic is tuned up as well as it can be, I’ll have a lot farther to deteriorate to reach that dangerous point. Let’s also not forget: Asthma can and does kill, some 250,000 deaths per year worldwide. Choosing alternative medicine over effective asthma treatment because placebo responses lead to feeling better without altering the underlying illness, could very well lead to preventable asthma deaths.

In the end, I’m a bit torn about this study. On the one hand, it irritates me to no end how it is being sold to the public as evidence of “powerful” placebo effects and as evidence that we physicians should be doing more placebo medicine. On the other hand, the fact that CAM advocates are reduced to spinning studies like this the way they are is pretty darned conclusive evidence that they now know that, from the standpoint of therapy, the vast majority of CAM modalities do nothing and are in fact placebo medicine. The problem is, in some diseases, such as asthma, placebos run the risk of allowing serious harm from lack of effective intervention that actually alters the course of disease. If the therapeutic relationship is so damaged in the U.S. that the beneficial effects of provider-patient interactions are not being realized, whether you want to refer to these effects at the “placebo response” or something else, the answer is to fix medicine to make it easier and more rewarding for physicians to spend that time with patients. The answer is not to embrace magical thinking like that behind acupuncture, homeopathy, and huge swaths of CAM. To argue otherwise is a false dichotomy.

Posted in: Acupuncture, Clinical Trials, Medical Ethics

Leave a Comment (59) ↓

59 thoughts on “Spin City: Using placebos to evaluate objective and subjective responses in asthma

  1. Sarah P. says:

    I was at TAM and got to see the panel discussion. It was very engaging and helpful for someone like me, who is a skeptic, but not a medical or science professional.

    After considering the placebo response I wondered what is it about our ability to interpret our physiological state that is faulty. If someone can receive sham treatment and think that they feel better while the objective measures still indicate they are not at all experiencing an improvement, then what is it about the ability to feel the sensation of the physiological problem that fails them? Is there work being done on this aspect of placebo response? The placebo works because the person is psychologically convinced that improvement must have occurred due to receiving some kind of treatment, but that has to be powerful enough to override the physical sensation of pain, or shortness of breath, or whatever. What mechanism is allowing the physical sensation to be ignored?

  2. Beowulff says:

    I really don’t see why this study would merit a discussion about choosing between subjective and objective results. Even on the subjective results, the Albuterol gets the highest score, and on the objective score nothing else even comes close.

  3. JamieGeek says:

    I am ashamed! U of M-Dearborn graduate here :(
    Fortunately for me it was from the Engineering college.

    Why would a professor of Anthropology write a medical paper? Wouldn’t the reviewing board stop for a moment to consider that what they are writing on may not be what they are an expert in?

  4. nybgrus says:

    @jamiesgeek:

    In short, because of a somewhat new field of anthropology in which I hold a degree – medical anthropology.

    Anthropologists think that they can redefine “medicine” as a purely culture bound syndrome that is different from culture to culture and yet is equally effective. It is very literally cultural reletavism taken to a massive extreme.

    I was literaly yelled at by my professors about how evil the “Western reductionists” were and how their science wasn’t adequately equipped to test these other “ways of healing.” I read books on the topic. I believed it.

    Then I couldn’t get into med school for a couple of years and in the meantime started work in a real lab doing anti-aging pharmaceutical research (I had a fortuitous background in evolutionary biology and molecular pharmacology). There are started learning to become an actual scientist. Until then my two degrees were held in cognitive dissonance from each other. Probably because my science professors were too busy doing actual work to bother screaming at their students.

    Then I got into medical school and really got into it. And now I know how absurd my Med Anthro degree was. And I honestly thought it would help me get into med school. I suppose it would today, but not so sure back 5+ years ago when I first applied.

    That is why I have become so passionate about it and teach my 1st year students how to be good critical thinkers from my very first tutorial with them – and anyone else who will listen.

    But yeah, I am still blown away that such an analysis could make it into the NEJM. I just today had to admonish a classmate not to always trust Cochrane 100% and gave her some examples. She was very surprised but says she will now be more wary.

  5. weing says:

    I suppose that Dr. Moerman is convinced that having $1 milliion in your bank account is the same as thinking that you have it.

  6. David Gorski says:

    And weing wins the Internets for today. :-)

  7. daedalus2u says:

    Sarah, nothing about our ability to interpret our physiological state is reliable. Our ability to interpret our physiological state didn’t evolve to give us reliable information, it evolved to induce us to exhibit behaviors that minimize the sum of death and non-reproduction according to what ever physiological state we are in.

    This is why feelings are inherently unreliable. Your feelings are trying to “trick” you into doing whatever was evolutionarily advantageous during the period of evolutionary time during which they evolved.

    If you are running from a bear, your physiology will give you the delusion that you can run forever, that you feel great running even as your muscles are dying. The euphoria of the near death metabolic state is to induce you to take actions that will maximize survival and reproduction, even of the chances of survival are slim and none. Slim is better than none, and survival with damaged muscles (slim) is infinitely better than being caught by the bear (none).

  8. daedalus2u says:

    Sorry, italics fail

  9. tmac57 says:

    Medicine is to placebo medicine,as truth is to ‘truthiness’ .
    Let’s call placebo medicine…mmmm…cure-y-osity ? (Just don’t use it on your cat).

    Keep up the good fight for science based medicine.Maybe it’s time for the ‘beer goggles’ crowd to be told “It’s closing time”,and be shown the door. They don’t have to go home,but they can’t stay here.

  10. mr. grieves says:

    How can we apply this amazing approach to hypertension? I have rarely encountered a patient that has symptomatic high blood pressure. So I guess they are cured as soon as they are diagnosed? In fact, why bother checking blood pressure at all! 130 million North Americans cured!

  11. GLaDOS says:

    Subjective value elevated to the status of objective value = egocentric asshole.

    TAM anecdote: My husband looks for two seats together with nothing on them and parks himself just as the next speaker is getting started. Few minutes later a woman sits in the chair beside him, marked as saved with her stuff. She then tells my husband that his seat is already taken.

    He says that he didn’t know that because there was nothing on the chair. She replies, “I was standing right over there. You could have asked me if the seat was taken or not.”

    My husband says, “Well how would I know where you were sitting?”

    Then the guy on the other side of the woman leans over with, “Y’know, you are starting to really piss me off.”

    Trufax.

    This is what you get, America, when you become “empowered” by your own subjectivity. I hope you enjoy your narcissism, tantrums, and unpopularity.

  12. WilliamLawrenceUtridge says:

    Trying for italics win.

  13. WilliamLawrenceUtridge says:

    Blockquote win?

  14. daedalus2u says:

    The idea that making the patient feel a certain way is the objective of treatment is wrong on many levels. One of the most reliable ways of making someone feel better is to give them a combination of stimulants and opiates. Cocaine plus heroin is pretty much guaranteed to make someone feel good. Is it good for them? No, it isn’t. If making people feel good pharmacologically is not within the standard of care, why would making people feel good with placebos or CAM be considered appropriate? The danger of using cocaine plus heroin is that they are addictive. Has CAM been evaluated for addiction potential? It should be.

    In a discussion I had with Kimball Atwood after the placebo panel, he chided himself for not pointing out that even subjective effects are mediated through physiology. Everything the brain does is mediated through physiology. Very, very, very complicated physiology, but it is physiology none the less.

    So even if placebos only have subjective effects, those subjective effects are still mediated through physiology. Physiology we don’t understand, but we still know it is physiology.

    I don’t know that much about asthma, but in this experiment, patients came in at essentially random times. If the symptoms of asthma wax and wain, then it would be expected that at some times there would be no effect, even of the Albuterol (as observed). I would be interested in seeing what the actual changes in FEV were.

    I haven’t seen the paper yet.

  15. daedalus2u says:

    Trying to end the italics once and for all.

  16. Jayhox says:

    Great post David.

    I would submit at the TAM panel did not go far enough in renaming the Placebo Effect. Just as the term “Placebo Effect” connotes an actual physiological response and thus implicitly suggests a valid effect, so too does the new term “Placebo Response.”. Placebo Response also suggests a therapeutic effect and is just as murky as Placebo Effect, IMO.

    I would nominate the term “Placebo Phenomenon” as an alternative to the others. This term sterilizes the effect someone and makes no claim to an actual physiological cause or effect of an inert variable. It implies that there might be something else going on that could fall into the categories of a psychosomatic response or experimental error or bias.

    My two cents.

  17. geack says:

    PARKINSON’S is “subjective”?? That’s just a bizarre thing to say. Maybe some days are a little less bad than others, but the overall progression (sadly) isn’t something that can be forestalled by a positive attitude.

    This discussion really cuts to the absolute heart of the CAM question. Serious practitioners (not the outright quacks) can’t refuse to acknowledge that their treatments provide solely subjective results. They’d dearly love to have a publicly accepted, clearly defined sandbox in which their “cheaper and harmless” treatments could be used (and be paid for by insurance), which would basically boil down to chronic pain and stress reduction. They sincerely believe it makes sense to do it their way in such cases. But to do it honestly, they’d have to abandon the mumbo-jumbo on which their treatments are based, which would likely reduce even the subjective benefits, and would certainly take the fun out of it.

    So you get well-intentioned people in bed with merciless frauds trying to legitimize the illegitimate by constantly fuzzing up the data. Maybe sometime we’ll see a burst of integrity that splits the CAM industry. Anyone want to start a pool?

  18. Rick says:

    Interesting Article in Scientific American called:
    Are Antidepressants Just Placebos with Side Effects?
    By John Horgan, which looks at two book reviews by Marcia Angell, former editor of The New England Journal of Medicine.

    The three books are reviewed are dammning when placebo are 82 percent as effective as antidepressants. That number goes higher when an active placebo (one that itself produces side effects, such as atropine) is given. The most telling book reviewed was The Emperor’s New Drugs: Exploding the Antidepressant Myth by Irving Kirsch (psychologist at the University of Hull in the UK). In trials using atropine as the placebo, there was no difference between the antidepressant and the active placebo. Everyone had side effects of one type or another, and everyone reported the same level of improvement (Kirsch).

    In his earlier study and in work by others, he observed that even treatments that were not considered to be antidepressants—such as synthetic thyroid hormone, opiates, sedatives, stimulants, and some herbal remedies—were as effective as antidepressants in alleviating the symptoms of depression. Kirsch writes, “When administered as antidepressants, drugs that increase, decrease or have no effect on serotonin all relieve depression to about the same degree.” What all these “effective” drugs had in common was that they produced side effects, which participating patients had been told they might experience.

  19. Sarah P.

    “The placebo works because the person is psychologically convinced that improvement must have occurred due to receiving some kind of treatment, but that has to be powerful enough to override the physical sensation of pain, or shortness of breath, or whatever. What mechanism is allowing the physical sensation to be ignored?”

    It’s hard to say for others, but as a person with mild/moderate asthma my experience is that the symptoms of asthma are not always as clear as one might think. For instance, I have been to the doctor for fatique and lightheadness, without having any idea that my asthma was acting up until the doctor heard wheezing with her stethescope and spirometry indicated it.

    There is often lots room for interpretation of how bad the symptoms* are (with a non-severe flare). There is also some anxiety that a flare will get worse if it’s not addressed. Of course anxiety symptoms and asthma symptoms can feel similar (to me), so it’s quite confusing. Since all of the patients experienced some improvement, they would have to subjectively interpret the degree of improvement. I don’t think I’d be able to do that.

    So my guess is that physical sensations are not being over-riden, they are being re-interpreted or possibly some patients might feel better than their objective test indicate due to reduction in anxiety symptoms.

    *for me the exception is when my main asthma symptoms is uncontrollable coughing, that’s pretty objective. :)

  20. I’ve always admired the prettiness of italics. Seems that the blogging code agrees.

  21. Oh, I forgot to mention on asthma symptoms. The albuterol also gives me a funny feeling in my chest (guess it’s those airway muscles “relaxing”)…very difficult to separate post-albuterol chest feeling from asthma chest feeling.

  22. aeauooo says:

    try again

  23. David Gorski says:

    I fixed Daedelus’ italics fail.

    Back to the study…

  24. Canucklehead says:

    I’m not sure that the FEV1 measure is that accurate in measuring an obstructive flow pattern. A test for FEF 25-75% would be much more accurate and would show more of the subtle changes that one sees in Asthma and it’s response to bronchodilator.

  25. Linda Rosa says:

    This makes me wish Bud Relman or Marcia Angell was back at the helm of NEJM.

  26. tmac57 says:

    Is it just me,or does there appear to be an element on the ‘wooish’ side of medicine that is seeking a more simplistic view of treatment? After all,medicine can be pretty complex at times,when the symptoms don’t neatly fit into the “common things are common” scheme of diagnosis.
    It must be very comforting to have the world view of: “Oh well,what the hell,whatever I prescribe will be sufficient because of the placebo effect”. I mean,why bother with all that fussy differential diagnosis nonsense? Am I right? It all come out in the sanding after all.

  27. Coming in to the discussion late as I have been taking it easy recovering from TAM,

    Some advocates of placebo treatment seem to be invoking mind body vitalism for placebos in that they seem to believe a placebo evokes the power of “mind over matter” to harness the mind’s supposed ability to heal the body through willpower and positive thinking or The Secret.

  28. pmoran says:

    The study has told us nothing new. We already knew that placebos don’t (generally) affect disease processes, and that the symptoms of asthma are very responsive to sham interventions, (remember glomectomy?).

    It is likely, as David suggests, that the authors hoped to find objective responses and they will be disappointed to find none of significance with such a highly placebo-responsive condition.

    It increases the onus upon mind-body theorists show exactly where mind-body “healing” is operative and where it is not, rather than puffing it up as an appealing abstraction with a suspiciously close correspondence to that which we include under “placebo and other non-specific influences of medical interactions”.

    OTOH, these remarkable subjective responses in a pilot study do seem to fit in with other experience. They are yet another warning that the last word is by no means “in” on this complex mixture of influences.

    Even if the mainstream managed to restrict itself completely to EBM-endorsed measures we would still needs sensible attitudes and policies towards the rest of medicine. An accurate understanding of the role of the placebo seems to me to be essential to that, regardless of how we may moralise about its use and object to the associated pseudoscience .

  29. chaos4zap says:

    I am also torn. It is difficult for me to believe that anyone can look over that data, read their conclusions and the editorial and not think “whhaaaattttt?” Now that is what I call some serious reaching and it is seriously misleading, especially since more people will probably have access to the summary only and not the full data (media will certainly be creating headlines based on the summary). To me, this fact, hangs their clear bias like a flavor-flav style sign from their necks. One begins to wonder why they wouldn’t file-drawer this one like most CAM practitioners would (I suspect they can’t since the study involved human subjects and pharmaceuticals). On the other hand, I would much rather see this space in the NEJM used for something more…..productive?

  30. hardindr says:

    I’ve read Dr. Moerman’s book on the placebo effect, and I can say that I don’t believe there is any “woo” in it. I was first made aware of it by Ben Goldacre, who cited it in his book “Bad Science,” where he recommended it highly. Not sure I see anything particularly objectionable in his editorial or his other comments quoted, either.

    Also, thanks for coming to TAM, Orac. I enjoyed hearing you thoughts on Placebo Medicine Panel.

  31. Calli Arcale says:

    If you visit Respectful Insolence, where Dr Gorski’s “friend” has posted this information, a number of commenters have provided anecdotes attesting to their own inability to accurately gauge their asthma symptoms — including myself. I rely on my peak flow meter; I can get a hunch that I’m not right, but I’m fairly unreliable, so I use the numbers to tell me what to do instead.

    I also raise an anecdote over there of my grandmother. She nearly died once because she had gone to work while suffering from a very obvious severe asthma attack. She protested that she felt fine, despite being barely able to speak, and her colleagues called 911 despite her protests. By this time, she was moving almost no oxygen at all and in imminent danger, so the paramedics used a nebulizer and rushed her to the hospital. I think she was in there for a week, and afterwards her doctor made her take a vacation to Hawaii to convalesce. (And while she was there, she took a tumble which necessitated plastic surgery due to her “cortisone skin”, which tears extremely easily.)

    The inability to tell just how sick one is is actually very common, and it’s amazing how sick a person can be without admitting it. My grandfather is just like that too, and has sometimes suffered tremendously without medical treatment because he just wouldn’t admit he was sick enough to justify it. I don’t think it’s pride or fear of doctors; I think it’s just that as much as we claim otherwise, we are creatures of the moment, and so it’s hard to remember that we didn’t always feel exactly like this and maybe it’s not normal.

  32. Calli Arcale “I think it’s just that as much as we claim otherwise, we are creatures of the moment, and so it’s hard to remember that we didn’t always feel exactly like this and maybe it’s not normal.”

    To true! In addition, I think that even a little improvement when you have felt very dreadful can seem like being “cured”, so people may initially over report their improvement with any remedy.

  33. I think I lime the term “placebo factor” best. Placebo response still can imply a physiological response rather than there just being some influential factor in the subjective assessment.

  34. hardindr says:

    I apologize if this seems like I am spamming, but Moerman was interviewed on a podcast shortly after his editorial came out, and he further explains his thoughts on the placebo effect.

    http://podcasts.jwatch.org/index.php/podcast-126-placebos-and-medical-meaning/2011/07/16/

    (Note: I do not necessarily endorse all of his ideas.)

  35. nybgrus says:

    I listened to the podcast. I was dissappointed – it felt like being back in undergrad for me. I swear it sounded exactly like one of my Med Anthro professors talking (except with less yelling and slightly less derision against the “Western biomedicine” model). I pulled out a few things:

    To start with, Moerman doesn’t believe there is a “placebo effect.” Not because he thinks there isn’t, but because he thinks it is a contradiction in terms (he likens it to saying “King of America”). To him, placebo means it is inert and therefore it can’t do anything (by definition) so for it to have an effect would be an oxymoron. Why is this important? You’ll see when we get to his straw man.

    First he goes to talk about how the “other stuff” of medicine is “drilled out of the med student.” He refers to being a kid and mommy gives you little orange pills and cuddles you and you feel better. Then says when you get to med school they “drill” that healing art out of you and leave you only with acetylsalisylic acid and that’s it.

    That is BS. I have so much patient interaction skill drilled into my head it is amazing. I have an entire course in clinical communication skills where I am recorded interacting with actor-patients to ensure I can display proper empathy, take a proper history, etc. And every week, every case has a specific learning objective on how might be the best way to interact with a patient to enhance and improve their patient practitioner input. So where does this inanity come from? My guess is the article the interviewer references: Franz Ingelfinger’s essay, “Arrogance.”

    In it that author discusses the lost art of patient interaction and how doctors are so paternalistic and arrogant. Moerman wholeheartedly agrees that this is the case. The interviewer then mentions that the article was written 30 years ago and Moerman says that it still applies today. That was the extent of the discussion on that topic. I call BS on it.

    Moerman then mentions that women are better empaths than men in medicine and that they are bringing a new freshness to the profession but that they are being stifled by the process. That doesn’t get much more attention.

    Next the interviewer begins to show us how he is pandering to Moerman and fluffing him up. He starts discussing “functional diseases such as depression” and claims that “sure you can measure chemicals but…” and somehow transitions directly into the NEJM article by saying “they didn’t come in for a low FEV1, they came in because they were suffocating.” Moerman, of course, agrees, and and then the interviewer goes on to comment that “clinical medicine resorts only to the FEV1″ and when the patient “feels better” and says “no, I don’t need more medicine, just let me go home” as if the doctor was keeping him/her there against volition. It was phrased and spoken rather derogatorily as if the clinician was blind to the patient in front of them and was so obsessed with the FEV1 that they would zealously overtreat in order to get that objective value to be on par even over the patient’s objections. What a crock.

    The interviewer then goes on to ask Moerman if doctors ask him for advice often. He responds, with a chuckle, “No, not often.” What would Moerman recommend then, now that there are about 1000 docs listening? He says that physicians are very well read and know their studies but that we are quick to dismiss anything that “just doesn’t fit” and uses lower back pain as an example. He first goes off on a discussion about how, apparently, our spines were not evolved to be bipedal and would be much better suited if we were quadripeds (yeah, go ahead and be quadripedal for a couple days Moerman and tell me how you feel). This is your typical anthropological “just so story” to inform us that we are “congenitally” defected and our backs will always begin to hurt by “around age 40 and up.” He then goes on to discuss the acupuncture studies that have been thoroughly dissected on this very forum and after some dodging around whilst asking “what does that mean?” and taking a detour through depression again (commenting about St. John’s Wort, sertraline, and placebo) he ends up concluding that this is a difficult question to answer since it depends on you as a physician and how you interact with your patients and what kind of people your patients are like (no duh!) but that the (finally!) ultimate conclusion is that “how you interact with your patients is more important than anything else.” Than anything else. Really? The funny thing is, no one here on this blog (myself included) has ever said that patient interaction, physician demeanor, conduct and empathy are not truly important. But more important than anything else? I think not. During my bike ride today with a 1st year student we were discussing this very topic on the concept of objective and subjective measures. I made a comment about the diabetic having a silent infarct with nothing but a bit of nausea. Do we give him some ondansetron and let him go when he “feels better?” “Oh no sir, never mind those ST segment elevations on the EKG. That is just a lousy objective measure of you having a heart attack. How do you feel? Is your nausea better?” Because after all – it wasn’t elevated ST segments that brought him in – it was the nausea and odd feeling he just couldn’t shake; same as it wasn’t the low FEV1 that brought in our asthma patient.

    Moerman then goes on to discuss the nocebo effect (though he doesn’t call it that) and once again demonstrates that this is a further example and proof of the significance of patient-practitioner interaction. Straw man much? So here is where his disbelief in the placebo effect comes in. He makes it seem like it is stupid to call it such, since that would be an oxymoron, but stresses that there is obviously something going on. Since it can’t be the placebo effect, it must be something else. To me, this is him setting up the T-ball for him to claim that this CAM garbage, which we SBMers attribute to the placebo effect, actually has something real to it since, by his own defintion, there can be no placebo effect. This is a clear swing for changing the nomenclature once again to obsfuscate the point. I’ve seen it done about a million times (give or take) during my training as a medical anthropologist. Scary how it becomes easy to read now that I have left “the dark side.”

    The interviewer then calls this “the shaman effect” and Moerman agrees it was a good term but admonishes us that we “better watch out, because shaman’s have some pretty amazing stuff in their arsenal” and comments that when it comes to American medicine there just “isn’t much there – it is slim pickens” and uses the FDA recall of drugs and marketing practices as a slam against “biomedicine.”

    Finally, when asked by the interviewer what Moerman would recommend to help people “open their minds” to these new wonderful things, he recommends his own article which he describes as “an introduction” to his own book. And the interview ends.

    That is exactly what I’d expect from a medical anthropologist. He talks a bunch of nonsense – nothing flowed logically and he just kept throwing out buzzwords and “functional diseases” – and finally concludes that all these studies show that patient-practitioner interaction is the only thing they demonstrate, but then doesn’t go on to apply that in any way. He says it triumphantly, as if he has given us of the SBM ilk some epiphany we never would have realized and then (somehow) that demonstrates his point – QED. He makes a few slams against “biomedicine” and closes by pimping his own book, though he was roundabout (and obviously so) and ultimately only did so by first pimping his article.

    In short, it was clearly a fluff piece with Moerman saying nothing of substance, making the standard CAM apologist sleights against medicine, and draws some deliciously subtle straw men.

    when asked what resource would be good to “open your mind” to “all this stuff” he recommends HIS OWN FUCKING BOOK and article

  36. nybgrus says:

    Dr. Atwood (or whomever may be reading these for moderation)- first off I added 4 links (whatever was open currently) to hold this comment up in moderation as well. Many many apologies for my other comment that is currently awaiting moderation. I believe it is so because it contains an F-bomb in it. I was taking notes on Moerman’s podcast and did so in the comments window so I could comment…. and managed to forget to erase that last tidbit. I will repost the comment without the word, so if you could be so kind as to simply reject both this and the other comment I would greatly appreciate. Honestly, I feel that my usage was somewhat justified but that it is still inappropriate. Thanks for your consideration

    http://podcasts.jwatch.org/index.php/podcast-126-placebos-and-medical-meaning/2011/07/16/

    http://worldblog.msnbc.msn.com/_news/2011/07/22/7143472-death-toll-jumps-suspect-still-being-questioned

    http://www.sciencedirect.com/science/article/pii/S0889159111004685

    https://www.teefury.com/

  37. nybgrus says:

    I listened to the podcast. I was dissappointed – it felt like being back in undergrad for me. I swear it sounded exactly like one of my Med Anthro professors talking (except with less yelling and slightly less derision against the “Western biomedicine” model). I pulled out a few things:

    To start with, Moerman doesn’t believe there is a “placebo effect.” Not because he thinks there isn’t, but because he thinks it is a contradiction in terms (he likens it to saying “King of America”). To him, placebo means it is inert and therefore it can’t do anything (by definition) so for it to have an effect would be an oxymoron. Why is this important? You’ll see when we get to his straw man.

    First he goes to talk about how the “other stuff” of medicine is “drilled out of the med student.” He refers to being a kid and mommy gives you little orange pills and cuddles you and you feel better. Then says when you get to med school they “drill” that healing art out of you and leave you only with acetylsalisylic acid and that’s it.

    That is BS. I have so much patient interaction skill drilled into my head it is amazing. I have an entire course in clinical communication skills where I am recorded interacting with actor-patients to ensure I can display proper empathy, take a proper history, etc. And every week, every case has a specific learning objective on how might be the best way to interact with a patient to enhance and improve their patient practitioner input. So where does this inanity come from? My guess is the article the interviewer references: Franz Ingelfinger’s essay, “Arrogance.”

    In it that author discusses the lost art of patient interaction and how doctors are so paternalistic and arrogant. Moerman wholeheartedly agrees that this is the case. The interviewer then mentions that the article was written 30 years ago and Moerman says that it still applies today. That was the extent of the discussion on that topic. I call BS on it.

    Moerman then mentions that women are better empaths than men in medicine and that they are bringing a new freshness to the profession but that they are being stifled by the process. That doesn’t get much more attention.

    Next the interviewer begins to show us how he is pandering to Moerman and fluffing him up. He starts discussing “functional diseases such as depression” and claims that “sure you can measure chemicals but…” and somehow transitions directly into the NEJM article by saying “they didn’t come in for a low FEV1, they came in because they were suffocating.” Moerman, of course, agrees, and and then the interviewer goes on to comment that “clinical medicine resorts only to the FEV1″ and when the patient “feels better” and says “no, I don’t need more medicine, just let me go home” as if the doctor was keeping him/her there against volition. It was phrased and spoken rather derogatorily as if the clinician was blind to the patient in front of them and was so obsessed with the FEV1 that they would zealously overtreat in order to get that objective value to be on par even over the patient’s objections. What a crock.

    The interviewer then goes on to ask Moerman if doctors ask him for advice often. He responds, with a chuckle, “No, not often.” What would Moerman recommend then, now that there are about 1000 docs listening? He says that physicians are very well read and know their studies but that we are quick to dismiss anything that “just doesn’t fit” and uses lower back pain as an example. He first goes off on a discussion about how, apparently, our spines were not evolved to be bipedal and would be much better suited if we were quadripeds (yeah, go ahead and be quadripedal for a couple days Moerman and tell me how you feel). This is your typical anthropological “just so story” to inform us that we are “congenitally” defected and our backs will always begin to hurt by “around age 40 and up.” He then goes on to discuss the acupuncture studies that have been thoroughly dissected on this very forum and after some dodging around whilst asking “what does that mean?” and taking a detour through depression again (commenting about St. John’s Wort, sertraline, and placebo) he ends up concluding that this is a difficult question to answer since it depends on you as a physician and how you interact with your patients and what kind of people your patients are like (no duh!) but that the (finally!) ultimate conclusion is that “how you interact with your patients is more important than anything else.” Than anything else. Really? The funny thing is, no one here on this blog (myself included) has ever said that patient interaction, physician demeanor, conduct and empathy are not truly important. But more important than anything else? I think not.

    During my bike ride today with a 1st year student we were discussing this very topic on the concept of objective and subjective measures. I made a comment about the diabetic having a silent infarct with nothing but a bit of nausea. Do we give him some ondansetron and let him go when he “feels better?” “Oh no sir, never mind those ST segment elevations on the EKG. That is just a lousy objective measure of you having a heart attack. How do you feel? Is your nausea better?” Because after all – it wasn’t elevated ST segments that brought him in – it was the nausea and odd feeling he just couldn’t shake; same as it wasn’t the low FEV1 that brought in our asthma patient.

    Moerman then goes on to discuss the nocebo effect (though he doesn’t call it that) and once again demonstrates that this is a further example and proof of the significance of patient-practitioner interaction. Straw man much? So here is where his disbelief in the placebo effect comes in. He makes it seem like it is stupid to call it such, since that would be an oxymoron, but stresses that there is obviously something going on. Since it can’t be the placebo effect, it must be something else. To me, this is him setting up the T-ball for him to claim that this CAM garbage, which we SBMers attribute to the placebo effect, actually has something real to it since, by his own defintion, there can be no placebo effect. This is a clear swing for changing the nomenclature once again to obsfuscate the point. I’ve seen it done about a million times (give or take) during my training as a medical anthropologist. Scary how it becomes easy to read now that I have left “the dark side.”

    The interviewer then calls this “the shaman effect” and Moerman agrees it was a good term but admonishes us that we “better watch out, because shaman’s have some pretty amazing stuff in their arsenal” and comments that when it comes to American medicine there just “isn’t much there – it is slim pickens” and uses the FDA recall of drugs and marketing practices as a slam against “biomedicine.”

    Finally, when asked by the interviewer what Moerman would recommend to help people “open their minds” to these new wonderful things, he recommends his own article which he describes as “an introduction” to his own book. And the interview ends.
    That is exactly what I’d expect from a medical anthropologist. He talks a bunch of nonsense – nothing flowed logically and he just kept throwing out buzzwords and “functional diseases” – and finally concludes that all these studies show that patient-practitioner interaction is the only thing they demonstrate, but then doesn’t go on to apply that in any way. He says it triumphantly, as if he has given us of the SBM ilk some epiphany we never would have realized and then (somehow) that demonstrates his point – QED. He makes a few slams against “biomedicine” and closes by pimping his own book, though he was roundabout (and obviously so) and ultimately only did so by first pimping his article.

    In short, it was clearly a fluff piece with Moerman saying nothing of substance, making the standard CAM apologist sleights against medicine, and draws some deliciously subtle straw men.

  38. nybgrus says:

    To the commentariat:

    I was taking notes on the podcast in this window and then expounded upon them. A couple of times I used a naughty word to describe my reaction to what I’d heard. In rewriting and fine tuning the above comment, I forgot one and it was hung up in moderation. I then wrote another comment with too many links explaining this hoping to get both rejected and reposted the comment, sans Francais (I also addressed the request to the wrong author which was just me bouncing between windows on my RSS reader, so my apologies Dr. Gorski). Just in case it does end up coming through, I thought I’d explain myself.

  39. hardindr says:

    @nybrus:

    I guess we were listening to different podcasts, because what you took away from it isn’t what I did. As an example, Moerman in the podcast clearly doesn’t think that medical paternalism is always wrong, since it can increase the meaning response to a treatment.

    FYI, I think CAM is a waste of people’s time and money.

  40. timrichpt says:

    Replying to # nybgruson 23 Jul 2011 at 2:58 am:

    I enjoyed your description of Dr. Moerman’s podcast. I think, however, that you mis-interpreted Engelfinger’s Arrogance article (N Engl J Med 1980; 303:1507-1511, December 25, 1980).

    In his article, Dr, Engelfinger decries the LACK of physician arrogance among his friends and colleagues. His fellow doctors could not or would not authoritatively and decisively make treatment recommendations for him.

    At the time of his own diagnosis with terminal cancer Dr. Engelfinger was a worldwide authority on GI and the emeritus editor of the NEJM. Despite having many qualified friends and advisors, Dr. Egelfinger had no doctor.

    Dr. Engelfinger states that he felt “confused” and “uncared for”.

    I think Moerman’s point is that physician “arrogance” can be positively interpreted by some patients as confidence and authority that can lend a meaning response to the patient experience. It can lead patients to feel like they are in good hands.

    I took from the podcast the understanding that I can use various “cultural” cues with my patients, eg: an authoritative demeanor, a white coat and a stethoscope may significantly improve outcomes and patient satisfaction with no side effects or additional costs.

    The condition of lower back pain, on which Moerman touches, is probably different from asthma. Cost drivers like excessive imaging and multi-level instrumented fusion surgeries create huge incentives to supply expensive procedures.

    Low-cost assessment tools, like patient self-report measures, accurately predict future disablement and chronic pain (which imaging doesn’t).

    Although precise measurement of patient outcomes and patient satisfaction are themselves difficult, future hospital and physician reimbursement in America will likely be based on these so-called “soft” measures.

    Tim Richardson, PT
    http://www.PhysicalTherapyDiagnosis.com

  41. nybgrus says:

    @tim:

    Thanks for the feedback. Honestly I had not read the article until just now, and I was going off Moerman’s use of the article in my analysis (hence why I said “my guess” – I hadn’t had the time to actually read it in detail, so I eschewed it since it was a minor point in my overall analysis).

    Having now read the article in full, I find it to be an interesting piece. My take is that Ingelfinger is arguing that the wanton use of the word “arrogance” does disservice to both patient and physician. He delineates that there are different kind of arrogance – namely that of ignorance and that of knowledge – and that their application is very important. Arrogance of ignorance is always wrong yet the arrogance of a scientist or physician is often right and necessary since it stems from education (and he juxtaposes the lay person making arrogant claims from ignorance vs the physician being dominating and paternalistic because of expertise). He further goes on to say that the application of expert “arrogance” is important as well – namely are you rude about it or are proper and cordial about it. To contrast he tells his own anecdote describing what a complete lack of arrogance would be like – i.e. the wishy washy contradictory advice that doesn’t help the patient. So to me, Ingelfinger’s article was in response to the public claiming doctors to be arrogant and full of hubris. He states that some arrogance is necessary and good, when applied properly, and should not be confused with hubris. He calls for more of that kind of arrogance and less of the others with a call for the public to recognize these differences and also understand the distinction of arrogance from ignorance.

    I then re-listened to the podcast to get a better sense of Moerman’s use of the article. It seems that they do both use the notion of hegemony to describe the patient-doctor roles. In other words, the infrastructure, medical garb, stethoscopes, etc all form a cultural experience to reinforce to the patient that (s)he is in a place of authority and expertise. However, Moerman then continues on and, I think, misses the distinction and central thrust of Ingelfinger’s article – he misses the nuance of types of arrogance to which Ingelfinger was writing and simply makes the blanket statement that doctors are trained to be arrogant, to dissociate themselves from the cultural context and patient interaction, and to become authoritarian and domineering, focusing solely on the biochemical interactions of the drug they are giving. He goes on to say that some patients like this sort of domination and paternalism whilst others, like himself, do not and prefer an interaction of equality.

    I think that my comment above was not quite right but pretty darned close, and that Moerman was indeed using Ingelfinger’s article (incorrectly, now that I have read it myself) to make his claim that physicians are trained to ignore the cultural cues and be “arrogant” (without distinction), establish hegemonic authority, and that even today this continues with no training for medical students to be empathic and caring.

    Of course, he does refer to the white coat and steth (etc) to be way of adding those “non-specific” effects into medicine. But for some reason he views that as establishing dominance that (he implies) most patients would not want whilst simulataneously viewing CAM as a way of doing the same thing “properly.” The difference is that medicine offers both (and I personally get training in the “proper” type of “arrogance” to use Ingelfinger’s terms) and CAM offers only the one.

    Moerman sees the medical professional use of “arrogance” and “domination” as a way of controlling the patient, removing patient choice, and justifying focusing only on biochemical interactions and objective measures (such as FEV1, in this case). In other words he sees medicine as teaching and espousing a “treat the lab value” ethos whilst CAM offers patient choice and empowerment and a “treat the patient” ethos.

    The error he makes is that a physician must never divorce the two and always treat the patient and the lab value. I think Ingelfinger argues for that balance (and I think I am actively taught that balance). Some physicians do not find it, and should be rightfully criticized. But Moerman doesn’t realize that CAM only treat the patient, and never the lab value, and that this is pretty much always the worst of 3 options. He goes on to further expound upon this and drive the point home later in the podcast.

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