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Placebo effects are not the “power of positive thinking”

Here we go again. I once said that, in the wake of study after study that fails to find activity of various “complementary and alternative medicine” (CAM) beyond that of placebo, CAM advocates are now in the midst of a “rebranding” campaign in which CAM is said to work through the “power of placebo.” Personally, I’ve argued that in reality this new focus on placebo effects as the “mechanism” through which CAM “works” is in reality more a manifestation of the common fantasy that wishing makes it so.

None of this, of course, can stop everybody’s favorite apologist for “complementary and alternative medicine” (CAM) and, in particular, using placebo effects therapeutically, from continuing to do what he does with a study that’s been widely reported in the news and even featured on Science Friday last week. Basically, it’s a study in Science Translational Medicine, in which our old friend Ted Kaptchuk teamed up with an investigator interested in migraines, Rami Burstein, to do a study that finds that believing a medicine will work can have a strong effect on its actual activity on migraine. As is the case with most studies in which Kaptchuk is involved, it’s mildly interesting from a scientific standpoint. Unlike most studies in which he is involved, Kaptchuk seems a bit more able to tone down the hyperbole, which is a good thing. Unfortunately, this study, as much as it’s being touted by the press as providing new information on placebo effects, really doesn’t tell us much that is new.

But first, in case you don’t remember who Ted Kaptchuk is, let’s take a moment to remind you, given that it’s been a while since he’s appeared as a topic on this blog. He’s the Director of the Program in Placebo Studies, Beth Israel Deaconess Medical Center, and a professor of medicine at the Harvard Medical School. His work on placebo effects has been a frequent topic right here on this very blog and has been a mixed bag. On the one hand, Kaptchuk sometimes does interesting work, but on the other hand he can’t seem to help himself when it comes to overselling it. For example, two years ago, Kaptchuk’s group published a study in which they evaluated subjective placebo effects and objective physiologic effects of “sham acupuncture” in asthma patients. The observations were actually intriguing, as I pointed out. Basically, Kaptchuk compared asthma patients receiving “placebo acupuncture” with patients receiving a real albuterol inhaler. What he found was that placebo effects from the sham acupuncture could make patients feel as though they were less short of breath, even though pulmonary function tests revealed that their lung function had not improved, a result that was not unexpected. It was also, as Peter Lipson described, a finding that indicated how dangerous it could be to rely on placebo effects to treat asthma in that it could easily result in the death of your patients by lulling them into a false sense of security of not feeling short of breath when, from a physiologic standpoint, they are on the knife’s edge of respiratory failure. Meanwhile, advocates of using placebo effects intentionally in medicine spun this study as some great evidence that placeboes could be useful in medicine when in fact it suggested that relying on placebo effects to alter physiology could be very dangerous.

The other message that Kaptchuk has been promoting is that it is possible to have “placeboes without deception.” One of the greatest difficulties as a physician with intentionally utilizing placebo effects, if they are useful, is that under our current understanding of how placeboes work deception is necessary. The patient has to be convinced that the placebo they are getting will help them, which requires the physician or health care provider, in essence, to lie. Indeed, Kaptchuk did a study a few years back testing placeboes in irritable bowel syndrome (IBS) in which he concluded that one could have placebo effects without deception. As I and others pointed out, his study showed nothing of the sort, as the power of suggestion, in which placebo pills were described as being capable of producing “powerful mind-body effects”, was used. Yet Kaptchuk’s old spin continues to persist, even in an NPR story about Kaptchuk and Burstein’s “hot off the presses” migraine study:

The group has shown: that placebos rival the effect of active medication in patients with asthma; that even when patients know they’re taking a placebo, they can get relief from the cramps, bloating and diarrhea of irritable bowel syndrome; and that those subliminal suggestions can activate patients’ placebo response.

Placeboes had no physiologic effect in the asthma study, and, I forgot to mention, in the IBS study the effects observed were actually very small and were not evidence of “placeboes without deception.”

So what about the study itself? Actually, like the asthma study, it’s a pretty well-designed study. Unlike the asthma study, whose results were often exaggerated and misrepresented to mean that placebo effects were as effective as real asthma medicine, Kaptchuk appears not to be willfully misinterpreting it, although he can’t always resist letting some of his old exaggerations slip into his discussion and interviews, as you will see. First, however, let’s look at the study.

Basically, it examined the effect of placebo or an active drug against migraine, Maxalt (rizatriptan), on the migraine headaches of 66 subjects. Each participant was asked to document seven migraine attacks, starting with one untreated attack at the beginning of the study and six subsequent attacks. These six attacks were randomly assigned to be treated with 10 mg of Maxalt or placebo, each labeled either as “placebo,” “Maxalt,” or “Maxalt or placebo.” Patients were asked to record one pain score 30 minutes after onset of the headache as a baseline and then to take the study pill, after which they were to record a second pain score 2.5 hours after the onset of the headache. They were provided with “rescue medications,” which the participants could use as needed at the 2.5 hour time point. Basically, if the participants’ headache hadn’t been adequately relieved, they could take the medication.

One of the strengths of this study is that there really wasn’t much interaction with the physicians running the study, thus minimizing the effects of personal interaction with health care providers after the first visit when subjects were recruited for the study. There ended up being six groups divided into three groups of two, as shown in the image below:

Fig1

The idea is that there were three conditions: “negative information” (placebo labeling), “neutral” or uncertain information (label says that the pill could be Maxalt or placebo), and “positive information” (Maxalt labeling). Each of these conditions is either true or not; i.e., the “placebo” envelope can contain placebo or the actual Maxalt or the “Maxalt” envelope could contain placebo or the actual Maxalt.” Two main outcomes were measured: (1) the decrease in pain score from 30 minutes after onset to the 2.5 hour mark; i.e., two hours after taking the drug or placebo; and (2) whether or not the subject was pain-free at the 2.5 hour mark.

However, contrary to a lot of the discussion that occurs later expressing how “powerful” placebo effects alone were even under “truthful” conditions, there was a bit of priming going on in the study materials, as published in the supplemental data and information:

Scripted Information Read to Participants. “You are invited to take part in a research study for the purpose of understanding the effects of repeated administration of Maxalt for the treatment of acute migraine attacks, and why placebo rates are so high in migraine therapy. Our first goal is to understand why Maxalt makes you pain-free in one attack but not in another. Our second goal is to understand why placebo pills can also make you pain-free. Our third goal is to understand why Maxalt works differently when given in double-blind study vs. real-life experience when you take it at home. These goals are scientifically important for developing new therapies for migraine.

I repeat for emphasis: “Our second goal is to understand why placebo pills can also make you pain-free.” Not to understand why placebo pills might be able to make you pain-free or could possibly make you pain free. “Can make you pain free.” To be fair, this isn’t nearly as blatant as the IBS study in which subjects were told that placeboes could produce “powerful mind-body effects” in the study information. Also, mentioning that “placebo rates are so high in migraine therapy” primes the subjects to expect placeboes to work.

With this suggestion, it’s not entirely surprising that placebo effects were fairly robust. The results can basically be summarized thusly as changes in pain scores:

  • No treatment: 15 percent increase in pain.
  • Known placebo: 26 percent decrease.
  • Placebo labeled Maxalt: 25 percent decrease.*
  • Maxalt labeled as placebo: 36 percent decrease.*
  • Mystery pill (Maxalt or placebo): 40 percent decrease.
  • Known Maxalt: 40 percent decrease.

Note that there was no statistically significant difference between the placebo labeled as Maxalt and the Maxalt labeled as placebo. This is perhaps the most interesting finding, and suggests that positive labeling can boost placebo effects (again, not a new finding) and that negative labeling can decrease whatever contribution there is by placebo effects to the action of the real drug). As for the other values in other groups, reported differences are a lot less impressive if you look at the graph, complete with error bars:

Kam-Hansen 1..7

Note the huge overlap between decreases in pain scores in the placebo group regardless of whether the label was “placebo,” “unspecified,” or “positive.” The same is true for decreases in pain scores in the Maxalt group regardless of label. This raises the question of whether reported differences, albeit statistically significantly different, are in any way clinically significant.

The second endpoint examined was whether or not the subject was pain free after 2.5 hours. It’s here where the real differences dwell:

Unlike the primary endpoint, the proportion of participants who were pain-free during the no-treatment condition (0.7%) was not statistically different from when participants took open-label placebo (5.7%). As with the primary endpoint, the proportion of participants pain-free after treatment was not statistically different between Maxalt treatment mislabeled as placebo (14.6%) and placebo treatment mislabeled as Maxalt (7.7%). The resulting therapeutic gain (that is, drug-placebo difference) was 8.8 percentage points under “placebo” labeling [odds ratio (OR), 2.80], 26.6 percentage points under “Maxalt or placebo” labeling (OR, 7.19), and 24.6 percentage points under “Maxalt” labeling (OR, 5.70).

One critical finding here is that Maxalt beat any sort of placebo effect, and not by a little bit, either. For all the Maxalt groups, the percentage of subjects who were pain free was 25.5% compared to 6.7% for all the placebo groups. That’s nearly a four-fold difference. Also note that the no treatment condition was not statistically different from the open-label placebo condition.

The error bars, however, remain wide:

Kam-Hansen 1..7

So what does this all mean? In the discussion, Burstein and Kaptchuk try to sell the reader on some old ideas about placebo and some CAM-friendly ideas about placebo:

By manipulating the information provided to patients, our primary analysis showed that the magnitude of headache relief induced by Maxalt (10-mg rizatriptan), as well as that of placebo, was lowest when pills were labeled as placebo, and higher when pills had uncertain labeling or were labeled as active medication. Two other findings were that (i) placebo treatment mislabeled as 10-mg Maxalt reduced headache severity as effectively as did Maxalt mislabeled as placebo, and (ii) open-label placebo treatment was superior to no treatment. We conclude that raising the likelihood of receiving active treatment for pain relief significantly contributed to increased success rate of triptan therapy for migraine, that open-label placebo treatment may have an important therapeutic benefit, and that placebo and medication effects can be modulated by expectancies.

Although Maxalt was superior to placebo under each type of information, we were surprised that the efficacy of Maxalt mislabeled as placebo was not significantly better than the efficacy of placebo mislabeled as Maxalt. We were also surprised to find that open-label placebo treatment induced pain relief as compared with the worsening of pain during the untreated attack. A therapeutic benefit of open-label placebo versus no treatment was also recently reported for patients with irritable bowel syndrome in a randomized controlled study (8) and in a pilot study in depression (9).

Methinks the authors doth protest too much surprise at seeing placebo effects in the open label placebo group, given that the study materials suggested that subjects would experience pain relief or even be pain free based on placebo effects and subjects were told that migraines are subject to placebo effects. Mentioning Kaptchuk’s previous IBS study in which he tried to argue that placeboes without deception were possible is just another way of insinuating the idea that it’s possible to have placebo effects without deception into this study, even though superficially the authors appear to be much more straightforward about discussing their results. On the other hand, when it comes to the endpoint that people with migraines really care about, being pain-free, open label placebo was no different than no treatment at all, a point that gets lost in all the discussions of “the power of positive thinking.”

It’s also rather frustrating that the authors state that many placebo researchers would have considered the providing of information about whether or not patients were receiving placebo, real drug, or had a 50:50 chance of receiving real drug as something that would affect expectancy; i.e., the expectation of benefit. However, they didn’t make any effort to assess expectancy because they were afraid of causing patients to question the accuracy of the information provided on the envelopes. The lack of assessment of expectancy greatly decreases the utility of this study and the ability to generalize from it a potential mechanism to explain their results. Worse, no assessment of blinding was performed because the investigators were worried that this would provoke suspicions in an in-study design. Quite frankly, this is not a convincing excuse. Assessment of blinding is such a routine and key part of randomized clinical trials that to not include it in the trial design is bound to leave an opening for suspicion that the subjects might have been able to guess whether the envelope containing the pill they were using for each migraine incident contained real drug or placebo.

In the end, however, this study really doesn’t tell us much that is new or that we didn’t already know. For a subjective finding, a significant part of the drug effect appears to be placebo. We knew that, which is why I found it rather odd that Kaptchuk exulted over how “half the effect” of Maxalt is due to placebo effects. I also find it rather odd how, in his interview on Science Friday, Kaptchuk emphasized how subjects were given different expectations; yet he didn’t actually assess expectancy. He also goes on about how most studies don’t include a no-treatment control, as if that were a major observation. Of course, the reason that most studies examining subjective outcomes don’t include a no-treatment control anymore is because scientists know from previous studies that placebo effects can be significant confounders.

So the observation that there was a difference between the no-treatment control the placebo arm was not unexpected for the main endpoint, decrease in pain, because that’s a subjective endpoint. Even less unexpected is the observation that there was no statistically significant difference in the chances of being pain-free at the 2.5 hour time point between the no-treatment control and the open-label placebo group. This is entirely consistent with what we’ve been arguing here at SBM for a long time, that the more “objective” or “hard” the endpoint (and, although there is still a subjective component, being pain-free is a harder endpoint than stating a pain score), the weaker any placebo effects observed are, to the point that the very “hardest” endpoints, such as tumor regression or survival, are not affected by placebo. None of this stops Kaptchuk from emphasizing the decrease in pain scores in the open label placebo group in his Science Friday interview but not mentioning that no more people were pain free in that group than in the no treatment group.

I think we get a glimpse into Kaptchuk’s mind in the part of the Science Friday interview when he says:

I think that in the same way a physician has to calculate what pharmaceutical I have to give, how many milligrams he has to give of that drug, he or she might have to calculate the exact right words to accompany the pharmaceutical. In this study the words actually double the effect or cuts the effect of the drug in half. What exactly those words are, I think that’s more research. Our experiment was a proof of concept to see if words work. Then we now have to figure out what’s an ethical way to provide a positive message that’s true, accurate, and is not an exaggeration.

Basically, Kaptchuk appears to be saying that we have to find the right magical words to invoke the mystical placebo effect. Seriously. This experiment had only three sets of words, the two of which that mattered were either affirming that drug was present or stating that placebo was present. It’s not fancy.

Certainly, Kaptchuk does nothing to discourage headlines like:

All of which miss the point. It’s not “positive thinking.” It might be expectancy, but we don’t know that because it wasn’t assessed in this study. The two are different.

In the end, this isn’t really a bad study. It’s just that, even though he’s doing a lot better than he used to, Kaptchuk still can’t seem to resist reading a bit too much into it. He’s not as blatant about it as he used to be, but he’s still implying that placebo effects without deception are possible and desirable. It really doesn’t tell us much that we don’t already know. Placebo effects can enhance subjective effects of pharmaceuticals, expectancy can affect the perception of how well drugs work on subjective outcomes. Understanding placebo effects is important. Overselling them does not help our understanding.

Posted in: Science and Medicine

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122 thoughts on “Placebo effects are not the “power of positive thinking”

  1. Discussant says:

    Thanks for highlighting the importance of assessing expectancy and blindness, and the spuriousness of clinical trials that omit these assessments. There are no psychotherapy studies to date that include these assessments and still show that it can outperform a well-designed placebo or sham treatment. (The studies that have attempted more rigor show that psychotherapy fails to beat the placebo.) Therapy’s roots lie in the anecdotes of interested parties, and when put to the test of science, it fails. Thus this widespread practice falls squarely in the CAM bucket.

    In addition to the importance of avoiding deception in healthcare, it’s also important to avoid ripping off/cheating naive patients out large sums of money (e.g., $50 – $200 per 45 minutes) for “treatments” that are no more effective than a free placebo or inexpensive alternative (e.g., talking to a friend, taking a nature walk, writing in a journal, etc.)

    Let’s help shine a light on the vast fraud taking place in the psychotherapy space, as well.

    http://trytherapyfree.wordpress.com/about/

    1. PoppleD says:

      “Therapy’s roots lie in the anecdotes of interested parties, and when put to the test of science, it fails.”

      Until mental illness has been accurately reduced to specific neuro-biological components that are successfully altered by specific pharm or non-pharm interventions, your assertion is absurd. Talk about quackery.

  2. Christine.Rose says:

    I’ve always thought that the essence of these things is that if you tell the doctor the truth, he’ll be disappointed and not give you the good stuff.

    Has anyone ever conducted a study designed to test exactly that? Or even asked the placebo responders about their attitude towards authority figures?

  3. Jay Lee says:

    I think the analyses and graphs would be clearer if the statistics were presented as risk ratios or ratio differences using the raw pain scale data. Percentages, ratios, and differences are not the same thing and the use of ratios and differences is more appropriate here. The graphs are nice but should have been presented with confidence intervals incorporating standard error.

  4. Jay Lee says:

    I think the analyses and graphs would be clearer if the statistics were presented as risk ratios or ratio differences using the raw pain scale data. Percentages, ratios, and differences are not the same thing and the use of ratios and differences is more appropriate here. The graphs are nice but should have been presented with confidence intervals incorporating standard error.

  5. Andrey Pavlov says:

    Should I get a prize for predicting what each outcome would be just by looking at the study design chart? Probably not since I’d imagine most people here would as well. AS Dr. Gorski stated, completely unsurprising results. The only surprise is Kaptchuk’s more tempered reaction into it.

    Though if there is some reading into that should be done, I submit it is this: that in subjective pain scores comparing what is a placebo with what is effectively a nocebo means that the perceived effect can overlap (take zero and add something and compare it to something and subtract from it and sure you can make two things meet in the middle) and the fact that since placebo can temper subjective pain scale but not result in pain free state, it is further support of the idea that most of placebo effect/response (as the two cannot be differentiated in this study) is enabling the participant to better ignore and manage symptoms rather than a genuine improvement of symptoms. Granted, in this case I fully recognize that there is very likely some component of placebo effect that actually modulates the pain experience by triggering the release of endogenous endorphins, but that is not a question assailable by this study and at least some of the effect is also due to simply ignoring the pain state.

    I also posit a significant confounder Dr. Gorski did not mention – the fact that the participant know that they have a “rescue medication” waiting for them at 2 hours time. Tell anyone that they just need to bear the pain for a finite period of time and that genuine and expected relief will arrive with 100% guarantee (i.e. knowing they will not get a placebo) and it will inevitably become easier for them to bear the pain and ignore it more effectively. It would be interesting to see the results if either the rescue medication were not provided (though perhaps unethical) or if the 2.5h mark meant they open another envelope where they are unsure of whether the pill is placebo or genuine. My prediction is that the effect size on pain score would be reduced and there would then (possibly at least) be a significant difference between Maxalt-as-placebo and placebo-as-Maxalt. (I’m not quite as confident in the latter, but fairly confident in the former).

    And of course, Dr. Gorski is spot on with noting that expectancy was built in to the study design and deception in some form was used. If we are testing to see the “power of placebo” we cannot a priori inform the participants that the “power of placebo” is demonstrated.

    As for his discussion on Science Friday, I still can’t grasp why we are mystifying and magic-alizing bedside manner. There is no one set of “magic words” to speak to heighten expectancy as if saying expecto Patronum will somehow improve the effects of drugs for all people. I imagine that might work on pediatrics wards though ;-) The point is that this is simply the art (yes, the genuine art of medicine) of interacting with your patients to comfort, educate, and empower them. If your friend calls you up and says he has been having a really bad week and needs to get together for beers, is there a particular script of “What exactly those words are” that ” [Kaptchuk] think[s] that’s more research” to find out? It is human interaction and what those words are, how they are delivered, and when to say them are necessarily individualized. I’ll also add they they are not always possible for every person to say to any other person. For example, the most comforting thing to say to one of my patients may be some sort of religious prayer or invocation. That is something I cannot provide. But I can provide what secular comfort I can and then call for the chaplain or their priest of choice to come and comfort them (and I have).

    1. windriven says:

      Well said, Andrey.

      I was going to opine that all the study demonstrated to me was that ‘selling’ a treatment to a patient has, at a minimum, subjective value.

      I would go on to say that it appears to be true that some significant fraction of physicians underestimate the value of or lack the skills to get ‘the patient on board.’ It would be interesting to see a study evaluating this for both near term and long term outcomes.

    2. MadisonMD says:

      If we are testing to see the “power of placebo” we cannot a priori inform the participants that the “power of placebo” is demonstrated.

      Why not? It may be self-fulfilling, but isn’t this how placebo medicine would be practiced in real life?

      It might be of academic interest to know what the outcomes would be without such priming… but then I’m not convinced these effects are worth studying at all. The effects seem small, short-lived, and quite frankly easy to evoke with a host of interventions.

      1. Andrey Pavlov says:

        @MadisonMD:

        My take is that this invalidates the claim because the study was not actually designed to measure the difference in placebo effects vs responses. By priming the patient you have no idea if you are just priming them to report a different score because they feel obliged to since they were told this should help or if it actually lowered their perception of pain because of being primed. We haven’t sussed out how much of each possible factor actually comes into play, so at best you are once again necessarily deceiving the patient (which makes it unethical) or are studying the tooth fairy (you are supposing an actual effect without demonstrating the effect is actually there). Either way, it tells you nothing about the placebo effect and merely demonstrates that you can muddy the waters of a study by introducing a priming bias.

        As Dr. Novella pointed out, a lot of what gets lumped into “placebo effect” is purely study artifact that has no bearing on real world outcomes or modulations of patient perception of pain. This design has no means by which to differentiate artifact (what I call placebo response) from genuine placebo effects. And I would further argue that such priming is just as likely (if not more likely) to heighten the artifactual placebo response than it is to be of any genuine symptomatic benefit to participants. As you well know patients often try to “please” physicians. How many times have you talked to a patient and had them say they are doing really well and all is hunky dory and then the nurse gets flustered that the patient is complaining to them about [x,y,z] but is somehow magically better for you (the physician)? Priming them can easily make them waffle and report a lower pain score for no reason other than they believe they should report a lower pain score based on the priming.

        Granted, I could be very wrong. But there is no way to determine that based on this study, which is the point.

        1. MadisonMD says:

          Priming them can easily make them waffle and report a lower pain score for no reason other than they believe they should report a lower pain score based on the priming.

          You make very good points here, again, Andrey. Thank you.

  6. WilliamLawrenceUtridge says:

    The authors talk about “manipulating information provided to patients”. What information are you manipulating? I’m really not sure what the clinical implications of this would be to a doctor with patients with migraines. “Oh, damn, I should stop telling them their medication is placebo”? Perhaps “oh, damn, I should start giving them real medicine instead of placebo”? Doctors are presumably already giving accurate information about the actual drugs they prescribe to their patients, how on earth does this study change anything about this practice?

    And this is particularly given Dr. Novella’s comments a while back (can’t find the link, of course) about what actually makes up the placebo effect – regression to the mean, reporting bias, a desire to please the researcher, subjective re-interpretation, and somewhere in there a genuine change in the regions of the brain that experience pain. It’s all lumped together as “placebo”, but you have no way of teasing out what is a genuine subjective change versus a confound in your reporting instrument (and the very act of saying “do you feel better now?”).

    And the opposite ideas and questions when giving a real drug but labelling it “placebo”.

    Seriously, scientifically interesting but I have a very hard time believing this will have any clinically meaningful implications.

    Although Maxalt was superior to placebo under each type of information, we were surprised that the efficacy of Maxalt mislabeled as placebo was not significantly better than the efficacy of placebo mislabeled as Maxalt.

    Really? I’m not. Label a placebo as a real drug and patients expect to get better. Label a real drug as “placebo” and patients don’t expect to get better. You split the difference and there you are. All it really seems to show is that Maxalt doesn’t seem to address the core cause of migraines very effectively and better treatments are needed.

    Or, basically, what Andrey said :)

    1. Andrey Pavlov says:

      Doctors are presumably already giving accurate information about the actual drugs they prescribe to their patients, how on earth does this study change anything about this practice?

      I agree that for the most part physicians do practice essentially what Kaptchuk is talking about here. However, there can be nuance to be learned from these sorts of studies to take to heart about how much information we give and of what kind. For example, I have learned that in cases where I will be providing pain relief for a patient or inflicting pain upon a patient (yes, some of things I do as a physician hurt, like sticking big needles in you are reducing fractures) that being up front and honest and taking the extra time to describe what we actually expect in real world terms with definite timeframes is very helpful.

      For example, when I used to reduce fractures in the ER I would give pain medication and say:

      “This is dilaudid which is a narcotic like morphine that is 10 times stronger. I will help a lot with your pain in the next 1-3 minutes and last about 15-30 minutes. It will not make your pain go completely away, because to do that we would have to knock you unconscious and that is dangerous to do. If the pain is really unbearable tell me and I will stop and we can give you more pain medicine. Since it is IV it will act very quickly. Now, when I reduce your fracture it will hurt. My goal is not to hurt you, but some pain is simply unavoidable. For some of my patients it is so much pain that they can’t bear it, but honestly the vast majority of people tell me it really hurt but were surprised that it actually wasn’t that bad. I’m pretty good at what I do, so we can do it quickly and get it over with, but nobody is exactly the same and things can be tricky sometimes with unpredictable changes in how things go. We’ll cross those bridges when we get to them, together, and in the end I promise you I will do my absolute best to make you better with as little discomfort as possible. Now, are you ready to work together to get this fixed?”

      Or something along those lines. You can modify you words to accurately reflect your actual knowledge and experience (e.g. if you haven’t seen many cases you can say “from my senior’s experience this is the case” or if you aren’t actually very good and have little experience you can say “I will give this one attempt and if it doesn’t work I will hand it over to my senior who has more experience, but I truly appreciate you letting me learn since we all have to at some point”).

      I really don’t understand why it is so surprising or mystifying that speaking to a patient like an actual human being – a person – is extremely helpful for everyone involved. Imagine how you would like to be spoken to and speak that way. Make sure and know your craft well enough to be able to avoid – or at least warn of – unexpected unpleasant surprises, never lie to your patient (even by omission), and make it clear that you are a team working towards a common goal.

      Of course this fails from time to time, both on the physician’s part and the patient’s (or patient’s family’s) part, but by and large this tack seems to work really well, is well supported by all the data, and is one of those things were what makes intuitive sense is also actually true!

      1. Andrey Pavlov says:

        Oh, I’ll add that this strategy worked surprisingly well with children also. I never went in assuming they couldn’t understand. I approached it as if they would, treated them like an equal, and if proven wrong adjusted accordingly. Sometimes you simply must hold down a child to accomplish a goal (like setting a broken bone) which I found discomforting, but necessary. We had a child life specialist at our ER and apparently I was doing something right because whenever I was on duty she always asked that I be the one to do what needed to be done.

        1. WilliamLawrenceUtridge says:

          Should I have a kid, when old enough I plan on using something similar when they get vaccinated. “This will hurt, for a short time. It will hurt a lot. But it means you won’t get sick. And also, and this is very important, it means you can’t make mommy, daddy, grandma or grandpa sick. You are being a big help to everyone around you by doing this, and it’s a very grown-up thing to do. I’m proud of you for it. Now hold my hand, squeeze it hard, and take a deep breath.”

          We’ll see how that works out in practice :)

          1. Alia says:

            I tell you what my sister did, when her 5-year-old daughter needed to get a shot (don’t remember exactly what it was). She showed her an episode of this great animated TV series: http://en.wikipedia.org/wiki/Once_Upon_a_Time…_Life devoted to vaccines. My niece loves this series (got a whole set for Christmas) and if I remember the episode correctly from my own childhood, it is a very good explaination of what vaccines do.

          2. Harriet Hall says:

            No! Don’t tell them it will hurt “a lot.” Tell them they will feel a little pinch but it will only be for a second.

            1. Andrey Pavlov says:

              I agree with Dr. Hall. I missed this comment until Dr. Hall’s came up. Besides the fact that you don’t want to sow fear which will heighten the unpleasantness, you also want to tell the truth. Vaccine shots (really any IM shot) if done properly are nearly painless. Granted, I have seen people screw up all sorts of needle based procedures (blood draws, IV’s, IM injections, etc) and cause unnecessary pain, but that is almost always because they are unconfident and nervous. A quick jab in a single smooth motion is nearly painless. I’ve given shots to kiddos where they didn’t cry until after I had already removed the needle because they didn’t register the pain, but pieced together the act.

              1. Jessica Sager says:

                Yes!! This has been my experience with my son, who is now three. He barely cries, more of the “silent scream” face with big tears, but it’s much more of an offended cry than any due to pain.

                And since last year’s shots, he has had two instances where he threw up when he was sick. All it takes me is telling him that the shots help him so he won’t “gag” (that’s what he calls throwing up) and he willing goes along.

              2. tmac57 says:

                Jessica,as a life long needle-phobe I have found that in scenarios where I might get nauseated,that if I lay down.such that I get more blood to my head,I will not get sick.I learned this from a nurse who regularly drew blood samples.Works like a charm for me.
                Also,knowing this trick reduces the anticipatory anxiety that really is the source of the problem for me.

              3. Harriet Hall says:

                In my experience, the 1 year well baby checkup was always the worst. The baby is too young to explain things to, has become wary of strangers, and almost always cries. I’m talking about the exam, and getting the 1 year shots was even worse. But when my daughter was 1, she didn’t cry at all with either the exam or the shots; then after we went home, she cried hysterically because a fly was buzzing around trying to get out a window. Go figure!

              4. Alia says:

                I’m afraid I have to disagree. Vaccines are virtually painful, blood donations are painful, even though the needle is really big – but some IM antibiotics _do hurt_. I had several as a small child and I remember it up now.

            2. mousethatroared says:

              I heard this report on SciFri, wondered what you all would think here at SBM. Thanks for covering it so quickly!

              Personally, I have done too many pain rating forms to trust observations based on them. I’m waiting for some sort of nerve/computer interface to measure things on a more reliable way…Don’t know if that’s even feasible, but I hate those bleeping pain rating systems.

              That said, as far as I can see, one thing that this research does have going for it is that patients are able to compare pain over a relatively short period of time. Hours, rather than days. It seems that reporting on how your pain has changed (or not) over the last two – four hours would be more reliable than how your pain has changed over the last two weeks or month.

              1. mousethatroared says:

                drat, my above comment was supposed to be a general comment. Not a reply to any other comment. Must have clicked something funny.

            3. WilliamLawrenceUtridge says:

              Noted, thanks! I always found my vaccines generally hurt, ached, with what I would imagine a child would define as “a lot”. But a different expectancy is a much better idea.

              I wonder, if I had a boy – would I take a “sack up” approach, versus a girl, with more emphasis on “you’re helping others”? It’s weird to see how feminist intentions can be undercut by sexist realities.

          3. CHotel says:

            Personally I was a wimp as a child, until after years of fears and tears (Yes I did that on purpose. The rhyme, not the scared crying) I had a public health nurse at a school immunization tell me to watch the needle. Years of look away, making sounds, don’t think about it, other distractions, it never worked so just watch the needle. Watch it go in, see that it’s small, fast, and painless.

            Worked like a charm, only now I always have to watch the needle going in, which confuses nurses when I donate blood.

            Note: I don’t recommend this for everyone, a few needle-phobic friends I’ve told to try didn’t have any relief, but it may be a strategy to keep in the back of your mind

            1. Andrey Pavlov says:

              Certainly would not work for my fiance. She is belenophobic to the extreme. I have honestly never encountered a person – patient or otherwise – with her level of deep rooted physiologic reaction to needles and other invasive procedures. I removed a small wart from her finger a few months ago and she had the kind of sympathetic response that I have only otherwise seen in victims of significant trauma after massive blood loss – pale, sweaty, cold skin, and nearly went unconscious. Afterwards she said I did an excellent job and she didn’t feel anything but the mere thought was enough. In fact, if I just remind her of it to this day she starts sweating immediately and becomes light headed.

          4. James says:

            I tell my daughter this when I brush her hair.
            It is going to hurt when it does just squeeze on the (what ever item I gave her).

            Now she does not complain or cry whenever we have to do her hair.
            The best part is she does not even ask for anything to squeeze anymore.

        2. CHotel says:

          I’ve always disliked when practitioners treated children like, well, children. They don’t have to be that old to have a half decent understanding of what’s going on in a given situation and as long as you don’t use words they won’t know they can usually follow along as well as adults. Whenever I was on a retail rotation during my pharmacy schooling the kids around like, 10-12 years old or so were my favorite patients to counsel. Usually that was when mom was finally going to try having them be responsible for their antibiotic or what have you, and as I taught them everything about what they’d be taking for the next week-ish most of them would be pretty pumped to be treated like a grown-up and be given the responsibility. Some of them asked great questions too. And as you say, if they’re not getting it, a nod for mom to come in to change the situation is an easy fix.

          We’re taught that the language we use with patients and in printed information should be at an average of a 5th grade reading level to ensure widespread comprehension. By that virtue, any studious 11 year old should be able to understand most of what we’d tell an adult (They may not have the experience to fully comprehend it, but they’d get the jist)

          1. Andrey Pavlov says:

            Agreed. Even with my nephews (the oldest of whom has just turned 10) none of us ever spoke to them like anything other than adults. There was never baby-talk or sugar coating of things. The straight dope at all times, so to speak. That doesn’t mean we didn’t have fun and read bed time stories in different voices or such things, but it was clear that that was theatre for entertainment and not the way one actually speaks to other people for normal conversations. Unsurprisingly their teachers have commented consistently at how impressed they are with their language capacity, comprehension, and speaking ability.

            1. Harriet Hall says:

              Sometimes kids are far more adult than we think. Many years ago I saw a 5-year-old in the ER with an ear infection, and just for fun I asked her “What did they give you the last time this happened?” expecting her parents to answer for her. She promptly answered “Ampicillin 250mg 4 times a day for 10 days.” (This was in the days when antibiotics were considered the standard of care.) I was tempted to hand her the pad and let her write the prescription!

              1. CHotel says:

                Resisting the urge to make a joke about the chance that the 5 year old’s handwriting being more legible

                (Though in reality, most MDs have good penmenship, or use computer generated scripts. It’s just that the ones that don’t really, really don’t)

      2. MadisonMD says:

        I really don’t understand why it is so surprising or mystifying that speaking to a patient like an actual human being – a person – is extremely helpful for everyone involved. Imagine how you would like to be spoken to and speak that way. Make sure and know your craft well enough to be able to avoid – or at least warn of – unexpected unpleasant surprises, never lie to your patient (even by omission), and make it clear that you are a team working towards a common goal.

        Oustanding, Andrey. Now why isn’t this obvious to all doctors? Do we undermine this honesty by teaching sCAM and placebo medicine to med students? Do we undermine the obvious need for humanity? Or do we merely undermine critical thinking skills to generate sCAM friendly doctors that fool themselves as well as their patients?

        1. Andrey Pavlov says:

          @MadisonMD:

          I wish I could answer your question. My feeling is that it is quite multifactorial and highly variable (duh…). I have no data to back up my thoughts, but from my anecdotal experience a lot of it has to do with confidence, inherent interpersonal skills, communication skills, and yes some bad education on our parts.

          (Bear in mind what I am about to write is a “just so” story based purely on anecdote, my own thoughts and experiences, and a very small smattering of actual data that exists)

          Most med students have almost no experience in dealing with people in a medicalized setting. Their first exposure to the patient is usually sometime towards the middle of medical school. It becomes an “other” experience for them. They approach the patient as they would a USMLE question rather than as a person. This is partly because that makes it easier to address the actual problem. It is useful to model the person as a “patient” in order to then reach an answer. I myself did about 10,000 practice questions for the Step 1 and another 4,000 for the Step 2. It is much easier to think that way about real people since we have so much practice doing it through our education. Now combine this with the fact that our patients are sick (duh) and that can be rather emotionally challenging and it becomes easier to have this differentiation between “me” and “my patient.”

          Next we have the fact that communication is a skill just like any other. It needs to be practiced extensively to become good at it. Something most people do not do. Something that I have personally spent significant amounts of time working on and actively seeking feedback on. So take someone without well developed communication and interpersonal skills and add in a distinct lack of confidence since, quite frankly, we don’t know jack at this stage and it makes it even more difficult to treat “patient” as “person.”

          Next we have some bad teaching. I, for example, got into trouble (well, minor admonishments) in my formalized patient interaction exams because I spoke at too high a level for my assessor’s liking. Well, I also personally feel that it is very, very important to never talk down to my patients. The moment you do that, you will lose them and have difficulty ever getting them back. The trick is that if you toss out too much jargon you will also lose them. So I make it a point to try and gauge roughly where I can expect my patient to be and then aim just a tiny bit higher. But you must carefully watch your patient* and look for cues that they are getting lost, frustrated, etc and adjust accordingly. Often I intentionally use a medical word I know they won’t know and immediately follow it up with an explanation. I take the time to say things like “This is just our fancy doctor word for [xxx] but you may hear it and I wanted you to know it so you can recognize it when it comes up.” In other words, I offer a little education. I not only believe and act like my patients aren’t stupid but are merely experts in different things than I am, but I often flat out tell them so. “Mr. Jones, I am an expert in medicine and have spent a lot of time learning it, just like you are an expert in plumbing. I couldn’t do your job any more than you could do mine. If I worked at it, I could learn yours and you could learn mine. It isn’t about you being stupid, it is about you having a different expertise than I, so let me take a few minutes to give you some background so we can be on the same page about what is going on.” I mean really, wouldn’t you like it if your plumber did the same with you and explained why they needed to rip out your wall and charge you an extra $500 for the service? And I am never afraid to tell anyone – patients or attendings – “I don’t know the answer to that, but I’ll find out.”

          I think part of our bad education is that we are implicitly and sometimes explicitly taught that our patients simply cannot understand these complicated topics and we need to dumb it down for them. Well, I’ve managed to explain area under curve and why that matters in terms of glycemic control to a diabetic with ESRD and 2xSTEMI who never finished high school and he understood it. This same patient who everyone else found to be “extremely difficult” and would often act out violently was someone I could sit down and explain AUC to. And I blew away my attending by having the patient explain the concept to her. I think we are often conditioned to underestimate our patients. Obviously there are exceptions, but my null hypothesis is that I should be able to explain complex topics to any patient until they prove me wrong.

          Another aspect is that we tend to think of such interactions as taking too much time. Time we don’t have. I agree, it does take more time, but as you practice it and become better at it, it takes less and less time. And, I would argue, that while it takes more time up front, it saves you even more time on the back end. Sometimes I genuinely don’t have time, but once I’ve established rapport with my patient I can walk in and say up front that I apologize but have very little time and they aren’t upset that I didn’t have time for the “fluff” of small talk or beating around the bush to get to the point. But if you don’t spend the time getting better at it, then you never will and it becomes a self fulfilling prophecy that you don’t have time for such things.

          And then, of course, the “difficult patients.” Yes, I have had some and it is unavoidable. But (so far, in my personal experience) 9 times out of 10 when someone tells me the patient is difficult I find them to be nothing more than frustrated at a lack of understanding of what is going on. I spend 15 minutes demystifying why certain things are or are not happening and the next thing I know, the patient is no longer “difficult.” Of course, I have my own reason for that. Before I started med school I worked as a trauma tech at a Level 1 trauma facility. One night I was working (I worked nights for 3 years) and was getting killed because it was flu season. Irate, I wanted nothing to do with the 19 year old with a pretty minor URI in room 8 (yes, I still remember the room). Her mother kept trying to catch my eye and I kept ignoring her. Finally she literally leaped out and grabbed me. Barely able to contain my contempt, I asked her how I could help. She said that I probably didn’t remember her but about 4 months prior she had been a trauma victim in a really bad car crash. Scared, strapped down to a backboard, naked, she had no idea what was going on in the flurry of activity. She remembers me out of everyone there because I was the only one who took the time to explain to her what was happening, why it was happening, and what to expect next and made her feel safe. She had just wanted to thank me all night, nothing more. I took that to heart and have made it a point to do on purpose what I did on accident that night.

          We forget that we know how our profession works but to outsiders it is completely alien in every sense imaginable. That what is mundane to us can very literally be the most profound moment of someone’s life. Patients get upset that we aren’t paying them enough attention, and my go-to answer is that they don’t want us to be paying that much attention to them. That means there is something very wrong with them. I set expectations and inform as much as I can.

          But I feel that most med students are just struggling to get the knowledge under their belts and that the interaction side of things becomes a distant second. Understandable indeed. The problem is that it snowballs into these thoughts and behaviors about patients and becomes that self fulfilling prophecy.

          I also recognize that so-called difficult patients are that way because of everything that has happened to them in their lives and the current pressure of their medical problem and that if I lived their lives and had their experiences I would act exactly the same way (I am with Sam Harris/Jerry Coyne on the notion of free will) and so I can genuinely not begrudge my patients (or anyone) the way they act towards me and instead work on how to change the milieu to improve things.

          Now throw in all the other things we discuss here – lack of critical thinking skills, poor education in biostatistics (you can completely fail biostats on the boards and still do just fine overall which means people study other things and ignore the “boring” stuff), and of course doctors are people too and some people are just assholes.

          How to address all of this, I don’t know. And I hope you’ll pardon my rambling and anecdoting – my thoughts on this topic aren’t as streamlined and organized as I hope they someday will be. But one thing is for certain – take a stressed, overwhelmed, often frightened medical student and teach them garbage like CAM and they will implicitly accept it. 10 years later they won’t have the time to do in depth lit reviews to see if acupuncture or homeopathy or reiki is legit (or even what it is, most of the time). They’ll remember that they heard something about it in med school which means that at worst it is harmless and it probably has something going for it. Med school is supposed to distill down the best of our knowledge and provide a solid foundation. If you teach garbage it will be internalized and a “soft spot” will be generated for bad ideas. This is precisely why I am also vociferously against the teaching of “Intelligent Design” in science class. So yes, in a sense we do undermine critical thinking skills in this instance.

          Anyways, once again, sorry for the huge ramble. I don’t really have answers to your questions, but just wanted to share my thoughts. Perhaps there are one or two useful nuggets in there somewhere.

          1. MadisonMD says:

            I agree wholeheartedly, Andrey. Some things are personality. Others are teachable.

            I hope you will be very involved in teaching students and housestaff to inculcate these ideas into them (if you are not already involved). It might help to boil down and streamline your ideas into teachable points. Once you have them, I anticipate you will be very effective– teach your points, observe your students, and then provide feedback. By doing so, you will be sought out for your teaching ability.

            I have an academic colleague whose career interests focuses on palliative care and effective communication with patients. The chair of Medicine has required all faculty in the department to take the training program of this colleague– I take it tomorrow. He is effective by doing– and teaching– exactly what you are saying.

            (Although my colleague expert in communication seems to have a mild blind spot for sCAM– I see this as undermining honesty. I think he needs a little more knowledge in SBM. Maybe I’ll give him the link.)

            1. Andrey Pavlov says:

              Thank you for the kind words Madison, particularly after my ramble. I do actually engage in some teaching though at my level (recently graduated physician) the opportunities are limited. I did, however, speak to the new Year 3 students at their orientation. My mentor and PI has commented that he feels I have a better grasp of these things than many of his fellows, which I take to heart. To me it means that I have more work ahead of me but at least I am on the right path. I do plan on ultimately trying to boil things down to teachable points, but am still in the process of getting there myself. I do well on my own, but tend to be more productive when I have at least some specific goals and deadlines. So once that starts happening more I will be able to begin somewhere and then refine and improve it over the years.

              I am also, incidentally, quite interested in palliative medicine and spent a lot of my time in the ICU speaking with families. I have come to believe that my role as a physician is not to stave off death at all costs (in no small part because I will always ultimately be a failure) but to use my expertise to allow people to live the best and fullest lives they possibly can. Sometimes, particularly in the ICU, that means a good and dignified death. And if I, as the physician, am not “okay” with death how can I possibly expect my patients and their families to be? In a very real sense, we have the power to make the inevitable death of a loved one “okay” for the family; something I take very seriously.

              As for your colleague and sCAM… it is a blind spot. The same as Francis Collins and religion. I just had this discussion with my fiancee last night and she doesn’t quite get that you needn’t be stupid or a liar to be both extremely smart and extremely religious (or in your case prone to sCAM). It just means that you haven’t examined that particular truth claim as rigorously as you have others. Shedding light on it may prove helpful. I’ve found that asking people to define CAM, how it differs from the medicine that we otherwise practice, and what benefit it brings often jars them into realizing what a crock it is (a la Dr. Hall’s post from today).

    2. mousethatroared says:

      WLU “And the opposite ideas and questions when giving a real drug but labelling it “placebo”.

      Seriously, scientifically interesting but I have a very hard time believing this will have any clinically meaningful implications.”

      I heard an example once that could fit this. Putting a pain medication into a patient’s IV without informing them of what the medication was and that it would help aleiviate the pain.

      I like AP’s approach, tell me what you are giving me and tell me the time frame that it usually takes effect.

      1. WilliamLawrenceUtridge says:

        But why would you do this, particularly given the knowledge that placebo effects can genuinely reduce subjective pain?

  7. goodnightirene says:

    I wonder if the producers/editors of the programs/headlines will ever read this post?

    It sounds to me as if they were testing hypnosis–suggesting to people that something (placebo) might help. How would they know whose headache simply improved a bit over time for physiologic reasons or who might have just perceived that it got better (whatever THAT means)? Even if there is some scant evidence for placebo, where is the science? Isn’t that what they should be looking for?

    If you’ve ever known someone who suffered from migraines, I cannot imagine simply telling him or her to “think positive” or even telling her to “think positive and try this pill, which may or may not have any active ingredient” and then standing there watching the person suffer when you know the pill is a placebo. Ted K is saying this is okay as long as you find just the right words and the person might say (s)he feels a little bit better?

    1. Andrey Pavlov says:

      @GNI:

      I used to suffer from migraines until I was in late high school/early college. They were brutally devastating. To the point where I anything that would make things worse (such as loud noises, bright lights, or even just taking a step that sent the slightest jar through my body) would literally make my vision explode in lights and my head explode in pain and it would take every ounce of will to not collapse and faint.

      I would have been absolutely livid if I found out someone like Kaptchuk was giving me placebo pills and using gussied up magical incantations to invoke the power of my positive thinking to try and treat me!

  8. Krotovina says:

    I have been disabled by chronic migraines for 15 years. I am unable to work and struggle often with the necessities of daily living. People like me are often told our suffering is psychosomatic, so when I heard Dr. Kaptchuk on Science Friday, my takeaway was “oh so not only is the condition my own doing but I can cure myself too according to this doctor if I just adjust my expectations enough.” Which made me want to jump through the radio and punch Mr. Kaptchuk in the face.

    The poor state of science reporting in larger media cannot correctly interpret a study like this, and Mr. Kaptchuk isn’t helping. It’s not doing migraine suffers any favors, that’s for sure. We are already drowing in crap woo and don’t need any more, even if it is a slightly less bad version. So thanks SBM for explaining the nuances of this research. My head now hurts a little less (figuratively.)

  9. tmac57 says:

    A couple of thoughts from a naive reader. Did any of the test subjects have any previous experience with this drug? If they did,and had concluded that it didn’t work for them,then wouldn’t they be bringing a negative (or in the reverse case a positive) bias to the study?
    Secondly,why did the researchers use the language they did that “primed” the subjects prior to the study? It seems like to create a level playing field you would want to give the minimum amount of information necessary to satisfy an informed participant requirement,otherwise you are contaminating the results in my opinion.

  10. jt512 says:

    - Placebo labeled Maxalt: 25 percent decrease.*
    - Maxalt labeled as placebo: 36 percent decrease.*
    - Mystery pill (Maxalt or placebo): 40 percent decrease.
    - Known Maxalt: 40 percent decrease.

    Note that there was no statistically significant difference between the placebo labeled as Maxalt and the Maxalt labeled as placebo. This is perhaps the most interesting finding…

    Placebo labeled as Maxalt decreased pain by 25%, whereas Maxalt labeled as placebo decreased it by 36%. I disagree that the fact that the difference was not statistically significant is an interesting finding. It might be interesting if there were no clinically significant difference, but that is not the case; there is an 11 percentage point difference. Relatively speaking, Maxalt labeled as placebo was almost 50% more effective at decreasing pain than placebo labeled as Maxalt.

    Thinking that a lack of statistical significance (especially in light of a numerically large difference) is interesting is making the mistake of interpreting a lack of statistical significance as support for the null hypothesis. It isn’t; it’s merely a failure to reject the null. It is virtually certain that with a larger sample size, there would have been a statistically significant difference between these two treatments. What would be interesting to know is the true magnitude of this difference; however, the study lacks the statistical power to estimate it.

    The finding that does seem interesting is the difference in pain reduction between Maxalt labeled as placebo and Maxalt either unlabeled or labeled as Maxalt. This finding does suggest that labeling an effective treatment as a placebo can attenuate its perceived benefit.

  11. I think the simplest interpretation of the data is this:

    Placebos do not work. The only “effects” were extremely minor, consistent with a small reporting bias. Labeling had no clinically relevant effect on the placebo response.

    The only clinically significant expectation effect I see in the data is a negative effect on the active drug – Maxalt. Telling people they were getting a placebo when they were getting Maxalt decreased their report of benefit.

    It’s deceptive to report this as – placebo labeled as drug was equal to drug labeled as placebo – as it implies an equivalency between placebo and drug.

    The only clinically significant effect from expectation I see is a negative one from telling patients they are getting a placebo. Otherwise it looks like the drug worked, the placebo didn’t and expectation did not matter.

    1. WilliamLawrenceUtridge says:

      “Reporting bias” seems to me a huge and poorly-understood aspect of the placebo effect. People (including myself until recently) assume “placebo” means purely that subjective easing of pain the second you swallow an aspirin – a real pain vanishing, even if it’s illusory, temporarily and intrapsychic. I don’t think most people realize how much of the placebo effect could be chalked up to simply the fact that you’re being asked a question as part of a structured study. That at least some part is totally dependent on the fact that a paper-and-pen questionnaire is involved. That at least some part is totally independent of any change in the throbbing in your head.

  12. oldmanjenkins says:

    Well I will try that “calculate the exact right words to accompany the pharmaceutical” with my PCP and my cholesterol medication. Maybe if he says “this will really lower your cholesterol” and of he emphasizes the “really” part it will lower it even more!! I’ll try that tomorrow!

  13. jt512 says:

    @Dr. Gorski:

    The results can basically be summarized thusly as changes in pain scores:

    - No treatment: 15 percent increase in pain.
    - Known placebo: 26 percent decrease.
    - Placebo labeled Maxalt: 25 percent decrease.*
    - Maxalt labeled as placebo: 36 percent decrease.*
    - Mystery pill (Maxalt or placebo): 40 percent decrease.
    - Known Maxalt: 40 percent decrease.

    Some of those numbers don’t seem to jibe with the figure from the original article or the published supplementary materials.

    According to the supplementary materials, pain decrease for known placebo was 15%, not 25%; and for known Maxalt 51%, not 40%. Furthermore, the amount of pain reduction for the “mystery pill” depended substantially on whether the pill was actually Maxalt (54% pain reduction) or placebo (23%), so averaging these effects (if that’s what you did) to come up with 40% is misleading.

  14. angorarabbit says:

    I also heard the SciFri interview and read the study, since my spouse is a migraine sufferer.

    In addition to the concerns mentioned:
    1) note that Maxalt was the only product giving relief 4hr post-migraine onset. I thought that was relevant.
    2) I also dislike those plots – one is so tempted to connect the dots and create a false interrelationship. If Kaptchuk was my grad student, I’d make him replot it with either column bars or reverse the axes (variance runs left-right not up-down).
    3) huge error? what does one expect when using a soft endpoint like subjective pain. Sigh. GIGO. No wonder the study is hard to interpret – he is burying any signal within his noise.
    4) when does Dear Spouse take migraine meds? When it’s coming on, to try and avoid the worst of the pain. Since he can’t predict which ones are bad and which one’s aren’t, the pain is such that he accepts the false negative and takes the drug even if needed. What’s the percentage of false positives? He’s unwilling to do that calculation because of the high penalty of being wrong. So how do the authors factor this error into their calculations? I don’t see how they can.

    There’s this great line from Kurt Vonnegut’s “Cat’s Cradle” that basically says, “Never write the index for your own book – it gives away your secrets.” Sometimes I think the same applies to PI’s* – never design the endpoints for your own clinical study.

    (* PI = principal investigator, not private eye)

  15. PMoran says:

    David will be expecting a comment from me so here it is.

    I agree that, as in the IBS study, the preliminary information provided to patients would encourage an expectation of benefit.

    So the key question regarding apparent placebo responses remains: ” How much is due to truly altered symptom perception and how much is due to the reporting bias of patients who actually feel no better at all?” There are no other options, that I can see. ( Is there even a clear demarcation therein, I wonder, given the likely complexities involved in symptom perception and evaluation? )

    The fact that “harder” outcomes are demonstrated from placebo use in some studies (weight loss in the one Mark Crislip has just discussed — probably an indirect “effect’–, complete resolution of migraine here, opiate sparing effects in others) keeps the question open. We thus should not be too dismissive of placebo influences (e.g. Mark’s “beer goggles of medicine” comment) on the available evidence.

    Kaptchuk could be regarded as one of scientific medicine’s heroes. To come from his TCM background into an understanding that acupuncture is elaborate placebo, and to thereafter devote his life to trying to understand more about placebos is somewhat remarkable.

    His perseverance on certain matters relating to placebo can be understood, aside from the fact that it is a tenable interpretation of much of the available evidence. It exists for the same reasons that CAM practitioners are stunned and disbelieving when their methods are not validated in properly controlled studies — they simply DO seem to work in daily practice! Ted’s strong belief that placebos can “work” in some conditions can be looked at in the same light.

    There are a number of sound reasons why the mainstream might wish not to encourage placebo use by doctors. Yet placebo responses remain an important area for study. I have expressed the opinion before that there is little risk that active CAM practitioners will ever embrace placebo responses as the “true mechanism” behind their methods, although it certainly prompts some supporters to ask “what would it matter?” as a fall-back position when under attack for their testimonial claims. At most CAM practitioners themselves will invoke “mind-body” influences from their “holistic” care.

    Placebo responses are of relevance to policy on many matters. At least fifty per cent of millions of daily medical interventions are for symptom relief and in many of these there are no satisfactory evidence-based options. I thus think we have some sorting out to do in our own minds and with respect to our own science. Then it will be clearer how to respond to CAM in its many manifestations.

    (It was a relief to find that the pharmaceutical actually seemed to work).

    1. MadisonMD says:

      Kaptchuk could be regarded as one of scientific medicine’s heroes. To come from his TCM background into an understanding that acupuncture is elaborate placebo, and to thereafter devote his life to trying to understand more about placebos is somewhat remarkable.

      Did Kapchuk say that acupuncture is an elaborate placebo? I’m more inclined to improve my opinion of him if he did say that. (Of course Dr. Novella, Dr. Colquhoun, Dr. Hall, and Dr. Gorski have also said it in one form or another– so they are heros of sorts to me as well.)

      (It was a relief to find that the pharmaceutical actually seemed to work).

      How did you doubt it? This is the definition of a pharmaceutical working and the requirement for marketing a drug in most of the world.

      1. Andrey Pavlov says:

        I honestly don’t even know how to address Peter’s comment. It is, as per usual with him, completely vague. To me it is at best useless and at least a little wrong. Kaptchuk, for example, is no hero considering that he almost certainly lied about his education and credentials and has essentially been making shit up ever since. Kimball Atwood has documented that with the acumen of a serious investigative journalist. But he’s obviously done it well enough to fool the people at Harvard and Peter as well.

        It also doesn’t jibe with the corpus of his written work and what he continues to do. He believes that as long as a system is internally consistent it “works.” In other words if (and I am making stuff up here as an example) a TCM practitioner were to diagnose you with “fung shung dung” and prescribe “ging ding dong” it would “work.” Now, what you and I would think is that “fung shung dung” is a pre-scientific and loose identification of “acute heart failure” and that “ging ding dong” is a decoction that happens to contain digitalis and that is why people seem to get better. This is the basis for why people think that investigating “traditional” or “centuries old” treatments holds promise – they think that these traditions stumbled across these sorts of benefits by happenstance. (Throw in some naturalistic fallacy and a few others things and you’ve completed the picture). But that is not what Kaptchuk argues. He believes that if you are diagnosed with “fung shung dung” and are given digoxin you will not get better, that if you are diagnosed with “acute cardiac failure” and are given “ging ding dong” it won’t help. But if you take the exact same person and diagnose the TCM condition and give the TCM treatment they will get better, and that same person diagnosed with the “Western BioMedicine” condition and given the “Western BioMedicine” treatment they will get better. In other words, it is the internally consistent system that generates the “working” beneficial outcome. This is something that was actually drilled in my head as an undergrad in my own medical anthropology degree. The part Kaptchuk (and indeed all the professors relevant to my degree’s subspecialty) is missing is that the premise upon which the system is based must also be sound.

        Nowadays, Kaptchuk (and other so-called CAM practitioners) is being forced to recognize that their internally consistent systems produce nothing more than placebo effects so he is being forced to include that somehow into his paradigm. And thence comes the “self healing power” of the human body and all that other nonsense, which fits nicely with the idea of Qi and vital energies and whatnot.

        But to my knowledge, Kaptchuk has never admitted that acupuncture is nothing more than an elaborate placebo. He has, at best, admitted that at least part of the way acupuncture “works” is via the “power of placebo” which is something that his colleague Daniel Moerman plays up heavily in the idea of the ritual of medicine, alluding to us as modern shamans (he is a medical anthropologist and, unlike the legitimate study of the field a la Paul Farmer, was apparently taught in the same BS way that I was). To them, we are all, at base, shamans who can practice magical healing and then have different toolkits at our disposal. The TCM practitioner uses magic and TCM treatments, we use placebos and modern medicine. But to Kaptchuk the two are equivalently internally consistent systems and thus equivalently effective. He may indeed be moving towards a more rational approach to some of the nostrums he believes in, as in this study, but that is not by choice but by force of where the data is taking him. He still tries to shoehorn that into his paradigm though.

        If there is good evidence that he thinks otherwise, I’d love to see it and be glad to admit my error and give credit where it is due. But I won’t hold my breath.

        1. MadisonMD says:

          ding dong” is a decoction that happens to contain digitalis

          I can’t remember where I heard it — but that seems to ring a bell. ;)

        2. PMoran says:

          Andrey, you sometimes show that you can enter into intelligent debate. Why not try it with me? The above is as sloppy as your very early days.

          Re your reading of Ted Kaptchuk’s mind, it is obviously wrong.
          This is a person who has signed his name to a study showing that neither acupuncture nor sham acupuncture had any physiological effect upon asthma while conventional bronchodilators did. Is he now about to claim equivalence for the TCM?

          He has published other studies showing that the effects of acupuncture are mainly placebo. That is completely inconsistent with the philosophy of medicine you want to ascribe to him.

          With regard to your non-contributory little preface describing my piece as “wrong”, “vague”, and “useless”, have you no salient response to this paragraph, which surely encapsulates the current dilemma in relation to placebo research? I will quote it so that everyone can judge its wrongness, vagueness and uselessness.

          Quote —

          “So the key question regarding apparent placebo responses remains: ” How much is due to truly altered symptom perception and how much is due to the reporting bias of patients who actually feel no better at all?” There are no other options, that I can see. ( Is there even a clear demarcation therein, I wonder, given the likely complexities involved in symptom perception and evaluation? )”

          Unquote

          I went on to give one of the reasons why we cannot yet close the book on that question. There are others.

          1. MadisonMD says:

            This is a person who has signed his name to a study showing that neither acupuncture nor sham acupuncture had any physiological effect upon asthma while conventional bronchodilators did. Is he now about to claim equivalence for the TCM?

            Yes, in fact he did claim equivalence. Viz:

            “…once I saw patients’ subjective descriptions of how they felt following both the active treatment and the placebo treatments, it was apparent that the placebos were as effective as the active drug in helping people feel better.”

            At the same time, adds Kaptchuk, the study results imply that placebo treatment is just as effective as active medication in improving patient-centered outcomes.

            Do you read his press release differently?

            So the key question regarding apparent placebo responses remains: ” How much is due to truly altered symptom perception and how much is due to the reporting bias of patients who actually feel no better at all?” There are no other options, that I can see.

            I agree that this is an important question. But an even more fundamental question is whether the effect is even clinically relevant. It would not clinically relevant if, for examples, it is modest and transitory, or if it could be elicited readily by sunshine, a kind word, a hug, a quiet evening with a good book, or a glass of fine wine.

          2. Andrey Pavlov says:

            Why not try it with you, Peter? Because when I do you fall into slippery language and obfuscate your meaning while laying accusations of dogmatic thinking and then resort to tantrums. Perhaps you have some clear thoughts in your head on the matter but none of us here can seem to discern them. Even when you try and use the non-medico commenters here to bolster your assertions that has failed you (or did you miss the comment where Mouse demonstrated my interpretation of her comment correct and yours not?) There is only so much I can learn from dancing around the same point over and over again with you.

            Re your reading of Ted Kaptchuk’s mind, it is obviously wrong.

            Really? It was nice of MadisonMD to cite the quote from Kaptchuk himself that clearly demonstrates you are mistaken. Have you read his book, The Web That Has No Weaver? I have.

            He has published other studies showing that the effects of acupuncture are mainly placebo

            I never said he didn’t. But what he then does with that information is precisely what I have said. Here, let me repeat the quote from Kaptchuk for your edification:

            it was apparent that the placebos were as effective as the active drug in helping people feel better.”

            At the same time, adds Kaptchuk, the study results imply that placebo treatment is just as effective as active medication in improving patient-centered outcomes.

            Do I need to spell out clearly that such equivalence should not indicate that placebo works like active treatment, but that (at best) the active treatment doesn’t actually have an active component to it? In other words, that it doesn’t work?

            As for your quote, yes… it is rather useless. Because it is utterly banal. Where you are wrong is that, just like the conversation I have been having with Andres regarding VitC, you take an absence of evidence (or more accurately in this case, evidence without a very clear demarcation) and then assume it to actually mean something useful rather than relegating it to the proper scientific realm of “we don’t know and this study doesn’t answer the question.” But it is also vague, because it fails to acknowledge the long conversations you and I have had wherein I have clearly demonstrated that the effect size is not actually that big, it is highly variable, unpredictable, and – as you yourself admit – is necessarily composed of the two aspects of placebo: response and effect. Response is useless. So total effect size – response = effect. Which means effect must be smaller than the most generous possible effect size which is, particularly in the better designed and controlled studies, small to begin with.

            So yes, you’ve said something vague, banal, and ultimately useless. That’s OK – I do the same as well from time to time.

            1. PMoran says:

              MadinsonMD, the startling thing about the asthma study was the disconnect between apparent symptomatic benefits and the objective findings.

              If we are to take notice of what is said in a press release, obviously Kaptchuk was referring to that and not demonstrating the essentially post-modernist. “all approaches have equal validity” stance that Andrey was attributing to him.

              You also said: “But an even more fundamental question is whether the effect is even clinically relevant.”

              That is another big question, not so much to do with asthma but in relation to placebo and non-specific influences generally.

              SBM needs to be wary about attributing to acupuncture the ability to obscure symptoms from asthma to the degree that they could be threat to life, while at the same time suggesting that such influences are generally too weak in any area of medicine to be bothered with or, — as Steve Novella has said “they don’t work”.

              1. Andrey Pavlov says:

                obviously Kaptchuk was referring to that and not demonstrating the essentially post-modernist. “all approaches have equal validity” stance that Andrey was attributing to him.

                Have you read his book? Do you have evidence you would like to cite that demonstrates a reversal of his beliefs since then? And no, simply not addressing it and doing other work while not actually changing his stance and saying such accommodationist comments as in the press release to try and bridge his old (and I contend current) views with some new data is not a reversal.

                SBM needs to be wary about attributing to acupuncture the ability to obscure symptoms from asthma to the degree that they could be threat to life, while at the same time suggesting that such influences are generally too weak in any area of medicine to be bothered with or, — as Steve Novella has said “they don’t work”.

                You are either intentionally ignoring salient facts about human psychology or just genuinely don’t know them. You do know there are innumerable examples of people who are in obvious agony, gritting their teeth through the pain, all the while fervently claiming they are not actually in pain? That there are people who claim to be pain free and helped by a treatment and then wince and have decreased strength and power when actually tested, yet still claim they are improved? Essentially the idea that you can show someone a blue sky while they fervently claim it is green is a demonstrable fact of human nature.

                So no, we are not so worried that the placebo effect is “so powerful” that it will genuinely mask the symptoms enough that people will actually feel perfectly fine until suddenly their asthma up and kills them. In fact, I am not concerned that fake treatments will even engender the trick of cognitive dissonance in many people at all. Dr. Gorski, feel free to chime in here, but I’d reckon you think the same. The vast majority of people will rapidly abandon the sham treatment, seek help, and be just fine. But a small subset will not. They will be gasping for breath while arguing that they are not, in fact, gasping for breath because they want to believe the acupuncture helped them. Another small (but larger) subset will have a low simmering bronchoconstriction that the small placebo effect size will allow them to ignore, untreated, until some trigger then sends them over the edge into a massive asthma attack which could well lead to their death.

                In any case the number of deaths attributable to placebo masking of asthma symptoms would be low – both as an absolute number and as a percentage. But I am of the opinion that any deaths is too many and absolutely unacceptable.

                And no, it absolutely does not require the placebo effect to be large in size in order to lead to asthma deaths. But then if you knew a little bit of the relevant human psychology and, more importantly, the actual pathophysiology of asthma that would be obvious. So rather than tut-tutting us for the seeming contradiction that we feel the placebo effect is so small as to be inconsequential whilst at the same time thinking it big enough to lead to deaths, perhaps you should learn about the pathophysiology and natural history of asthma to understand how a small effect can indeed lead to a large outcome.

      2. MadisonMD says:

        Andrey,
        I liked the the part about Kaptchuk becoming a hero when he falsified his hypothesis–AND THEN REJECTED IT. IF he did reject the hypothesis and IF this makes one a hero, then– hallelujah! I’m a hero too!

        I love my hypotheses. The so dearly fit my precise conception about how the world must be working. But every week or so I seem to falsify one. And then I pick up a copy of Nature or another fine journal and find some good evidence that my notions were wrong. I try to find the flaw in the paper, but sometimes there is no avoiding it– the flaw was in my conception.

        It is so difficult to reject my hypotheses, to change what I am thinking when I love my dearly held ideas so. It is more comforting to me if I become a HERO by accepting that was wrong when the data says it is so.

        1. tmac57 says:

          For what it’s worth,I salute your heroism ! It takes an unnatural amount of self esteem to forthrightly admit to being wrong about something.

        2. Andrey Pavlov says:

          Yes, excellent point as well Madison. That’s sort of how we praise Congress for doing its job. Kaptchuk gets to be a hero for doing what a scientist is supposed to do…. it seems Peter has some low standards for heroism.

          Now, I would be much more like to call Mark Lynas a hero. He single handedly started and led the anti-GMO wingnuts and then recanted after he learned he was full of it. That’s not what makes him the hero though – he is heroic because he now actively advocates against the anti-GMO folks and support GMO crops.

          So if Kaptchuk became anti-CAM and started campaigning for how bankrupt a position it is, then I may be more willing to call him a hero.

    2. Carl says:

      No, I think Kaptchuk is doing this as a way of NOT changing his position from quackery to science. “Placebo = works” has been used in the past by quacks who want to dismiss reality and still sort of justify their previous belief. And regardless, even if that isn’t his motivation, his current antics certainly do not represent a real move to science. It’s more of an illusory sham.

      1. PMoran says:

        Carl: ““Placebo = works” has been used in the past by quacks who want to dismiss reality and still sort of justify their previous belief.”

        So it has been said, but give me one example where a quack has admitted “I am exploiting placebo influences”.

        CAM practitioners may use the placebo as a last ditch defence when attacked by sceptics, but they will NEVER overtly concede that their practices are wholly based upon placebo. They know that this would amount to a death knell for their practices.

        They also know, if at all self-aware, that they don’t really need to do that. They only have to maintain tiny little bits of scientific doubt or mystery, just enough to keep the lay mind insecure. They hardly even need that, because many people will try just about anything without any sense of scientific commitment if the medical need is there and there is someone saying it worked for them.

        Most of those urging that placebo influences be taken more seriously and/or seeking ways in which they can ethically be used are conventional-oriented — for obvious reasons, because placebo theory requires a full acceptance of the logic and meaning of the RCT.

        Having said all that, I recognise that CAM practitioners probably see some advantage for themselves from placebo theory. It may act behind the scenes to soften opposition in some ways. .

        1. Andrey Pavlov says:

          Well gee Peter, you keep making that same claim over and over:

          So it has been said, but give me one example where a quack has admitted “I am exploiting placebo influences”.

          You phrase it conveniently enough to move the goalposts as you see fit. However a 30 second google search reveals the article titled Placebo effect behind many natural cures.

          The very. first. sentence:

          People looking for natural cures will be happy to know there is one. Two words explain how it works: “I believe.”…University of Maryland Medical Center’s shock trauma center is offering some patients Reiki therapy, which claims to heal through invisible energy fields manipulated by a special “master.” The hospital’s anesthesia chief, Dr. Richard Dutton, says it is self-hypnosis and compares it to Lamaze classes that teach pregnant women breathing exercises to take their minds off the pain of labor.

          Or how about Kaptchuk himself?

          Can an alternative ritual with only nonspecific psychosocial effects have more positive health outcomes than a proven, specific conventional treatment?

          So sure, phrase it in a way to cover your ass by saying:

          CAM practitioners may use the placebo as a last ditch defence when attacked by sceptics, but they will NEVER overtly concede that their practices are wholly based upon placebo. They know that this would amount to a death knell for their practices.

          but when you have headlines, ideas, and research called “The Power of Placebo” in relation to CAM it seems like a mere quibble to say that indeed, CAM practitioners are embracing “The Power of Placebo” to justify their nostrums. Especially considering that Kaptchuk himself is often flipping the world on its ear by arguing that placebo is as good as active treatment.

          But hey just to make sure you can’t be pinned down on anything:

          Most of those urging that placebo influences be taken more seriously and/or seeking ways in which they can ethically be used are conventional-oriented

          Let’s throw in a little No True Scotsman while we are at it. Because, according to Peter Moran, if an alternative practitioner does actually claim to be harnessing “The Power of Placebo(TM)” then that isn’t really an alternative practitioner since obviously that person is already “conventional-oriented” (whatever the hell that means).

          Heads I win, tails you lose. And you wonder why I didn’t engage you in my “sometimes” ability to have intelligent conversation?

          1. David Gorski says:

            Andrey,

            Thanks for answering this. After a long day in the OR I wasn’t sure I was up to it. I can say, however, that when Peter repeated his claim that no quack ever claims that his nostrums work through the “power of placebo” I’m just glad I hadn’t just taken a swig of a drink. I would’ve coughed and spit it all over the keyboard and screen of my laptop. He’s been told on multiple occasions that this is not true and, each time, shown a number of examples demonstrating precisely why it is not true. Yet periodically he repeats the same erroneous claim that CAM practitioners would never make this claim because it would be a “death knell” for CAM. Au contraire, Peter.

            1. Andrey Pavlov says:

              Dr. Gorski,

              My pleasure. I mean really, does all this popular media and peer reviewed talk of “the power of placebo” just mean nothing to him? Of course, it was rather telling how he painted the question and gave himself multiple outs so that he would never be able to be pinned down with evidence that quacks actually do claim to harness the “power of placebo.” No True Scotsman? And he chided me about how I can “sometimes… enter into intelligent debate.”

            2. Andrey Pavlov says:

              An additional thought I just had – on what basis can he assert that it would be the “death knell” of CAM? What sort of evidence or even just prior plausibility is that based? On the demonstrated fact that people won’t buy garbage that is marketed well? Or how about the fact that religion no longer exists because science has shown its central tenets to be false? Because we have a long history of the Emperor being shown to be naked and people no longer believing in his clothes? Or perhaps because we have myriad examples of ideologies that were never based in science failing to adapt and change in the face of scientific evidence?

              No?

            3. PMoran says:

              The challenge still stands. Find a practicing CAM practitioner who will publicly concede that his methods are placebos. They have had the opportunity to do that for some decades, so there should be dozens by now, having their own organisations, and everything.

              It won’t happen, for the reasons I mentioned, among others.

              The only name to come up previously was Kaptchuk’s who is hardly a typical CAM practitioner, if he is now practicing at all.

              Furthermore, if medical interactions came to be explicitly based upon placebo and non-specific influences the whole intellectual framework changes. It could hardly be called CAM. These are distinctly mainstream concepts and supported by a considerable body of evidence. And, as I have said many times, there are sound reasons for the mainstream not to be encouraging such approaches.

              1. Andrey Pavlov says:

                The challenge still stands. Find a practicing CAM practitioner who will publicly concede that his methods are placebos. They have had the opportunity to do that for some decades, so there should be dozens by now, having their own organisations, and everything

                Find the man a crocoduck! Either there is the missing link he demands, or the phenomenon doesn’t exist at all. It is sad to say that I am reminded of the times I debate creationists here. They like to put specific timeframes that suit their arguments, demand evidence for something specific that doesn’t exist and if that isn’t true, none of it is. Ignore the idea of gradual change over time and make argumentum ad absurdum as if that proves a point. Because clearly, if in a decade or two there aren’t “CAM as placebo organizations” that means CAM as a whole is not at all embracing “the power of placebo” as a mechanism of action for their nostrums. If it isn’t a chicken already, it is still clearly and only a dinosaur.

                The only name to come up previously was Kaptchuk’s who is hardly a typical CAM practitioner, if he is now practicing at all.

                And then double down on the No True Scotsman just to make sure you can never be wrong.

                Furthermore, if medical interactions came to be explicitly based upon placebo and non-specific influences the whole intellectual framework changes. It could hardly be called CAM. These are distinctly mainstream concepts and supported by a considerable body of evidence.

                Oh you mean like the CAM practices of diet, exercise, and mindful meditation/relaxation? Or are those “distinctly mainstream concepts and supported by considerable bod[ies] of evidence” and thus cannot be called CAM? Because we know, for a fact, that such mainstream and heavily evidenced modalities could just never be construed, considered, called, or used as “CAM.” So neither can placebo or anything else with an evidence base and employed by the mainstream.

                Honestly, why do I even bother?

              2. David Gorski says:

                Of course, once science-based modalities like diet, exercise, and the like are assimilated into CAM, they rapidly evolve under the evolutionary pressure of magical thinking into something that resembles science-based diet and exercise only by coincidence, and the claims for them rapidly evolve into ever more grandiosity. We see a similar thing going on right now for placebo effects. The science-based version is being co-opted by CAM and, under the power of “The Secret”-like magical thinking saying that “wishing makes it so” (i.e., we can attract “healing” to ourselves if only we want it badly enough), it’s rapidly evolving into “powerful mind-body medicine.” Again, this “powerful mind-body medicine” is rapidly changing such that the claims for it and the mechanisms behind it are coming to resemble actual placebo effects as described by science based medicine by coincidence only.

  16. Frederick says:

    I mean even if you got decrease in pain that time because of placebo, you condition, is still there, and next time even if you believe in it it might not work.

    I’m not a specialist, but i can guess that if a person had a placebo effect once, it won’t have it each time automatically. You cannot use as a treatment soemthing that “might” not just only take effect in like 25% of people but also only 25% of the time on people, in reality the odd for a placebo happening to you are pretty small.

  17. Ceridwen says:

    I’m curious about how this sort of effect would hold up over time. I suffer from migraines and normally take Relpax for them. I was taking Relpax only because it was the first med prescribed to me when I was diagnosed with migraines, and worked well for me, so I stuck with it. I did have some side effects, but over time they seemed to reduce and I was generally happy with it. Unfortunately, Relpax is pretty expensive compared to generic sumatriptan (Imitrex) under my insurance so a while ago I decided I wanted to try that in the hopes of saving some money ($60 for 6 pills for Relpax vs. $15 for 9 pills for sumatriptan).

    My expecations were high for the sumatriptan. It’s in the same class as a drug that has worked well for me in the past, and I had specific reasons for very much wanting it to work. And it does work, to a degree. I get some relief of the headache but the side effects are so bad that I tend to avoid taking it if at all possible because they incapacitate me for 1-2 hours before I start to feel real improvement. And instead of getting better over time as I *expected* the side effects to do based on my history with Relpax, they got worse. I suspect the positive expectations I had going into using sumatriptan probably made me think it was working better than it was for the first few times I took it. But over time more experience with the med eliminated the positive expectations and just left me dissatisfied. After 3 packs of sumatriptan I asked to switch back to Relpax. I’m curious whether this effect of losing confidence over time would happen with the placebo in these studies. It becomes even less useful if it’s the sort of thing that only happens the first few times you use something. I’m especially interested in how that could hurt long-term confidence in your doctor and the other things they prescribe for you. It’s one thing to give a treatment that doesn’t end up working for a patient when you had a reason to expect it to work and quite another to undermine confidence for something you know is ineffective.

    1. Andrey Pavlov says:

      @ceridwen:

      Firstly I am sorry about your migraines. I had them as a child and young adult and beyond thankful I no longer get them.

      However, your story seems rather typical from what I would expect (and I would imagine others here as well) in regards to the placebo effect. Just because a drug is the same class doesn’t mean it will behave in exactly the same way in every person. It is perfectly reasonable to expect that it will and your expectancy reflected that. Yet when it actually didn’t, that added “boost” you got faded and went away. In your case it is hard to deny when the sumatriptan isn’t working as well as the Relpax. In conditions that are more variable, more chronic, and less acutely debilitating the placebo “boost” can last much longer, but is still subject to the same waning effect over time.

      Now, can you imagine if I, as your physician, had given you a sugar pill instead of sumatriptan and you learned that you had to suffer because I deceived you? Or what if you learned that sumatriptan was known to be likely ineffective and I gave it to you anyways because I wasn’t up on the literature or denied the literature because it seemed to work for my patients “in my experience”? I’d imagine either way you’d not like to have me as your physician very much.

      Thank you for sharing your story – it underlines much of what I have been saying in regards to placebo medicine and how that relates to so-called CAM.

  18. PMoran says:

    Andrey: “Either there is the missing link he demands, or the phenomenon doesn’t exist at all.”

    Well, does it? You haven’t shown it.

    I remind you Andrey, that it is the claim of you, David and others that there is now an important shift within CAM away from traditional CAM theories into evoking the placebo as a raison d’etre.

    I have given you that there will be a certain amount of “well what would it matter if it was placebo so long as it works?” (mainly from CAM supporters) which is a question we do need a very solid answer to. That is not the same thing as conceding the point in public where patients/clients can see it, or advertising oneself as “the placebo specialist” .

    Evoking the placebo cannot be regarded as another way of “dismissing reality”, as you have claimed — it surely undermines every one of the dozens of previous fanciful theories of CAM. I thought bringing people closer to an understanding of science was one of the objectives here.

    In fact, a lot of effort has gone into and will still go into getting CAM practitioners to understand that their methods work, to the extent that they work, via placebo and other non-specific influences (among other illusions, of course), so that we could hardly now backtrack and condemn such an evolution in CAM thinking as deriving from yet another creepy CAM conspiracy, even if it were the robust, general development that is being claimed.

    That could indeed be looked upon as the first stage of a new enlightenment, a footing for further progress. Never by the more crusading types within SBM, apparently. They want clear-cut villains, and for their heroes to be free of the slightest CAM-sympathetic taint.

    And even if there were such a drift it would pose fresh intellectual, practical, and sometimes ethical challenges for all interested parties. Very much would hang upon questions about placebo and non-specific medical influences that we don’t yet have a secure answer to, and, in the case of SBM, are not seeking because we believe we already “just know” the answers. We don’t, because of the placebo influence/reporting bias dilemma and limitations to our means of measuring either.

    Andrey: “You do know there are innumerable examples of people who are in obvious agony, gritting their teeth through the pain, all the while fervently claiming they are not actually in pain?”

    Not really. So your argument is that clinical studies are exceptionally able at selecting such people, then?

    1. Harriet Hall says:

      I wouldn’t say there is an “important shift” but we are seeing that many CAM advocates are being forced to recognize that the scientific studies show their treatments to be no better than placebo, and since they are not about to give them up, their only recourse is to say that they should be used for the placebo effect.

    2. MadisonMD says:

      I’m not really understanding the point of this whole discussion whether or no CAM practitioners admit they are using placebo. Most practitioners only need to fool the gullible few who seek them out. These are the very people who will not ask nor care about the niceties of what is placebo versus specific effect. Why would a CAM practitioner introduce the concept of placebo to individuals that are “challenged” in critical thinking skills?

      Only the academicians are forced to deal with the data that demonstrates CAM is placebo. Take all the data showing no difference between acupuncture and sham acupuncture, for instance. Academic proponents have a few options:
      (a) move on to a new therapeutic indication (Cassileth/lymphedema– no plausibility required);
      (b) admit acupuncture IS a placebo and then study placebo a la Kaptchuk;
      (c) use a meta-analysis to prove that acupuncture does work, even though, admittedly, it lacks any clinically significant effect specific to the intervention (a la Vickers)*

      [I have to agree with Peter here that path (b) is the most intellectually honest.] There might be more paths for the quackademics, but why does the average CAM practitioner need to concern itself about facts?

      ——————-
      * and moreover Vickers et al. glosses over the finding that only 2 of 4 primary endpoints allowed rejection of null hypothesis with p<0.05, and even these disappeared when eliminating trials by Vas. The Vas trials were–strangely– major outliers from the rest of the pack showing a very large effect size relative to placebo. Why? Careful review of one of these trials reveals that completely different procedures were used for acupuncture (actually electro-acupuncture) and sham such that the therapist was not blinded. Although Vickers et al, says it believes the blinding was intact, it didn’t seem to fool the subjects –dropout was 8x higher in placebo control (What’s the p value on THAT happening by chance, Dr. Vickers?).

    3. Andrey Pavlov says:

      Very much like “debating a creationist.” I probably shouldn’t waste my time…. but I already did.

      Well, does it? You haven’t shown it.

      So at some point in a creationist debate that exact line will come up. And the scientist will be forced to point out that no, he hasn’t shown precisely what you have asked for, because that is not what the claim was. And then be forced to point to the corpus of literature on evolution. So I will now say that the straw man of the CAM practitioner who embraces the scientific meaning of placebo, believes that all his nostrums are based in nothing but placebo, and proudly advertises his ability to deceive you into thinking you are better does not exist. Your CAM crocoduck is indeed nonexistent. And then I will point you to the corpus of writing here at SBM (though by no means the only) source as to what we are truly talking about here. And you will crow victory, just as the creationist does.

      I remind you Andrey, that it is the claim of you, David and others that there is now an important shift within CAM away from traditional CAM theories into evoking the placebo as a raison d’etre

      And I will remind you that, as Dr. Hall has just said, that our claim is not that they have shifted placebo as the raison d’etre but that they have adjusted their rhetoric such that the fact that at least some of their nostrums work by placebo is not an issue for them. That in fact, the “power of placebo” actually explains part of what they do. The same way that the Catholic church vehemently denounced evolution until it was forced to accept it and then neatly sidestepped the issue by declaring that is the mechanism of god… but that he still inserted a soul somewhere in the hominid lineage. And then do some PR to make themselves look good by pretending they are comporting with science and saying both their religion and science are valid, true, and compatible even though the science destroys the religion.

      It is precisely the same with the world of CAM. After decades of crying that their nostrums “worked” in the classical RCT sense and demanding that they simply be validated, the data shows they are nothing but placebo. Rather than admit the nostrums don’t work, they shift their rhetoric to now incorporate “the power of placebo” as if that validated their practice. In other words, they embrace placebo in a PR move to try and gain some glint of scientific legitimacy and “keeping up with the times” and then bastardize the whole thing to suit their own purposes. In exactly the same way as the Catholic church has accepted evolution.

      Evoking the placebo cannot be regarded as another way of “dismissing reality”, as you have claimed — it surely undermines every one of the dozens of previous fanciful theories of CAM.

      Yes, in precisely the same way that evolution undermines every one of the dozens of previously fanciful theories of Catholic doctrine. You seem to fail to understand that when something is based in ideology and belief rather than reason and science, the way in which actual science interacts with it is different than what a logical and reasoned person would imagine. And CAM is just as much a belief based ideology as religion.

      so that we could hardly now backtrack and condemn such an evolution in CAM thinking as deriving from yet another creepy CAM conspiracy, even if it were the robust, general development that is being claimed.

      Once again, you miss the point. You are now arguing that because it was we (scientists) who demonstrated the placebo nature of CAM, that the embrace of placebo by CAM is not their fault. Agreed. They would have happily not embraced placebo and kept up their previous fanciful ideas if we hadn’t pressured them for actual evidence in the first place. So what? That doesn’t make the fact that they are evolving – as the church has – to keep spreading lies and duping people any less true. It doesn’t make their nostrums any more real or useful. It doesn’t make their existence any more valid. It just means that, like any other ideology or belief based system out there, people can rationalize literally anything to keep their conclusion intact. We aren’t claiming that they are useless because they embrace placebo we are claiming that they are continuing to be useless whilst using rhetorical tactics to embrace placebo.

      That could indeed be looked upon as the first stage of a new enlightenment, a footing for further progress. Never by the more crusading types within SBM, apparently. They want clear-cut villains, and for their heroes to be free of the slightest CAM-sympathetic taint.

      I actually don’t necessarily disagree with you here. And I never claimed that the forced acceptance of placebo as mechanism wasn’t a step in the right direction. But it isn’t the solution, merely a step in the slow death of a bad idea. But just because it is a step in that direction, doesn’t mean I have to now laud CAM. CAM should not exist – it is a nonsensical category, purely a product of rhetoric and politicking. It has no place in scientific discourse. Hell, even the NCCAM cannot even define it!. I’ve pressed John Killen on it and he has responded numerous times, even with an entire blog post as a direct response to me, and his conclusion was that it can’t be defined and the NCCAM doesn’t bother even trying. So why should I view the bastardized partial acceptance of placebo by CAM as something praiseworthy? The “progress” we are arguing for here is a single standard to evaluate all medical claims no matter where they come from, and to apply proper Bayesian prior probabilities to improve the quality of research and the efficiency of dollars spent on research. That means abolishing CAM as a distinct entity, because it is simply not a valid scientific construct. Feel free to read my comments over at the NCCAM blog for more on that.

      So no, the fact that CAM is beginning to embrace placebo as a mechanism of action for their nostrums does not demand they be lauded and is not a positive step in the existence of CAM since the idea of CAM is nonsensical to begin with. It is nothing more than a forced adaptation that involves rhetorical tactics and bad science to maintain their status quo, rather than change what they are actually all about.

      And even if there were such a drift it would pose fresh intellectual, practical, and sometimes ethical challenges for all interested parties.

      No, it wouldn’t. Legitimate placebo research does that for legitimate medical science. There is no need to involve the idea of CAM in this since the foundational basis of the thinking of CAM, the reaction to disconfirming evidence, and the very process of approaching medical issues is fundamentally warped. It is just another opportunity for a bad way of thinking to evolve and survive in the face of facts they can no longer ignore.

      Not really. So your argument is that clinical studies are exceptionally able at selecting such people, then?

      Then you must have been particularly unobservant during your clinical days. And no, it is astounding by how much you have missed the point. And – just like CAM and religion – conveniently ignored the direct challenge to your spurious argument about effect sizes viz: the asthma and acupuncture study. You chastise us – erroneously I may add – about not sticking close enough to the science. Yet you fail to understand the massive role that human psychology plays in all of this and the implications of that.

      1. Andrey Pavlov says:

        I’ll add that the key point here – and the single best fact of evidence to bear – is that there is now a shift in the rhetoric which completely and utterly belies the point. In the past, if something worked no better than placebo, it didn’t work. That does not preclude research or interest in placebo. Now, we have folks like Kaptchuk arguing that the placebo works as well as the active treatment. This is as much a bastardization of the science as one can imagine. You might argue that placebo is interesting, has genuine effects, might be useful for medical treatment, should prompt a review of medical ethics to allow physicians to knowingly use placebo treatments with a clear conscious, but none of that justifies the completely unscientific statement that placebo works as well as active treatment. Do you genuinely not understand the significance of that small twist of the words? Or do you agree that it makes sense to make such a statement?

        That, right there Peter, is the clearest embodiment of exactly what our argument is – that CAM is embracing placebo and that this embrace does not make CAM more scientific. They are bastardizing the science and co-opting the language to suit their purposes since the conclusion is already made in their minds – their nostrums work. Period. And, when forced, will say that the mechanism by which they work is placebo. And since, as you rightly say, the majority of people will not go to a practitioner of pure placebo, they invent this idea that placebo doesn’t just do something but that it works as well as active treatments. In other words that their still works just like my actual medicine does, and the mechanism is placebo which is just as good as an active treatment.

        We here disagree, believe that sort of thinking to be fraudulent at best and harmful at worst, and is precisely the “embrace of placebo” we have been talking about and the authors here documenting studiously. But no, it is not your CAM crocoduck.

  19. Tim says:

    David Gorski , i truly believe that you’re a lying scum dying for attention!!

    WOuld you mind sharing your profession and your lifestyle , I wouldn’t be surprised that you’re one of the medical doctor driving high end cars, live in an upscale neighborhood, snort cocaine, and all you see is $$$$ when a patient comes to see you, and would do anything to keep your lifestyle!!

    1. Andrey Pavlov says:

      LOL! It’s rare to have such inanity come around but when it does it’s always good for a hearty chuckle (on my part at least). All us rich doctors with high end cars and in our upscale neighborhoods should go snort a lot of cocaine and get totally potted up on weed! LMFAO!

      This was the first thing I read this morning over my cuppa and I almost spit it out on my keyboard. Thanks for the laughs!

    2. Chris says:

      Some simple instructions:

      Go to the top of the page.

      Hover your mouse over the “About SBM” and notice how other words appear.

      Click on “Contributors”…

      Then click on Dr. Gorski’s name.

      Then all will be revealed!

    3. Harriet Hall says:

      If you believe he is lying, instead of offering general insults to him and other doctors, how about telling us exactly what lies he is telling, and give us the evidence that shows they are lies.

      1. windriven says:

        I think Tim is a sock puppet for Ted Kaptchuk. Just guessing…

    4. WilliamLawrenceUtridge says:

      I’ll never understand the “you’re evil for making money” rhetoric of some comments. I thought this was ‘Merica! Making money is supposed to be a good thing!

      It’s like people getting mad at Monsanto for daring to make a profit off of genetic modification. How dare a privately held company exist for profit! How dare they!

      I’m sorry, “you make money” is not an argument in any debate. “You make money off of this topic and it could influence your decisions”, that is a factor to be considered. But when the start and end is purely an ad hominem of “you make money”, that’s just stupid.

      1. nancy brownlee says:

        I think I get it, WLU. I’m 66. When I was 30, I could cover my medical expenses out of my own pocket, with no problem. A well-woman check-up was about $60 from my OB-GYN, labs included, and in spite of my modest circumstances, easy to pay for. Same thing with prescribed meds- I went to the drugstore and paid for them, no problem. The same services for a thirty-year-old woman today are much higher- not just more $, but a much bigger chunk of the paycheck for the self-paying, and priced out of reach for many people..

        I was picking up a prescription yesterday, and the fellow ahead of me, who must have been about 80, was told his ‘scrip came to $200. He was humiliated; tears came to his eyes; he said, “What are they thinking? I can’t pay that!”
        It’s so easy, for people of limited means (that’s almost all of us, really) to feel victimized by a medical conspiracy to pick their pockets- by doctors who make so much more money than they do. A couple of my local hospitals, all not-for-profits, are so massively endowed and funded that they are constantly building new additions, not wings but new buildings that cover multiple city blocks, scrambling to spend enough so they can keep their tax status. But a self-pay admitted to one of these behemoths is going to be up shit creek on a rubber duck when he gets the bill.

        I’m not excusing the attitude- but I get it.

  20. PMoran says:

    Andrey: “Now, we have folks like Kaptchuk arguing that the placebo works as well as the active treatment. ”

    Andrey, think this through.

    In an unjustified slur on either his good sense or good faith you are ignoring my point that he has just signed his name to a study showing that an apparently very active presumed placebo did not expand the air passages of asthmatics.

    This is also a man who is now rubbing shoulders with Benedetti and other respected placebo researchers, and who shows a good grasp of the mechanics and meaning of clinical studies. Can such a man be nevertheless unaware of the massive body of research showing that certain pharmaceuticals and other interventions are vastly superior to placebo or sham interventions?

    While I think his use of the term “patient-centred outcomes” was unwise in this setting (death from untreated asthma would be somewhat “patient-centred”), he can mean no more than that there may be exceptions to the general rule and that he has in mind mainly subjective or psychosomatic outcomes.

    There are a few studies around, other than the asthma one suggesting much the same. I don’t make too much of them, regarding them as rather preliminary evidence.

    Nevertheless they will mean a lot to Kaptchuk, because of his concept of the “enhanced placebo”. That predicts the possibility that a powerful combination of placebo and non-specific influences could outperform a weakly active pharmaceutical within the usual format for comparative clinical studies. I know of no evidence that completely precludes that possibility.

    This is a space we should be watching, not totally misinterpreting.

    1. Andrey Pavlov says:

      Andrey, think this through.

      In an unjustified slur on either his good sense or good faith you are ignoring my point that he has just signed his name to a study showing that an apparently very active presumed placebo did not expand the air passages of asthmatics.

      It is not. It is a trivial matter that he collaborated with a group to show some data that got published. Yes, I suppose he could have repudiated the findings as disconfirming of his preconceptions and refused to have his name on the paper. I’ll give him all the kudos he deserves for not doing that. There, done. But what he does with the data afterwards, how he interprets them, and how he does or doesn’t defend them is more important.

      Not only did he very clearly state that “placebo is as good as active treatment” but he has not repudiated the editorial on his asthma piece by one Daniel Moerman who most certainly is trying to make precisely the claim you are fervently saying is not being made. It was Moerman who said that asthma patients don’t come in for a low FEV1 but for SOB and if we’ve made that SOB go away (or be ignored) then we have done our jobs. So at least someone is most certainly making the claims – in high academia nonetheless – that you are saying don’t exist. If I were Kaptchuk and someone wrote that about my article you bet your ass I would be writing a response to that and repudiating that ludicrous interpretation. Instead he is not doing that and making clear statements that his data shows that placebo is as good as active intervention.

      You are desperately trying to save him and I don’t know why. He didn’t say that “a crappy active intervention may produce an effect size smaller than a good placebo in certain very specific circumstances.” That is a statement I would agree with. What he said was in the context of his own data that his data showed that placebo can be as effective as active treatments.

      So he isn’t quite as bad a Moerman. You are trying to convince me to congratulate the equivalent of an otherwise developmentally normal person learning to wipe themselves after the toilet at the age of 16. No, he isn’t actively progression and seeking truth to his claims. He is being dragged along as he tries to prove his claims and failing and then creating a post-hoc rationalization to maintain his conclusion that CAM – as an entity – is useful. Yes, it is a nuanced distinction, but one you should be smart enough to understand.

      This is a space we should be watching, not totally misinterpreting.

      I am watching. And pay close heed to the statement above that I said I would agree with. But I am not the one misinterpreting the results – Kaptchuk is. And you are trying extraordinarily hard to give him every single conceivable benefit of the doubt in the matter when he has not earned it.

    2. weing says:

      “concept of the “enhanced placebo”. That predicts the possibility that a powerful combination of placebo and non-specific influences could outperform a weakly active pharmaceutical within the usual format for comparative clinical studies.”

      Tell you what. If a study showed such an effect, the pharmaceutical would no longer be recommended.

  21. PMoran says:

    “Not only did he very clearly state that “placebo is as good as active treatment”

    Where, exactly?

    ” It was Moerman who said that asthma patients don’t come in for a low FEV1 but for SOB and if we’ve made that SOB go away (or be ignored) then we have done our jobs.”

    I would also like a source for this exact assertion.

    I suspect that you are again putting words into people’s mouths, that in at least the case of Kaptchuk are unlikely to have been said or meant in the general sense that you are maintaining.

    There is also little evidence that these persons’ current primary interest is the defence of pseudoscience. They both sincerely believe that they are onto something useful, with a reasonable body of evidence to support that opinion. If the phenomena they are exploring should indirectly support some of the activities of CAM then that is a bummer for medical scepticism, but otherwise neither here nor there, so long as it is the truth.

    Both authors are probably also taking it as read, given the mainstream audience that they are mostly talking to, that where superior physiologically active agents are available they should have precedence over placebo. I have not heard of them advising placebo for the treatment of cancer, or diabetes, or infections, as your unjustified over-simplification of their views would require.

    I suspect they have not felt the need to spell that aspect out, leaving the ultrasensitive antennae of SBM to sense an intent that is not quite there.

    This is not a matter of me mounting a determined defence of anyone. Simple courtesies should require you to be very sure of your ground before lambasting people on little more than not obviously reliable workings of your own mind.

    Why not write to them and ask them? Better still, get them to outline their current views in a piece on this blog. Further studies may force us to confront their views eventually.

    1. Andrey Pavlov says:

      In his Science Friday interview he says @ 2:52 (my transcription since I couldn’t find a transcript):

      ….made the placebo as good as the drug and the drug no different than the placebo…

      Sloppy use of language? Perhaps. But as a supposedly serious researcher at a place like Harvard in a field so hotly contested with so much written, you’d think he’d have the sense to not be so sloppy. But he also continues at around 4:05 minutes in:

      … I think the message here is that a positive message is important… the effect of a positive message was equal to the pharmacology of a drug

      But hey, one sloppy interview I agree should not condemn a man.

      From another interview on the same study (as referenced by MadisonMD:)

      “While I was initially surprised that there was no placebo effect in this experiment [after looking at the objective air flow measures] once I saw patients’ subjective descriptions of how they felt following both the active treatment and the placebo treatments, it was apparent that the placebos were as effective as the active drug in helping people feel better.”…At the same time, adds Kaptchuk, the study results imply that placebo treatment is just as effective as active medication in improving patient-centered outcomes.

      So he belies that he expects objective changes in placebo and is surprised when they aren’t there and then scrambles to rescue his power of placebo by saying it is just as good as active treatment for “patient-centered outcomes.”

      Just that alone is probably pretty thin and belies more of a sloppy thinker, but wait – there’s more!

      Over at NPR he reiterates his same message:

      “There was no difference between the pharmacology of the drug in reducing pain and the placebo dressed up with a nice word,” study author Ted Kaptchuk tells Shots.”Basically we show that words can actually double the effect of a drug. That’s pretty impressive.”

      Maybe Kaptchuk just doesn’t know what the definition of “pharmacology” is?

      Now in another SciFri interview he talks about the asthma study and states that they were surprised that objective outcomes had no change and that they scrambled to try and salvage something from the data and did analysis to see about subjective changes (~9:38minutes):

      …oh my god this whole experiment didn’t work and I said someone get the statistician to get the subjective outcomes how did people feel and when they crunched the numbers while we were waiting… for subjective outcomes there was no drug effect, because the drug was no different than the two placebos…

      So Kaptchuk is saying that albuterol didn’t help the subjective symptoms and that was all placebo effect.

      Then Ira Flatow says:

      …the patients didn’t mind as much…

      (his emphasis, not mine)

      and Kaptchuk jumps in quickly and says:

      …well they felt much… they felt as good as taking the drug…

      I will give him credit where he deserves it in that he says the “bottom line message” for doctors is that “drugs are very important” but then he immediately follows that up by saying placebo is “critical.” I would argue that drugs are critical and that the placebo of non-specific effects are “important.”

      It is also clear that he is dedicated to his conclusions about things in spite of science. From many sources he is noted as saying:

      “Patients who came to me got better,” he says, but sometimes their relief began even before he’d started his treatments. He didn’t doubt the value of acupuncture, but he suspected something else was at work.

      Now, I will concede he does deserve some credit for improving his ideas and methodology and he has learned to hedge his comments a bit more. But it is still my contention that this is not a product of him actually changing his thoughts on placebo and TCM and acupuncture (as evidenced by how he consistently flips the verbiage on its head as I show above), but because he is forced to do so or else be in serious trouble with serious academics. He clings to what he believed before and changes his rhetoric to be more sly, exactly as CAM has been doing. It is telling that he thought Hróbjartsson would completely sink him and admits that Hróbjartsson’s rigorous study forced him to sack up his own work a bit. As a side note, especially since you’ve referenced Hróbjartsson to me a few times, want to know what he himself said about the placebo research?

      “We found little evidence in general that placebos had powerful clinical effects”

      Funny that.

      In the same Harvard Mag article from above he gives up a bit more of his bent when none other than Dr. Hall is mentioned in the asthma study pointing out the dangers of a false sense of security. His response? At first somewhat reasonable in that he admits he is forced to be a little more cautious in what placebo can do, but then quickly points out:

      “Our job is to make people feel better”

      (his emphasis)

      So overall, I’ll agree that a slightly more tempered attitude on my part is warranted, but that my thesis still stands – he is credulous in acupuncture and TCM when there is no evidence to support them as working better than placebo, he is determined that placebo is powerful and intrinsically useful, and that he turns the idea of placebo and active treatment on its head by equating the two in a backwards manner that belies his biases.

      Which is a convenient point to jump over to Moerman in his NEJM editorial on Kaptchuk’s piece (which is behind a paywall). Thankfully this should be more brief.

      You ask:

      I would also like a source for this exact assertion

      It’s linked above, where he says:

      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? [conflating objective outcomes with "the doctor's perception" and making it clear that the "problem" of asthma was the subjective symptoms, not bronchial constriction]…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. [He feels that "anything described by symptoms" means that subjective outcomes trump all else, which includes asthma]… 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.

      So did I put words in his mouth? How can it be more clear that he feels asthma is a “subjective and functional” condition, that in such conditions patient perception of improvement trumps anything objective, and that patients came in for their symptoms, thus – as he concludes – whatever treatment yields significant improvement “for the patient” which he defines as non-objective (which is somehow equivalent to “for the physician”) means we have treated them successfully? This is a gussied up form of the “treat the patient, not the number.” Well, you need to treat both and here he is arguing that for certain conditions, as specified by him explicitly, the treatment of the “patient” trumps any treatment of the “number.”

      Now to the rest of your comment (which they seem to continually lack addressing very salient points like my rebuttal to your fatuous argument that there is a contradiction in how we are so afraid of the effect of placebo can lead to death in asthma but at the same time we argue it is a small effect)…

      They both sincerely believe that they are onto something useful

      Belief that you are doing something useful is, in and of itself, useless. I’m sure that the Catholic church believes they are doing something useful by spreading lies about condom use and AIDS in Africa and I am sure the Homeopaths Without Borders that gave homeopathic cholera vaccine to the victims of the Haitian earthquake also genuinely believed they were doing something useful.

      If the phenomena they are exploring should indirectly support some of the activities of CAM then that is a bummer for medical scepticism, but otherwise neither here nor there, so long as it is the truth.

      I agree, but as I demonstrated above, their results and interpretations are tainted with their first and foremost allegiance to CAM. Kaptchuk has “no doubts” that acupuncture “works” beyond placebo despite the fact that it is clear that it is nothing more than an elaborate placebo. There is no Truth(TM) to be found – everything is interpreted through the lens of the investigator.

      Both authors are probably also taking it as read, given the mainstream audience that they are mostly talking to, that where superior physiologically active agents are available they should have precedence over placebo. I have not heard of them advising placebo for the treatment of cancer, or diabetes, or infections

      With Kaptchuk, I’ll agree here. Moerman not so much.

      …as your unjustified over-simplification of their views would require.

      Why would anything I have written require them to say outright that placebo can cure cancer? I do not see how this logically follows anything I have said. Perhaps you’d be willing to show me.

      I suspect they have not felt the need to spell that aspect out, leaving the ultrasensitive antennae of SBM to sense an intent that is not quite there

      Actually, Kaptchuk has flat out said that placebo alone cannot treat cancer and other such things. For that I certainly give him kudos. Moerman on the other hand is much more nebulous and I do not give him the benefit of that doubt.

      Simple courtesies should require you to be very sure of your ground before lambasting people on little more than not obviously reliable workings of your own mind.

      I have been pretty sure, as I documented above. And yes, I am somewhat more honed in to the double-speak of medical anthropology since I have education in it. The same way I also have honed in on the double-speak of religious creationism since I have studied that extensively as well (though not formally, as I have in medical anthropology).

      Perhaps Kaptchuk is indeed becoming transformed, though he is being dragged there desperately clutching to his TCM/CAM/acupuncture. He is not there yet. Moerman is a different story though.

      Why not write to them and ask them?

      And what if Kaptchuk writes me back and says “No! Placebo is secondary to objective changes and they should be used in concert together, rather than placebo alone” or something like that? So I can now say that in private he seems more rational than what he puts out in the public sphere? I see little utility in that. I’ve tried such exercises before, writing to the head of the Memorial Sloan-Kettering Cancer Center’s head of CAM. It was positively fruitless. She admitted that energy medicine is total bunk but then defended the use of Reiki at the center by saying it wasn’t energy medicine. When I documented why that doesn’t make sense, she stopped responding.

      Better still, get them to outline their current views in a piece on this blog. Further studies may force us to confront their views eventually.

      That is not my place here- you should be directing that comment to the editors here.

  22. PMoran says:

    I apologise if I have made you go to all that trouble, Andrey, when you have other studies. But good for you that you were prepared to research the matter more thoroughly.

    Kaptchuk saying that placebos cannot treat cancer, etc (a comment of his that I once sent to this blog but had forgotten) does finally belie the position of “major equivalence of placebo/CAM/ scientific medicine” that you and some others seemed at one time want to ascribe to him. You are also softening your stance on him — also good for you.

    I agree that some of the statements you have found for Moerman are scary and they do at first sight carry the implications that you suggested.

    He does, however, insert a somewhat clarifying qualification — ” 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 and long term“. (My emphasis)

    That is evidence-based medicine. It suggests that he believes the actual clinical evidence should be the final arbiter of good practice. Such a belief would be incompatible with the notion that a treatment would be looked at in such total isolation that proven physiological interventions, critical to patient outcomes, would be overlooked.

    Perhaps he was unaware of this apparent inconsistency in his writing, or perhaps he is assuming that the audience of an NEJM editorial would be able to read between the lines.

    It is also hardly a very soft position on CAM to ask for cost/risk/benefits of its use to be demonstrated. Nevertheless, my take is that in this NEJM editorial he is talking to US, speaking to our intense (but mostly quite justified) prejudice against forms of medicine that don’t fit into niches of our own shaping. He is in effect asking us to heed the evidence wherever it may lead.

    This will be too charitable an interpretation for many on this blog, and it will be like claws on a blackboard for some. So be it. I am not saying that he is right, only that the available evidence on the matters he is exploring is consistent with a range of resolutions. (I am prepared to talk about the Hrobjartsson’s studies another time. It is not necessarily the final word on “non-specific influences including placebo”. )

    1. Andrey Pavlov says:

      No apologies necessary Peter. I am actually in a limbo state at the moment, having graduated with my medical degree but not starting my specialist training until July. I do have other things to do, which I am, but have much more time to devote to comments here which is why I am doing so now. I envision that I will once again have very little time once my residency begins in July (and actually before that as well, if my top choice comes through which will necessitate a 3,000km move on my part).

      I am always prepared to follow the evidence where it leads me and will admit when I am wrong. I will admit that I was too harsh on Kaptchuk as he is today and that said harshness is a product of my own education in medical anthropology of which Kaptchuk was required reading (not an excuse, an explanation that will become more relevant in a moment). However, my error was in degree, not kind.

      I still believe there is good reason to assume that Kaptchuk is being dragged into the light of the science of placebo medicine (and he tacitly admits that himself) and that his fundamental stance is demonstrated by his clear statement that there is something intrinsically and uniquely beneficial about acupuncture that works beyond placebo and that he is absolutely convinced of this. He has taken this idea further in recognizing that there is an “additional” placebo component that adds to the “work” done by acupuncture. In this latter endeavor he is being forced to be scientifically minded, but his cognitive bias is still to mold that science into his pre-existing ideas about acupuncture, TCM, and CAM in general. Not to say that his work is utterly useless. Quite the contrary. But the problem is that it cannot be taken at face value since he clearly exercises his “researcher degrees of freedom” (as Dr. Novella has coined the phrase) to draw occasionally spurious but commonly overreaching conclusions from his data.

      As for Moerman, this is where I disagree with you. You are not only giving him too much benefit of the doubt, but you are reading into his work in a way that is not justifiable. You already concede that to make sense of what he is saying some reading in is necessary. The problem is that you are reading in as if he were a rigorous medical scientist. He is not. He is a medical anthropologist of the ilk like those that I studied under for my own degree. In the same way that a physician is better able to parse the writing of another physician, so it is for medical anthropologists. I studied the field diligently and even graduated with honors in the degree. I left my undergraduate days genuinely believing what I had been taught. And that included the notion of the CAM/medicine split, the “east” vs “west” of medicine, the extreme relativism in looking at medical practices rendering anything valid so long as it was internally consistent, the trope that “Western BioMedicine” (that was the actual term given, with those capitalizations, to clearly demonstrate it is different from “other” medicine and that “other” medicine was equally valid) was very good at acute illnesses like myocardial infarction and trauma, but terrible at chronic conditions which is where “Eastern” medicine was king, and so on and so forth.

      I wish I was exaggerating Peter, but honestly I am not. There was a specific language and rhetoric that was used to deliberately bash and denigrate so-called “Western BioMedicine” whilst sounding respectable and academic. And that is the language I see Moerman using. The field of medical anthropology can be respectable (once again, a la Paul Farmer). But it is a lot like evolutionary psychology – too much “just so stories” and cultural relativism. I read books that would pick apart details of medical practice (like the definition of hypertension and how that varied slightly amongst countries) as evidence that even “Western BioMedicine” was just as relativistic as any other “system” of medicine. I even used the phrase “Medicine is intrinsically a culture bound system, with healing being the common thread and each system achieving it in different ways.” And that included “Western BioMedicine.”

      So when Moerman talks about what is “really important” he is trying to assert a validity for “other systems” of medicine by arguing that they produce outcomes in patients that are equally as valid and important as actual physiological changes in disease processes. This is further belied by the fact that he includes asthma in his list of diseases (which is by no means exhaustive from his perspective) as a purely “functional” disorder defined “only by symptoms” and puts it on the same level as “all idiopathic conditions.” That is absurdly false. Asthma is not defined by the symptoms but by numerous objective findings that are measured and define the disease. I myself do not have symptoms classically associated with asthma and Moerman would say I don’t have it, but I do. It affects me in different ways and my pulmonary function tests are unequivocal.

      The last line that you emphasize means something different to you and I than it does to him. What he would view as evidence of harm in the short and long term is different than what we would. Which is why CAM lives in the shadows of the ambiguous, the chronic, the highly variable, and the world without hard end points. It is very hard for CAM to argue against a corpse. But if you have a corpse as a result of a multifactorial disease process you can always pin it on something else. Which is precisely what CAM does and medical anthropology a la Moerman (and my own education) strives to do as its raison d’etre.

      This is not meant as a slight, but you really do not understand the psychology of these sorts of people or of this field because it is so foreign to you. I can sympathize since I experience the same strangeness when I see religious rhetoric. We feel it is impossible for someone to think so incredibly absurdly and wrongly and we try and shoehorn it back into our understanding of the world. This is what you are doing with Moerman and Kaptchuk. But I actually believed the same things they do and was trained in the same way Moerman was. Where I see his rhetoric going is different than the benefit of doubt you give him because I have more knowledge and experience in this than you. Take for example one of my professors in my degree, who still teaches at my alma mater.

      The second project investigates alternative ways of thinking, doing and being human. It begins with an exploration of how Daoism and especially its insistence on “oneness” not only provide the conceptual underpinning for traditional Chinese medicine, but can also serve as an immanent, sideways analytic that suspends practices of bifurcation in modern knowledge production.

      That is her research and what she does and teaches. I remember her lectures. Go ahead and parse that and tell me what you think it means. This is what medical anthropology a la Moerman is like. If you wish, I will take the time to look up specific books and texts we used in my classes and reference them (I just don’t have the time right at this very moment and this comment is becoming long enough as is).

      That is the mindset you must use to read into Moerman’s NEJM editorial. Not our shared mindset of rigorous science and rational inquiry.

      So yes, your read is too charitable and yes the available evidence is consistent with a range of resolutions. The difference is you lack the necessary knowledge and understanding of the field he is a part of to parse his writing to limit that range and understand what it is he really (most likely) means.

  23. PMoran says:

    Last comment, unless provoked.

    It is just not possible for anyone to seriously hold the extreme post-modernist ideas you encountered in some of your anthropology work and to also value the results of conventional scientific study.

    If someone is doing that then we simply need to point out that clinical trials would have no point whatsoever if all methodologies could “work” much the same. Not only that, but literally thousands of clinical studies prove that some methods DO work much better than others. You would also be obliged to be studying things like “too much heat in the triple burner”; it would make no sense even within post-modernist thought to adopt the diagnostic system of totally different subculture but to ignore all other consequences of their understanding of medical conditions.

    Both Moerman and Kaptchuk clearly place a high value on such scientific studies. Moerman quotes dozens of them. So, no, I don’t accept your view of ” — the mindset you must use to read into Moerman’s NEJM editorial”.

    I would agree that Moerman needs to be asked to clarify what he means about asthma, and I doubt very much if he would defend a medical practice that did not employ bronchodilators. If he did then he is more of a fool than I expected, although he is not a doctor and I cut him a little slack in his understanding of medical conditions. He needs to be made aware of the risks if some of his statements are interpreted too literally.

    Our main role in all this should be to make it clear that we already have enough information to be able to place a fairly confident upper limit on what placebo and non-specific influences can achieve within medicine. There are a few blurred areas, mainly to do with the effects of stress on the human body, but, mainly, placebo-type influences can only affect subjective and psychosomatic complaints. We don’t expect any effect on the course of most diseases, but they may affect the level of suffering experienced.

    1. Andrey Pavlov says:

      It is just not possible for anyone to seriously hold the extreme post-modernist ideas you encountered in some of your anthropology work and to also value the results of conventional scientific study.

      This is verifiably incorrect Peter. The cognitive dissonance involved is great to be sure, but it does absolutely exist. Take a look at the “Intelligent Design” movement and things like the “Institute for Creation Research.” They very much want the legitimacy of science and so will value whatever at least appears to be “conventional scientific studies” so long as they comport or can be twisted to meet their already held conclusions. Which is precisely what Moerman was doing in his NEJM editorial – using that data to twist it into a justification for his relativistic ideas about what “healing” is and what our “real” job as physicians is. The same way that Kaptchuk is twisting the results of such studies into lines like “this shows the placebo was just as good as the active pharmaceutical” when the correct interpretation is either a failure of the experiment or that the active pharmaceutical is not active and no better than placebo. These word choices and phrasings are important. And just because you cannot conceive of people who hold such post-modernist views valuing “conventional scientific studies” doesn’t mean they don’t exist. It just means you are poor at conceiving certain things. My old professor being a prime example – Stanford PhD and publishes regularly in the peer reviewed literature.

      it would make no sense even within post-modernist thought to adopt the diagnostic system of totally different subculture but to ignore all other consequences of their understanding of medical conditions.

      That’s the problem you are having. Of course it doesn’t make sense. But your false assumption is that it must actually make sense in order for people to engage in that sort of thinking, writing, work, etc. It absolutely does not make sense, yet they will find a way to claim it makes sense for them. I’d probably think more like you if it weren’t for my own education in the matter demonstrating to me quite clearly otherwise. And at an institution that touts the fact that it has a number of Nobel Laureates as professors! I did not attend some hack university (though I have a classmate who did*) but a legitimate and well regarded institution of the sciences. And yet this sort of post-modernist tripe was taught alongside.

      And there are many universities out there which are absolute hack places and are yet still fully accredited and produce people who become physicians and other professionals. Places like Bob Jones University, for example, where they believe the earth is 6,000 years old, go to the Smithsonians as field trips to laugh at the stupid scientists doing science wrong, and still have their own labs with beakers and chemicals and everything! They do “research” and get published in their own BS journals, and cherry pick actual science to fit their ideas.

      So it does happen. And as you generate more people who think that this sort of thing works, it leaches into legitimate universities – like my own.

      Obviously you will not get some radical post-modernist tripe to just suddenly appear in a top tier journal. It is necessarily a slow process… which is exactly what we are talking about here and documenting. But I won’t belabor the point any further. Suffice it to say, the fact that you think something inconceivable does not make it so.

      Both Moerman and Kaptchuk clearly place a high value on such scientific studies. Moerman quotes dozens of them

      By your logic, creationists must also clearly place high value on such scientific studies and cannot possibly have a radically distorted view of reality. Because, guess what? they also cite and quote dozens of actual scientific studies.

      although he is not a doctor and I cut him a little slack in his understanding of medical conditions.

      So because you don’t know what the hell you are talking about it should be OK to publish inanity in the NEJM??? I’m sorry Peter, but if we were sitting at the table having beers I would cut him slack. If he is publishing in a top tier medical journal he gets no slack at all. He should know better, regardless of what his actual expertise is, or else he shouldn’t have the hubris to write such garbage.

      He needs to be made aware of the risks if some of his statements are interpreted too literally

      Why on earth would I not take what is written in the NEJM literally??? This is a top tier scientific journal, not the the Bible. We don’t have scientific literature so we can all sit down and have our own generous interpretation of what the authors have written. That is precisely the problem we here – and myself included – staunchly oppose. Scientific writing – anything published in a peer reviewed journal – should be, by definition and necessity, clear and literal. It is utterly ridiculous to approach it as you are, trying to “read into” what you think Moerman may have been intending to say.

      Our main role in all this should be to make it clear that we already have enough information to be able to place a fairly confident upper limit on what placebo and non-specific influences can achieve within medicine. There are a few blurred areas, mainly to do with the effects of stress on the human body, but, mainly, placebo-type influences can only affect subjective and psychosomatic complaints. We don’t expect any effect on the course of most diseases, but they may affect the level of suffering experienced.

      Here we can agree. But the proponents of CAM do not have the rational clarity of thought you are so generously granting them. And it is this attitude that is precisely why they are indeed infiltrating legitimate academia and why I had lectures in medical school teaching us that your personality type determines not only what cancers you will get, but what cancer therapies will work to cure your cancer. How do you parse that, Peter? Do you think that is a legitimate stance? Do you think that should be taught to first and second year medical students? Or will you simply not believe me that this was the case and I must be over dramatizing it? If I send you the lecture slides (happy to, if you like) will you then say that I shouldn’t interpret them so literally? Or that he must have meant that it will change your subjective feelings about your cancer?

      *as for the classmate from a hack university she once argued with me that I was too stringent and couldn’t be so sure I was correct in some comments I had made about bad studies. Another classmate even said to me “well, I can’t argue with your stats and you really seem to know what you are talking about but medicine is an art and so I think this study can still be worthwhile and we can use it in our practice.” So after I said no, bad data is bad data and I’ve just clearly demonstrated why the results do not and cannot support the conclusion of this paper the response was “Well, really Andrey, don’t you think in 300 years everything we know about in science will be completely different?” My jaw dropped. I clarified what she meant and she clearly explained that literally everything we know is likely to be turned completely on its head and so I cannot assert with such confidence anything. And yet these are still people in medical school who supposedly have been learning EBM and how studies work and use the principles of science to inform their education.

      So no, just because to you it is inconceivable such people exist doesn’t mean they don’t. I have been educated by them and interacted with them.

    2. David Gorski says:

      It is just not possible for anyone to seriously hold the extreme post-modernist ideas you encountered in some of your anthropology work and to also value the results of conventional scientific study.

      Peter, you must not get out much anymore if you really believe that.

  24. Could someone direct me to papers describing the mentioned confounding effects of placebo’s in experiments?

    1. WilliamLawrenceUtridge says:

      You could start here, by searching for “Benedetti”, but here’s an article:

      http://www.sciencebasedmedicine.org/benedetti-on-placebos/

      Benedetti is an Italian researcher who has done a lot of work on the subject. For instance, from pubmed:

      http://www.ncbi.nlm.nih.gov/pubmed?term=Benedetti%20F%5BAuthor%5D&cauthor=true&cauthor_uid=17666008

      http://www.ncbi.nlm.nih.gov/pubmed/?term=Benedetti+F%5BAuthor%5D+placebo

      That would be a good place to start, and you could trace the articles back through the references.

  25. Andrew says:

    Much, dare I say most of the “placebo effect” is due to various reporting biases. This includes the willingness to report pain for example. Studies examining the brain or sensory factors are still speculative and remain to be scientifically established.

    Strangely enough, no one seems to care that double blinded placebo controlled studies are not used in RCTs testing psychological therapies, nor does anyone care that most of the studies entirely use subjective measures and when objective measures (even objective measures of behaviour) are used, very little or no benefit is shown.

  26. It’s unethical to give someone a drug when they think they’re getting a placebo, or vice versa; both were done in this study. For example, what if one of the subjects, believing they were not under the influence of a drug, decided to drive a car and had a collision, or decided to make a difficult phone call and damaged a relationship? The pills were falsely labelled with a deliberate intent to deceive.

    Could drinking water account for all or part of the placebo benefit in this study? Could the placebo-takers have drunk more water than the no-treatment group? Many people take water with a pill to make it easier to swallow, and might take the opportunity to drink the rest of the glass once they have it in their hand. “We speculate that water deprivation may play a role in migraine, particularly in prolonging attacks.” in abstract of “Water-Deprivation Headache: A New Headache With Two Variants” Joseph N. Blau, C. A. Kell, J. M. Sperling
    6 JAN 2004 DOI: 10.1111/j.1526-4610.2004.04014.x

  27. Badly Shaved Monkey says:

    More Kaptchuk;

    http://www.bbc.co.uk/programmes/b03wcchn

    I actually found it interesting. Quite convincing provided the locus of action of the placebo effect was confined to pain.

    1. Andrey Pavlov says:

      BSM:

      Doesn’t seem to be working for me.

      1. Badly Shaved Monkey says:

        I think BBC iPlayer restricts usage in foreign territories. The problem is that in 1776 America became foreign. Sorry.

        I don’t know whether people more web-savvy than me can get around this for you.

        1. mousethatroared says:

          If anyone knows how to get around that restriction please post it. The lag time between Doctor Who and Sherlock being shown in the U.S. is a killer.

        2. Andrey Pavlov says:

          I once got around that using a plugin to route my IP through a foreign country. It is pretty simple but I don’t recall how to do it off the top of my head. I don’t know if I am motivated enough to re-figure it out to watch Kaptchuk speak for a couple minutes though.

          1. Badly Shaved Monkey says:

            The programme lasts an hour and Kaptchuk occupies quite a big chunk.

            Just in case that alters your calculation of reward/effort.

            :-)

            BSM

  28. Stephen S. Rodrigues, MD says:

    You can not sham Acupuncture the way those studies did! This invalidates the studies and they must be repeated with updated knowledge. Actually I would find it very difficulty to being the thought process to study the concept. With new data why would you want to anyway.

    Acupuncture and Placebo are a powerful tools in clinical practice when used appropriately. — resistance is futile!

    Today, the mechanics of action of the 2 are beyond our intellect. —lets all get over it!

    1. weing says:

      “Acupuncture and Placebo are a powerful tools in clinical practice when used appropriately. — resistance is futile!”
      Could just be that Acupuncture = Placebo? Using placebos, in the US at least, is unethical.

      1. mousethatroared says:

        If you google his name, Stephen S. Rodrigues, MD appears to a native born and educated U.S. citizen who practices in the U.S. and specializes in accupunture.

        Of course there is no way for us to confirm that the person commenting here is the same person, not a different person of the same name or a person posing as Stephen S. Rodrigues, MD.

        1. MadisonMD says:

          resistance is futile

          @MTR: I think this indicates that the poster is a Borg.

          1. mousethatroared says:

            He is very verbose for a Borg.

  29. PoppleD says:

    ” Meanwhile, advocates of using placebo effects intentionally in medicine spun this study as some great evidence that placeboes could be useful in medicine when in fact it suggested that relying on placebo effects to alter physiology could be very dangerous.”

    What a loaded comment. The results of this study (asthma) suggested both that relying on placebo effects to alter physiology could be dangerous as well as that placebos may be useful in treating conditions and associated symptoms in which the underlying physiology is not clear or is not responsive to typical treatment (chronic or acute pain, symptoms of Parkinson’s disease, fibromyalgia, cancer related physical symptoms such as pain, nausea, quality of life). To suggest that subjective experience of illness and associated symptoms lies outside the realm of medicine is also dangerous dehumanizing, and assumes that patients receiving treatment are only concerned with objective outcomes. Further research is needed to elucidate the potentials, limits, and the dangers of placebo response for specific conditions. Furthermore, research must look into psycho-bio-genetic markers for placebo response and responders, so that treatment can be tailored to a patients’ values; I for one would gladly accept placebo treatment for treatment-resistant symptoms such as pain (or symptoms that respond well to treatment with dangerous side effects such as opiates).

    1. weing says:

      “I for one would gladly accept placebo treatment for treatment-resistant symptoms such as pain (or symptoms that respond well to treatment with dangerous side effects such as opiates)”

      How much would you be willing to pay for it? I’ll charge you twice as much as the effect is greater as the cost increases. BTW, in the US, it is unethical to treat patients with placebos. You would need to change that fact first.

      1. Sawyer says:

        I am continuously amazed that people who love to complain about how corrupt and dishonest the healthcare industry is don’t seem to have any qualms about a new generation of doctors relying on the placebo effect to treat patients. Do they not foresee the dozens of ways that they can be cheated out of proper treatment using this approach?

        If I was an incredibly cynical consultant for an insurance company I would be jumping for joy that so many people are willing to not only take *nothing* for their illness, but are often willing to pay for it themselves.

    2. mousethatroared says:

      ” The results of this study (asthma) suggested both that relying on placebo effects to alter physiology could be dangerous as well as that placebos may be useful in treating conditions and associated symptoms in which the underlying physiology is not clear or is not responsive to typical treatment (chronic or acute pain, symptoms of Parkinson’s disease, fibromyalgia, cancer related physical symptoms such as pain, nausea, quality of life). ”

      You appear to think that placebo could success when the condition is not responsive to other treatments…but those other treatments (for chronic pain and the like) should have, at a minimum, elicited a placebo responses in patients even if the active ingredient wasn’t helpful. What gives, why would you think placebo could give a superior impact?

  30. Cody says:

    Articles are not science. Research quantum physics, idiot.

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