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The Great and Powerful Oz versus science and research ethics

That Dr. Mehmet Oz uses his show to promote quackery of the vilest sort is no longer in any doubt. I was reminded yet again of this last week when I caught a rerun of one of his shows from earlier this season, when he gazed in wonder at the tired old cold reading schtick used by all “psychic mediums” from time immemorial, long before the current crop of celebrity psychic mediums, such as John Edward, Sylvia Browne, and the “Long Island Medium” Theresa Caputo, discovered how much fame and fortune they could accrue by scamming the current generation of the credulous. Speaking of Theresa Caputo, that’s exactly who was on The Dr. Oz Show last week (in reruns), and, instead of being presented as the scammer that she is, never was heard even a hint of a skeptical word from our erstwhile “America’s doctor,” who cheerily suggested that seeing a psychic medium scammer is a perfectly fine way to treat crippling anxiety because, well, Caputo claims that it is. Even worse, apparently it wasn’t even the first time that Dr. Oz had Caputo on his show, and Caputo wasn’t even the first psychic whose schtick he represented as somehow being a useful therapeutic modality for various psychological issues. “Crossing Over” psychic John Edward was there first in a segment Oz entitled Are Psychics the New Therapists? I could have saved him the embarrassment and simply told him no, but apparently Oz is too easily impressed. As I said before, if he’s impressed by clumsy cold readers like Browne, Caputo, and Edward, it doesn’t take much to impress him. Also, apparently his producers aren’t above editing science-based voices beyond recognition to support their quackery.

I was further reminded how Dr. Oz promotes quackery by an article in Slate yesterday entitled Dr. Oz’s Miraculous Medical Advice: Pay no attention to that man behind the curtain. I suppose it would be mildly hypocritical of me to snark at the rather obvious “Wizard of Oz” jokes aimed at Dr. Oz. After all, I’ve used the same joke myself at one time or another and, in light of the Slate.com article, couldn’t resist using it in the title of my post. However, I wasn’t about to let that distract me from the article itself, which is very good. The reason is that there are two aspects to Dr. Oz’s offenses against medical science. There is the pure quackery that he features and promotes, such as psychic scammers like John Edward and Theresa Caputo, faith healing scammers like Dr. Issam Nemeh, and “alternative health” scammers like reiki masters, practitioners of ayruveda, Dr. Joe Mercola, who was promoted as a “pioneer” that your doctor doesn’t want you to know about. Never was it mentioned that there are very good reasons why a competent science-based physician would prefer that his patients have nothing to do with Dr. Mercola, who runs what is arguably the most popular and lucrative alternative medicine website currently in existence and manages to present himself as reasonable simply because he is not as utterly loony as his main competition, Mike Adams if NaturalNews.com (who has of late let his New World Order, anti-government, “Obama’s coming to take away your guns” conspiracy theory freak flag fly) and Gary Null.

The second aspect is that Dr. Oz also does give some sensible medical advice. The problem, as I’ve pointed out before, is that he “integrates” all manner of quackery into his science-based advice. Now, that pure nonsense is being “integrated”is pretty obvious when we’re talking about faith healing and psychic mediums, but Dr. Oz’s “integration” is actually seamless in that he integrates all manner of dubious and scientifically questionable claims with the more standard, stodgy, boring science-based advice (e.g., lose weight, exercise more, eat more vegetables and less red meat, treat your high blood pressure, and the like). For example, it is not surprising that Oz features a lot of dubious diet supplements on his show, given that losing weight is one of the single most important health issues many people face and the fact that effective weight loss strategies are rarely easy. They involve diet and exercise, neither of which is fun or easy for many people. So what we hear from Oz are stories like this:

As people were getting ready for the holiday season and its accompanying waist expansion late last year, Dr. Mehmet Oz let viewers of his TV show in on a timely little secret. “Everybody wants to know what’s the newest, fastest fat buster,” said the board-certified cardiothoracic surgeon and one of People magazine’s sexiest men alive. “How can I burn fat without spending every waking moment exercising and dieting?”

He then told his audience about a “breakthrough,” “magic,” “holy grail,” even “revolutionary” new fat buster. “I want you to write it down,” America’s doctor urged his audience with a serious and trustworthy stare. After carefully wrapping his lips around the exotic words “Garcinia cambogia,” he added, sternly: “It may be the simple solution you’ve been looking for to bust your body fat for good.”

In Dr. Oz’s New York City studio, garcinia extract—or hydroxycitric acid found in fruits like purple mangosteen—sounded fantastic, a promising new tool for the battle against flab. Outside the Oprah-ordained doctor’s sensational world of amazing new diets, there’s no real debate about whether garcinia works: The best evidence is unequivocally against it.

As Julia Belluz and Steven J. Hoffman, the authors of the article, point out, garcinia extract has been tested, and in a randomized trial in 1998 it was no better than placebo for weight loss. A more recent systematic review of the literature concluded that the evidence was at best equivocal and that the effects, even if real, were so small as make it unlikely they were clinically relevant. Belluz and Hoffman also point out that Dr. Oz takes full advantage of the scientific respectability that his current position affords him:

Oz may be the most credentialed of celebrity health promoters. He’s a professor and vice-chair of surgery at Columbia University College of Physicians and Surgeons. He earned his degrees at Ivy League universities, namely Harvard and the University of Pennsylvania. He’s won a slew of medical awards (in addition to his Emmys) and co-authored hundreds of academic articles. He’s clearly a smart guy with qualifications, status, and experience. It’s reasonable to assume he is well-versed in the scientific method and the principles of evidence-based medicine. “Because he’s a physician, that lends a certain authority and credibility to his opinions,” said Steven Novella, a clinical neurologist and assistant professor at Yale University School of Medicine who has taken Oz to task for his science. “But it lends credibility to anything he says.”

Indeed it does. I often wonder about this. First of all, I wonder how Dr. Oz can manage to do a daily hour-long talk show and still see patients and hold all the academic positions that he holds. I realize that it’s Oz’s producers and writers who do most of the grunt work for his show, but it’s still hard to believe that during the nine months or so a year when his show is in production Oz doesn’t spend at least 20 hours a week working on it. Just the taping of five episodes a week alone must surely, when added up, take up at least a full (and long) day, given all the filing of audiences in and out, changes in the set, and the like. Then there’s oversight, consultations with the producers and writers, story approval, not to mention travel and promotion. It’s a huge time commitment. Or, if it’s not a huge time commitment and Oz really doesn’t do that much, then we’d have to conclude that Dr. Oz is nothing more than a figurehead, a Ted Baxter- or Ron Burgundy-like character, who comes in one day a week, reads his cue cards, and has little or nothing to do with the creative process behind the show. Somehow, given how driven he’s always been, I think Oz has more involvement in putting his show together than that. Sheer ego alone, at the very minimum, makes me think that, too, as I doubt Oz would want his brand and message to be completely controlled by others. Assuming he does have significant involvement in putting his show together, it’s hard to figure out how from September to June Dr. Oz has enough time to take care of patients, handle his administrative duties, and do anything resembling academic work. Besides the difficulty of maintaining one’s technical operative skills and knowledge base in a surgical specialty as complex as cardiac surgery, Dr. Oz must have the most understanding surgical partners in the world, given how often and for how long they must have to cover his patients, and he must have the most understanding department chair in the world given how little time he probably has left after his show to do any real administrative work. (Remember, he’s not just the vice chair of the department of surgery; he’s also the director of the Cardiovascular Institue and the Complementary Medicine Program at New York Presbyterian Hospital.) On the other hand, no doubt Columbia derives considerable rewards from Dr. Oz in terms of publicity for its medical school, programs, and hospitals, not to mention probably a not insignificant amount of cold, hard cash. So it’s probably not that surprising that Oz’s administration and partners put up with him and bend over backwards to enable him.

The sad thing is that Dr. Oz, for all his fascination with reiki even as far back in the 1990s, used to be a halfway decent surgical scientist. The vast majority of his publications from that period are pretty mainstream and unremarkable. They were competently done, although I didn’t find any major breakthroughs or any new really interesting findings, admittedly Oz did produce a lot of publications.

Of course, all of this makes it even sadder to see what Dr. Oz has become. He’s already proven that he knows how to do decent science; the evidence is in dozens of publications from years past. Yet when he’s on TV all of that flies out the window, and Oz apparently either forgets (or rejects) everything his pre-Oprah scientific career. For example:

Take a breaking-news segment about green coffee-bean supplements that “can burn fat fast for anyone who wants to lose weight.” Oz cited a new study that showed people lost 17 pounds in 22 weeks by doing absolutely nothing but taking this “miracle pill.”

A closer look at the coffee-bean research revealed that it was a tiny trial of only 16 people, with overwhelming methodological limitations. It was supported by the Texas-based company Applied Food Sciences Inc., a manufacturer of green coffee-bean products. Oz didn’t mention the potential conflict of interest, but he did say he was skeptical. To ease his mind, he conducted his own experiment: It involved giving the pills to two audience members for five days and seeing what would happen. Unsurprisingly, both women reported being less hungry, more energetic, and losing two and six pounds, respectively.

Dr. Oz knows as well as any regular reader of this blog who has imbibed of its content and message how worthy of ridicule such a TV “study” of two is: no blinding, no control group, far too short a time period of observation, and a number so small as to be meaningless; yet somehow Dr. Oz thinks that something like this “eases his skepticism” about the tiny study (which only had either four or six subjects in each experimental group). Particularly informative is Figure 2 of the study, in which all three groups basically decreased their BMI at the same rate in the initial period regardless of whether they were in the group to receive placebo, low dose, or high dose green coffee bean supplement. One also notes that there were no error bars on any of the graphs to provide an idea of the scatter in the data. All in all, it’s a pretty worthless and unconvincing study, not even taking into account the conflict of interest. Come to think of it, one wonders whether Dr. Oz (or any promoter of alternative therapies and supplements) would accept a study like this from a pharmaceutical company as convincing evidence that the company’s product worked. Somehow I doubt it.

Oz then went beyond this, as Scott Gavura described yesterday, setting up what he called the Green Coffee Bean Project. Scott quite accurately described it as a “made for TV clinical trial,” and that’s exactly what it was: a randomized clinical trial set up for Dr. Oz’s television show. True, it was a shoddily designed and useless clinical trial, but it was clearly a clinical trial nonetheless. Unfortunately, there was no statistical analysis and no approval by an institutional review board (IRB), even though this was clearly human subjects research. Quite frankly, doing a research project like this involving human subjects is profoundly unethical without IRB approval. In fact, arguably, Dr. Oz was in direct violation of Columbia University’s Human Research Protection Program, which states:

The IRB has the responsibility to oversee the conduct of research that it approves. Consistent with this responsibility, the IRB may audit research studies conducted at Columbia University or Columbia University Medical Center as well as research in which faculty and/or staff of Columbia University are engaged outside the institution. The Compliance Oversight Manager is responsible conducting audits at both campuses and reports to the Executive Director of the IRB.

If that’s not clear enough, the executive summary states:

The Columbia HRPP covers all entities, offices, and individuals engaged in and/or responsible for the review and conduct of human research at Columbia and New York Presbyterian Hospital (NYPH). CU has two Federalwide Assurances (FWAs): one for Columbia University Medical Center (CUMC) and one for the main campus at Morningside Heights (CU-MS). NYPH has its own FWA and is a separate legal entity from CU. Although there are three FWAs, the Columbia HRPP is responsible for all human research conducted at CUMC, CU-MS, and NYPH, or by any affiliated faculty, employees, or staff of CU and NYPH regardless of location.

Let me emphasize: This policy applies to research carried out by all Columbia and NYP-affiliated faculty regardless of the location where the research is done. Quack researchers like Mark and David Geier seem to be able to manage to skirt these laws because they aren’t faculty at an institution that receives federal funding and because they fly under the radar. In contrast, Dr. Oz is Columbia faculty. Even though he conducted human subjects research outside of Columbia university and clearly his research is not federally funded, it’s hard not to wonder whether he violated Columbia’s HRPP policy. Federal law is very clear on this. Institutions receiving federal funding must abide by the Common Rule, which states that all human subjects research that’s federally funded carried out at such institutions or by the faculty of such institutions must be overseen by a duly constituted IRB. All such institutions that I’ve ever worked at or had dealings with also agree to apply the Common Rule to all human subjects research conducted at their facilities and/or by their faculty, regardless of whether the research is federally funded or not. Also, it doesn’t matter if the research in question is being carried out at a location outside of the university. If the Office for Human Research Protections ever had a mind to investigate and concluded that Oz did perform human subjects research without proper oversight by Columbia’s IRB, Columbia University could potentially be in for a world of hurt, up to and including the possibility of having its federal research funding withheld. At the very least, a federal investigation would be very intrusive and painful, even if it ultimately exonerated Oz and Columbia. At the very least we have to wonder whether Oz violated Columbia policy on human research subjects protection, which is why the university should investigate, in my opinion. It likely won’t, however. This is the Great and Powerful Oz, and the university gets too many rewards in terms of publicity and probably cash.

I can speculate endlessly why Dr. Oz has devolved from a respected cardiothoracic surgeon and surgical investigator into, let’s face it, a huckster selling whatever he thinks his audience will buy. Well, that’s not exactly true. As Dr. Oz so often and so piously reminds us, he doesn’t make any money from endorsements, and he claims to aggressively go after companies that falsely advertise his endorsement to sell products. The product that Dr. Oz is selling to America is, above all else, Dr. Oz. There’s also the relentless pressure to come up with material to fill five hour-long episodes a week for nine months a year. TV is a bottomless sink for material, and it demands material that will attract, engage, and, above all, entertain its audience. Telling people to lose weight and exercise isn’t that entertaining or interesting. Telling people there are supplements that will let you lose weight without dieting or exercise is. Strategies to deal with anxiety based on research are difficult to present in an entertaining fashion. Presenting psychics like John Edward or Theresa Caputo as being therapeutic is easy and potentially entertaining even to skeptics, and it can be done with Dr. Oz’s “aw, shucks” disclaimer that fools no one in which he opines over and over again that “science doesn’t know everything” and that “medicine can’t explain everything.” So, as Dara O’Briain puts it, Oz fills in the blanks with whatever fairy story appeals to him—or, more accurately, appeals to his audience.

As 2013 begins, I’ve been thinking a lot. We skeptics and supporters of science-based medicine are massively outgunned, and Dr. Oz is simply the most telling example of this. Quacks have Dr. Oz to sell their products. We have a loosely-knit, unorganized bunch of bloggers trying to refute the torrents of nonsense that promoters of quackery like Dr. Oz spew forth, and a few academics like Dr. Edzard Ernst trying to counter the flood of quackademic medicine filling academic journals. Dr. Oz has an audience of millions every day. Bloggers like Steve Novella, Steve Salzberg, and I have an audience of a few thousand each every day, and our audiences have considerable overlap. Moreover, even in the skeptic movement itself, countering quackery and medical pseudoscience is all too often the neglected stepchild that gets far less time, attention, and love than creationism, Bigfoot, the paranormal, and religion. Even within the skeptical movement itself, I’ve personally all too often seen a shocking level of tolerance or even acceptance of antivaccine views and alternative medicine.

That’s why one of my aims this year is to come up with ideas about how we can work to change this, because this matters, or should matter, to everyone. All of us will get sick at some point in our lives. Many of us will become seriously ill at some point in our lives, and all of us have known or will know someone who becomes seriously ill. All of us will require medical care, and many of us require chronic treatment for some condition or other. Blogging is important. Exposing quackery and medical pseudoscience is important. However, it isn’t enough.

Posted in: Clinical Trials, Science and the Media

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47 thoughts on “The Great and Powerful Oz versus science and research ethics

  1. windriven says:

    For decades Dean Edell fought quacks and scammers and the credulous thinking that made fertile ground for their depredations. For his effort he lost his flagship station in San Francisco and retired – out with a sigh, not a roar.

    Mehmet Oz, a man of evident intelligence, has deduced that fame and fortune come easily to those who dole out cups of soma in a cornucopia of flavors to the dim and the delusional and the willfully ignorant. Oprah gave him the recipe and he never looked back.

    “Dr. Oz has an audience of millions every day. Bloggers like Steve Novella, Steve Salzberg, and I have an audience of a few thousand each every day…”

    Oz serves soma. You guys serve cod liver oil. The mass market will never beat a path to your door. But that does not mean that what you do isn’t monumentally important. The facile and the important are rarely the same.

    In my humble opinion the problem starts with elementary education. Children are not taught critical thinking skills and they are not taught science. They are taught technology. They are taught a lot about what we know but damned little about how we came to know it; how we separated the wheat from the chaff. And they are served up mixed messages: believe in science but also believe that religion explains the inexplicable and negates the unpalatable.

    So you’re stuck saving one soul at a time ;-)

  2. cervantes says:

    I’m still touting litigation. Taking people’s money under false pretenses is fraud. If the authorities won’t prosecute, a few class action lawsuits will drive these scumbags out of business. I cannot understand why it doesn’t happen.

  3. windriven says:

    @cervantes

    I agree with you that litigation certainly has a place here. I have mooted the idea of putting together a bureau of expert witnesses and marketing it to plaintiff’s attorneys. But many of those who would be the best witnesses have obligations that preclude that kind of investment in time.

    Unfortunately, you can’t sue Oz for being an a$$hole. But some of the more egregious peddlers of dangerous woo could probably be taken out.

    Still, the larger problem is the herd of ovine prey; so long as pickings are easy there will be predators happy to thin the herd.

  4. BobbyG says:

    ” First of all, I wonder how Dr. Oz can manage to do a daily hour-long talk show and still see patients and hold all the academic positions that he holds. I realize that it’s Oz’s producers and writers who do most of the grunt work for his show, but it’s still hard to believe that during the nine months or so a year when his show is in production Oz doesn’t spend at least 20 hours a week working on it. Just the taping of five episodes a week alone must surely, when added up, take up at least a full (and long) day, given all the filing of audiences in and out, changes in the set, and the like. Then there’s oversight and consultations with the producers and writers, not to mention travel and promotion. It’s a huge time commitment. Or, if it’s not a huge time commitment, then the alternative is that Oz s nothing more than a figurehead who comes in one day a week, reads his cue cards, and has little or nothing to do with putting the show together, and somehow I think Oz has more involvement than that. Assuming he does, it’s hard to figure out how from September to June Dr. Oz has enough time to take care of patients, handle his administrative duties, and do anything resembling academic work. Besides the difficulty of maintaining one’s technical operative skills and knowledge base in a surgical specialty as complex as cardiac surgery, Dr. Oz must have the most understanding surgical partners in the world, given how often and for how long they must have to cover his patients, and he must have the most understanding department chair in the world given how little time he probably has left after his show to do any real administrative work.”
    __

    It’s called “upcoding.”

    ;)

  5. Janet says:

    Windriven is probably right–in stating the problem and in his conclusion.

    Has anyone questioned Oz’s employers? It does seem extraordinary that they look the other way when he promotes outright quackery. But then the Mayo Clinic now has a whole department of Woo that includes even “cupping” as one of its alternatives, which are now listed at the end of each entry discussing a treatment. Can a revival of bloodletting be far behind? Phrenology anyone?

    Perhaps a reasonable goal could be to try to get more shruggies off the fence at medical institutions?

    My personal goal this year is to simply find a hairstylist who can cut my hair without mentioning her devotion to “holistic” methods or her distrust of “conventional/allopathic” medicine. Honest to imaginary being, I do NOT start these conversations!

  6. nybgrus says:

    @windriven:

    In my humble opinion the problem starts with elementary education.

    I know at least one person who would seem to disagree with you.

    But in all seriousness – why can’t charges be brought against Oz to demand evidence he following human research protocols? I am truly neophyte in human subjects research, so I don’t know the exact rules here, but shouldn’t there be a mechanism in place to compel him to provide evidence he met the Columbia requirements? If he has no documented evidence, that is the same as it not having happened (as the old saying goes: if I didn’t chart it, it didn’t happen). Is there a federal office we can email about it? Or an office at Columbia HRPP?

    You lament that there is only a readership of thousands here, but if you post the appropriate emails and a partial general form letter for those who wish to make use of it in order to make it easy for us to voice our concerns, a few hundred or even couple thousand emails would be likely to trigger action. At least it would gain some traction.

    On another front, a class action suit seems quite reasonable. Boiron just recently lost a class action suit for fraudulent marketing of their product (take a note pmoran – they “genuinely believed” in their product and yet were still culpable of fraud). I would be happy to buy some green bean BS so that I could have a stake in being duped as part of the suit. And with Jann Bellamy being in the circle of people to bring forth such a suit, could we not organize and incentivize a group of lawyers to bring suit? I’m sure they’d be happy to work on contingency when the target is so rich, especially with the support of the expertise here at this blog.

    Perhaps that is the new direction things can take around here? Using this forum to generate action in the form of emails and calls to the appropriate regulatory bodies when appropriate and to organize class action suits with the legal, medical, and scientific expertise available through this blog and its readership. I’d certainly be willing to help however I can. The FFRF does exactly that and it is changing the tides and tenor and raising awareness of the issues they deal with. If SBM started something similar, it could have profound implications including helping get a bunch of shruggies off their laurels and educating the general population that CAM is quackery by not allowing it to slink in the shadows any longer.

    Thoughts?

  7. cervantes says:

    It’s called the Office for Human Research Protection and yes, come to think of it, you could report him. I’m not sure what the law is here — technically only federally funded research has to comply with the common rule, but generally institutions with Federal Wide Assurances (i.e., certified IRBs) apply it to all research done at their institutions and by their affiliated faculty. Oz might not have violated the law, but he should be in trouble with Columbia University. It’s worth looking into, I would say.

  8. Robb says:

    I find it humorously ironic that nybgrus would buy green coffee bean extract and falsely claim that he was duped into purchasing it in order to take part in a suit claiming ethical wrong-doing on the part of Dr. Oz. The ends justify the means I guess?

    I’m not a fan of Dr. Oz or his show but I look at it as I do for most of television – caveat emptor – I would watch Dr. Oz in the same way I would watch Fox News and expect similar distortions of the truth. I suspect his legal team, legal precautions and funds are prodigious so going after him on technicalities like this would be akin to tilting at windmills.

  9. nybgrus says:

    It is a fair point Robb, one I did not think through all too well. The rest of my point stands.

    As for your assiduous viewing of Dr. Oz… that misses the point entirely.

    And you would think that a multi billion dollar international company like Boiron would have their legal bases covered too… but they still lost the suit.

  10. Richard says:

    I was thinking, what if you folks at Science-Based Medicine got together and started a monthly podcast. That might put SBM more in the public eye. Each of you could talk about something, and you could have fund drives, too. But what everyone can do right now is donate to this blog and other pro-SBM sites.

  11. pmoran says:

    We skeptics and supporters of science-based medicine are massively outgunned, and Dr. Oz is simply the most telling example of this.

    I can cheer you up a bit, David. .

    You may remember that a few years ago I said that CAM contained within itself the seeds of its own decline. I pointed out that it had been making so many greatly overblown medical claims regarding serious illnesses that it had to eventually become obvious to the public that its claims were not very trustworthy. I was howled down at the time, but I see indications here and there that this is starting to happen.

    Below are two quotes from contributors to an alternative cancer mailing list, one that I have been booted off twice for speaking supportively of mainstream cancer care. .They have a CAM slant, but you must realize that not long ago these comments would have been attacked viciously, should they have even managed to get past censorship. This represents a sea change, at least for this, probably the largest mailing list of its type..

    -”J—–, you go with the numbers. For all it’s faults conventional cancer
    treatment is far, far superior to alternative in keeping statistical records.
    Alternative therapies are such a hodge podge that it is easier to herd cats.
    Anyhow, conventional therapy is right for some people. I think there is too
    much polarization in health care. The smart person doesn’t divide the world
    into a false dichotomy of conventional vs alternative, but asks oneself what is
    more effective, less toxic, and more affordable.”

    “Actually, it is not always true that “people who do chemo and radiation live
    despite it, not because of it”. However, there is a lot of ineffective and
    unnecessary chemo and radiation done. The secret is to know when to use these
    modalities and for what purposes. There is no question that certain leukemias
    and lymphomas can be cured by chemo (of course albeit with side effects…remember
    risk benefit ratio). Would you subject a child to an unproven therapy of any
    kind when at an early stage, their acute lymphoblastic leukemia has a 90%cure
    rate with chemo? Similarly some types of stage IV testicular cancers are
    curable through chemo. Radiation to the breast after lumpectomy can definitely
    reduce (but not eliminate) the risk of recurrence (remember risk/benefit ratio).
    It is most important that people be informed of their choices and of the risks
    vs. benefits. Unfortunate, conventional doctors are NOT in a great position to
    discuss risk vs. benefits of alternative treatments because they are generally
    uninformed, prejudiced or both. Many of us alternative docs suffer from
    misinformation and prejudice on the other side. There are no easy nor pat
    answers.”

  12. pmoran says:

    NYbrgus: “In my humble opinion the problem starts with elementary education.”

    I know at least one person who would seem to disagree with you.

    I’ll own up to that. I’d like kids to be well-taught in science. It might help a little bit. But it is right to be very skeptical about anything more than that, for reasons that I will provide again if anyone has already forgotten them or never thought seriously about the matter.

    One worry is that this is a too-convenient scapegoat for our frustration at not being very successful overall in persuading adults, even very well educated and basically science-oriented adults, over to exactly our way of thinking. So is the other main approach: “if only we could get that outlawed — “.

    These ” solutions” permit us to stop thinking further, about either the way we try to get our message across, or whether the content of the message might be a bit too precious for present realities, or whether it does not adequately take into account the extreme complexities of medical interactions. This last is what I think most academics, some integrative medical practitioners and “shruggies” will be struggling with. They honestly are not sure what to do about CAM because the very science of therapeutic interactions allows for some contrariness.

    Boiron just recently lost a class action suit for fraudulent marketing of their product (take a note pmoran – they “genuinely believed” in their product and yet were still culpable of fraud).

    Yet they are still selling the same products, after a slap on the wrist, a disclaimer, and some repackaging. It seems to be very difficult to legally ban “alternative” products unless they are clearly unsafe, as was the case with Laetrile, Aristolochia and Ephedra.

    Kudos to David for suggesting a rethink.

  13. tmac57 says:

    @Janet-

    My personal goal this year is to simply find a hairstylist who can cut my hair without mentioning her devotion to “holistic” methods or her distrust of “conventional/allopathic” medicine. Honest to imaginary being, I do NOT start these conversations!

    This is why I started cutting my OWN hair ;)

  14. nybgrus says:

    For someone constantly winging that we don’t listen to you, understand what you say, and put words in your mouth you sure do a lot of the same with us… all while inserting subtle Nirvana fallacy.

    As for your cheering up – you realize that now that such grandiose claims are failing the result is a shift from “alternative medicine” to “complimentary and alternative medicine” to “integrative medicine”? And that the new bent is an appeal to the power, utility, and ethics of placebo? After demonstrating through the scientific trials they demanded so heartily that CAM is nothing more than placebo, the mantra now is that placebo is actually the way they “work” and thus should still be used anyways! And you have learned folks like David Katz at Yale saying that CAM therapies are not amenable to the standards of scientific inquiry and a lower threshold of evidence is reasonable to apply to CAMs to justify their use alongside actual medicine. All while the NCCAM itself can’t even define what CAM is (so to what are we supposed to apply this double standard?) and further claiming it doesn’t even bother itself with such determinations.

    No doubt, I believe we are making some headway even just by igniting a conversation to motivate a few shruggies to stop shrugging so much. But with slick medical anthropologists at Harvard making asinine claims that only *sound* good and having non-scientists and non-physicians running “alternative” therapy centers at large institutions (e.g. the MSKCC) our progress is limited.

    I’ll own up to that. I’d like kids to be well-taught in science. It might help a little bit.

    It might help a little bit. So educating children to properly understand scientific inquiry and critical thought is, in your mind, at best a maybe with a small effect size? Seriously, what else could POSSIBLY help more?

    One worry is that this is a too-convenient scapegoat for our frustration at not being very successful overall in persuading adults, even very well educated and basically science-oriented adults, over to exactly our way of thinking.

    And there is your Nirvana. Exactly our way of thinking? Maybe I missed something in my 3 years of being at this blog, but I don’t recall anyone advocating turning people into clones of myself and Dr. Gorski (though if I could take on Dr. Atwood’s brain to replace a large part of my own I wouldn’t complain).

    No, it doesn’t need be exact. My very crunchy granola hippy friend doesn’t even think remotely like me, but even she has learned from me and does eschew the most ridiculous of woo-ish claims and now rarely indulges in the supplement du jour (though she does maintain that eating vegan, doing yoga, and balancing her “energies” is good for her… which is fine, since she outright acknowledges it isn’t scientific, advocates seeing a real doctor for actual medical problems and doesn’t push her beliefs on others or otherwise malign the scientific knowledge we have which is common of sCAMsters). So no, I don’t need or care for her to think exactly like me. That would be quite boring. She is an interesting, vibrant, and fundamentally different thinking person yet still managed to learn enough about why CAM is bullsh!t that if every person thought like her I would consider our goal nearly complete.

    These ” solutions” permit us to stop thinking further, about either the way we try to get our message across, or whether the content of the message might be a bit too precious for present realities, or whether it does not adequately take into account the extreme complexities of medical interactions.

    Utter bollocks. You continually critique this blog for being something it isn’t, was never intended to be, and never professed to be. It should be beyond blatantly obvious by now that everyone here understands the need for various tactics in various circumstances and that different people are good at different tactics. You take the sampling of the tactics here, at only this blog, by people doing what they are good at and assume us so incredibly one dimensional that you must think all I can do is wander around the streets robotically repeating verbatim what is written by the authorship here. Never mind that if you look back three years at my own posts here they have changed, improved, and – dare I say it? – matured. You imply that Dr. Gorski runs around his hospital telling his patients what a load of fetid dingo kidneys their ideas are and thumping his chest like some science based silverback gorilla before he wheels them back to the OR.

    And especially that last sentence completely ignores the post which Dr. Hall just made and on which I commeted about a deeper understanding of medical partnership with patients to understand and address their individuals concerns and values. But of course, you can’t go over to that thread and snark about how strident and off putting we are, now can you?

    Yet they are still selling the same products, after a slap on the wrist, a disclaimer, and some repackaging. It seems to be very difficult to legally ban “alternative” products unless they are clearly unsafe, as was the case with Laetrile, Aristolochia and Ephedra.

    And your last subtle Nirvana fallacy. We’ve only dealt them a slap on the wrist instead of felling them in a single swing of the legal axe, so… what? Something is difficult so we… what? Give up? Accommodate? Accept? Bollocks.

    You are entirely too quick to discount small victories and use them as evidence that our tactics and desires are futile. Small victories add up. That is the first lesson I learned in being a professional poker player – let the fish take the big pots so they feel good while you (the shark) swim around picking up all the little ones. I’ll let you guess who ends up with more money at the end of the night (and guess as to why my professional playing days were, to date, my highest paying job I’ve ever held).

  15. pmoran says:

    And that the new bent is an appeal to the power, utility, and ethics of placebo?

    While something like that has been said by SBM principals, a little thought demolishes it. I know of no “alternative” practitioner or CAM supporter who wants their pet methods to be regarded as placebo and I defy you to find one.

    They may not care too much if it IS a placebo. They may say “what does it matter how it works, so long as it does?”. But they know, even if you don’t, that once you take away the mystique of the method — its “schtick”, if you like — all is lost; their clients will go to someone who says that their treatments actually do stuff.

    And why should we care if this was the case? Nothing is more destructive of the pseudoscientific content of CAM than that its observed effects (such as they are) are from placebo responses. If CAM admitted it was based mainly upon placebo responses almost all of the problems that it poses would disappear.

    It actually is some conventional doctors who question the strictures against using placebos, and any doctor who says they have never used one is probably lying. But I am against it as a formal policy.

  16. Quill says:

    Oz serves soma. You guys serve cod liver oil. The mass market will never beat a path to your door.

    Assuming that this soma refers to the fictional drug in Huxley’s novel, then I think this analogy is sort of backward. SBM serves up drugs that, like soma, have a real, consistent, measurable and large effect while Oz serves up various old oils in new bottles, some of which work wonders, others of which are waste of bottles.

    But more to the point I’d like to make: the “mass market” is something that does not move by itself. It does not discover anything but rather has to not only be told to buy something but also why one can’t live without it in the first place. Especially when the mass market didn’t’ even know it wanted anything like it or that the new thing even exists. This gets me to a point I made in an earlier blog entry, namely that the story SBM sells (its narrative) is fine but it is the presentation (the marketing) that needs a lot of work.

    Quick: name five scientists who are scintillating public speakers! Now name ten Oz-like CAMsters…or twenty if you like. The latter is much easier and requires no fudging while the former needs…work.

    Science as expressed by CGI and fabulous movie stuff is seen as totally, like, cool by almost everybody. Actual science can be made just as cool if not more so if more attention is paid to how it is presented.

  17. David Gorski says:

    While something like that has been said by SBM principals, a little thought demolishes it. I know of no “alternative” practitioner or CAM supporter who wants their pet methods to be regarded as placebo and I defy you to find one.

    Uh, nice straw man ya got there, Pete. That’s not what nybgrus said or what I’ve said. Let’s take a look again at what nybgrus said:

    After demonstrating through the scientific trials they demanded so heartily that CAM is nothing more than placebo, the mantra now is that placebo is actually the way they “work” and thus should still be used anyways!

    Which is absolutely correct. Having failed to demonstrate any specific therapeutic effects for the vast majority of their treatments above and beyond that of placebo, the CAMsters are now retreating to the claim that their remedies work their magic through the “power of placebo.” Ted Kaptchuk is an excellent example, but there are many more. It’s not that they want their methods to be regarded as placebo. It’s that science gave them lemons by failing to validate their favored treatments; so they’re trying to make lemonade by pivoting to placebo effects as the explanation for why their woo “works.” In fact, it was almost exactly a year ago that I wrote a post entitled The rebranding of CAM as “harnessing the power of placebo” in which I discussed this very phenomenon. Here are two paragraphs from the introduction that set up the issue:

    There was a time not so long ago when proponents of unscientific medicine tried very, very hard to argue that their nostrums have real effects on symptoms and disease above and beyond placebo effects. They would usually base such arguments on small, less rigorously designed clinical trials, mainly because, if there’s another thing I knew before from my medical education but that has been particularly reinforced in me since I started blogging, it’s that small clinical trials are very prone to false positives. Often they’d come up with some handwaving physiological or biological explanation, which, in the case of something like homeopathy, violated the laws of chemistry and physics. Be that as it may, the larger and more rigorously designed the clinical trial, the less apparent effects become until, in the case of CAM therapies that do nothing (like homeopathy), they collapse into no effect detectable above that of placebo. Even so, there are often enough apparently “positive” clinical trials of water (homeopathy) that homeopaths can still cling to them as evidence that homeopathy works. Personally, I think that Kimball Atwood put it better when he cited a homeopath who said bluntly, “Either homeopathy works, or clinical trials don’t!” and concluded that, for highly implausible treatments like homeopathy, clinical trials as currently constituted under the paradigm of evidence-based, as opposed to science-based, medicine don’t work very well. Indeed, contrasting SBM with EBM has been a major theme of this blog over the last four years. In any case, for a long time, CAM enthusiasts argued that CAM really, really works, that it does better than placebo, just like real medicine.

    Over the last few years, however, some CAM practitioners and quackademics have started to recognize that, no, when tested in rigorous clinical trials their nostrums really don’t have any detectable effects above and beyond that of placebo. A real scientist, when faced with such resoundingly negative results, would abandon such therapies as, by definition, a placebo therapy is a therapy that doesn’t do anything for the disease or condition being treated. CAM “scientists,” on the other hand, do not abandon therapies that have been demonstrated not to work. Instead, some of them have found a way to keep using such therapies. The way they justify that is to argue that placebo medicine is not just useful medicine but “powerful” medicine. Indeed, an article by Henry K. Beecher from 1955 referred to the “powerful placebo.” This construct allows them then to “rebrand” CAM unashamedly as “harnessing the power of placebo” as a way of defending its usefulness and relevance. In doing so, they like to ascribe magical powers to placebos, implying that placebos can do more than just decrease the perception of pain or other subjective symptoms but in fact can lead to objective improvements in a whole host of diseases and conditions. Some even go so far as to claim that there can be placebo effects without deception, citing a paper in which the investigators — you guessed it! — used deception to convince their patients that their placebos would relieve their symptoms. Increasingly, placebos are invoked as a means of “harnessing the power of the mind” over the body in order to relieve symptoms and cure disease in what at times seems like a magical mystery tour of the brain.

    As I said, nice straw man ya got there, Pete. Now I know that either you haven’t been reading very carefully or you haven’t been reading at all.

  18. pmoran says:

    Nybgrus: “It might help a little bit.”

    So educating children to properly understand scientific inquiry and critical thought is, in your mind, at best a maybe with a small effect size? Seriously, what else could POSSIBLY help more?

    Possibly nothing, but are we going to look elsewhere for helpful measures, or smugly defend improbable scenarios?

    This is onbe of the matters illustrating why we need to truly understand why people turn to CAM, and the actual conventions under which it operates, not what we believe to be true because it seems right enough and what everyone is saying.

    For example, If we have never considered the key role of unmet medical needs in CAM use (and I cannot recall anyone on SBM explicitly doing so, while there is often the unspoken assumption that conventional medical care should be enough for anyone ) we will never work out why the above plan is most unlikely to work very well. And not only because it will be one remote influence in a long chain of them, having to compete with the influence of parents and peers, among others.

    We are in effect requiring that young children of varying levels of interest and intelligence are to be raised to a level of scientific sophistication and personal conviction such that later on in life they will tolerate ongoing symptoms and threats to life rather than respond to strong instinctive impulses and external urgings. We are also not allowing for the fact that very little personal CAM use is based upon a conscious scientific decision — all that is needed is sufficient reason to think that it is worth a try and that there is nothing much to lose.

    So surely we should be considering whether there are other more direct ways of achieving our ends, perhaps thinking again about what our ends should be, even what is achievable given the terrain we have to work within. You seem to have reasonable aims, from your experiences with your friend.

    The provision of good information is a given. Whatever they may say, most CAM users have some respect for science and are interested in its opinion on medical matters. They simply reserve the right explore other avenues when rightly or wrongly dissatisfied with what the mainstream offers. You know and I know that the most they can expect are placebo influences but to be secure in that knowledge when being assailed by the virtually untestable theory and the few inevitable “positive” studies requires a level of scientific sophistication that is far beyond that teachable in schools.

  19. LovleAnjel says:

    Really, none of this is surprising. Oz’s first foray onto tv was the “John of God” documentary many years ago. I was surprised they got an actual MD for the show. I was even more surprised when this MD was astounded by the miraculous cures. Really, the man was groping his patients and shoving tweezers up their noses, and none of them were actually cured. When I saw Oz as Oprah guest I was no longer surprised by anything he did. The man may be intelligent, but he has no sense.

  20. pmoran says:

    David, Ted Kaptchuk could not in any way be regarded as a typical CAM practitioner. He would be better classified as a placebo researcher nowadays.

    So again, find me a currently active CAM practitioner who is admitting to the world that his methods work as placebo. For the reason I gave they will never do so.

    Those most close to allowing that they are using placebos are not CAM practitioners, but reasonably sensible MDs practicing “integrative” medicine, but even they do so under various euphemisms that disguise any association with placebo: “self-healing”, mind-body, holism, psychoneuroimmunology etc. There is also Moerman and his “meaning” but he is an anthropologist.

    I will partially give you Andrew Weil, because I personally heard him say many years ago that “placebos are the ‘meat’ of medicine”.

  21. pmoran says:

    Also, David, what is your response to the rest of my post? –

    And why should we care if this was the case? Nothing is more destructive of the pseudoscientific content of CAM than that its observed effects (such as they are) are from placebo responses. If CAM admitted it was based mainly upon placebo responses almost all of the problems that it poses would disappear.

    There are, as you say, exaggerated expectations from placebo in some quarters but I cannot see that ever catching on with the public, and we also have a lot of material showing that placebos don’t affect disease processes, in general.

    So, if there were the trend you describe, why would it not be something to be welcomed and encouraged?

    But I cannot see it evolving that way. CAM will steer clear of that precipice somehow.

  22. weing says:

    “They may not care too much if it IS a placebo. They may say “what does it matter how it works, so long as it does?”. But they know, even if you don’t, that once you take away the mystique of the method — its “schtick”, if you like — all is lost; their clients will go to someone who says that their treatments actually do stuff.”

    That’s why they invoke magic, like water memory, chi, etc. That’s why they want a double standard. One to apply to SBM and another to them. My view is that CAM use by practitioners and their victims is dependent on superstitious behavior. Variable ratio reinforcement is what results in superstitious behavior. Of all the operant condtioning schedules, the resultant behavior is the most difficult, if not impossible, to extinguish.

  23. David Gorski says:

    And why should we care if this was the case? Nothing is more destructive of the pseudoscientific content of CAM than that its observed effects (such as they are) are from placebo responses. If CAM admitted it was based mainly upon placebo responses almost all of the problems that it poses would disappear.

    Again, you either haven’t read posts by myself, Steve Novella, Kimball Atwood, and others very closely or you’ve conveniently forgotten. We’ve discussed this matter again and again and again and again. In fact, in the summer of 2011 in the wake of Kaptchuk’s asthma/placebo study, we wrote a slew of such posts, and there have been more since. I might even do another one soon, as Sharon Begley has written a rather credulous article about placebo effects that I found the other day.

    This is why discussions with you are so frustrating. We explain these things over and over and over and over again to you. You don’t like the explanation and disagree with it. Usually you don’t have a good rebuttal to it. Then, a few weeks or months later you ask us to explain the very same thing again, as if we had never done so in the first place. Rinse, lather, repeat. It gets very tiresome and is why I rarely engage with you anymore. I have to be in a certain mood, as I can only go around and around so many times before I get dizzy and frustrated. I also get very tired of your condescension and insults and sometimes, in a moment of weakness, respond in kind, which is something that I don’t like to let myself be provoked into doing.

  24. David Gorski says:

    That’s why they invoke magic, like water memory, chi, etc. That’s why they want a double standard. One to apply to SBM and another to them. My view is that CAM use by practitioners and their victims is dependent on superstitious behavior. Variable ratio reinforcement is what results in superstitious behavior. Of all the operant condtioning schedules, the resultant behavior is the most difficult, if not impossible, to extinguish.

    An interesting idea.

    It also has religion-like aspects to it, which is perhaps why CAMsters so frequently claim that SBM is a “religion.” If it’s a “religion,” then they can dismiss it as competing dogma and heresy without actually having to provide scientific evidence to back up their position.

  25. nybgrus says:

    (I will provide links in a separate post to avoid moderation concerns)

    I know of no “alternative” practitioner or CAM supporter who wants their pet methods to be regarded as placebo and I defy you to find one.

    I call “shifting goalposts” on this one. We are talking about the general acceptance and usage of CAM, the rhetoric surrounding it, what the public hears, and what the most vocal pundits say. Not what an individual CAM practitioner says. The public is not informed about and swayed by the machinations of individual CAM providers. They look at the news reports, articles written, and what perceived authorities on the matter say.

    Andrew Weil is one such authority whom you have already admitted contradicts your statement.

    Just do a google search and you will find myriad sources – journalistic, medical, institutional, scientific, and otherwise – which essentially say the same thing:

    Alternative practitioners argue that the placebo should be regarded as just as valuable as a drug. It is in a sense a drug. It’s a therapy. It produces an indirect effect, perhaps, rather than the direct effect of a drug, but still it does provide benefits for patients and so it should be incorporated into therapy and utilized rather than disdained.

    (1)

    That is from a perceived authority on what is considered to be a hard-hitting and highly factual news program by an organization esteemed for education and objectivity. Namely, an MD who is professor of medical history at at a highly respected school of medicine on a Frontline interview done by PBS.

    So whether mom-and-pop altie practitioner says so or not actually doesn’t matter – what the majority of the public are hearing, what the purveyors and proponents of quackademia are saying, and what the totality of the “CAM” and “integrative medicine” movement are doing is exactly what Dr. Gorski said – turning lemons into lemonade and making it look scientific at the same time.

    And why should we care if this was the case? Nothing is more destructive of the pseudoscientific content of CAM than that its observed effects (such as they are) are from placebo responses. If CAM admitted it was based mainly upon placebo responses almost all of the problems that it poses would disappear.

    Now this is something I actually agree with. The problem is, as I described above, “the power of placebo” is highly, highly overstated and the narrative in our culture – from movies, stories, powerful anecdotes, TV shows like Dr. Oz and “Dr.” Phil, etc etc – is to reinforce that notion. That is the wedge by which the altie movement uses to then extrapolate even further and meld the placebo with the “schtick” and handwave away the fact that they are all nothing more than placebo. This is further evinced by the fact that things like herbals, exercise, diet, and prayer are all lumped in as “CAM” so that sussing out the fluidity of claims and the role of placebo is nigh impossible for the lay person and difficult even for my colleagues who don’t devote the time to it.

    The problem is this: I challenge everyone here to go around and start asking “Do you think that a positive attitude will help improve cancer survival?” I think we can all reflexively answer what we expect the answer to be, even if we here know the actual science that demonstrates the answer to be “no.” So I posit that this general cultural attitude of the “power of placebo” which is genuine when it comes to subjective outcomes is (intentionally or not) maintained as a fluid concept with the miss-mash that is referred to as “CAM” such that exposing CAM as placebo is not quite as detrimental as you would have us believe. Unless we change the narrative to reflect reality I do not think the fact that CAM is placebo will be its downfall… especially considering that CAM is so fluid with so many permutations the easiest riposte is “well, that CAM is placebo, but when you use my magical joo-joo – whic is the real CAM – it not only utilizes placebo but the actual intrinsic benefit of the real CAM as well.”

    This is supported by the fact that even in magazines like Scientific American have headlines like Placebo Effect: A Cure in the Mind with the sub-title Belief is powerful medicine, even if the treatment itself is a sham. New research shows placebos can also benefit patients who do not have faith in them (2) and of course the recent article by Begley in The Saturday Evening Post (3) which Dr. Gorski mentioned where she says “But if doctors and scientists have learned one thing about the placebo response or placebo effect, it is this: There is nothing “mere” about how thoughts, beliefs, and the power of the mind affect the body“. This further popularizes the notion that “placebo is powerful” so when CAM is shown to be placebo what do you think that the common lay person will think? That it is still “powerful medicine.” Do you really expect the lay person to separate out what the really means, especially since most sources conflate it all anyways?

    So educating children to properly understand scientific inquiry and critical thought is, in your mind, at best a maybe with a small effect size? Seriously, what else could POSSIBLY help more?

    Possibly nothing, but are we going to look elsewhere for helpful measures, or smugly defend improbable scenarios?

    You have no evidence that it won’t work, good evidence that it does and with significant prior plausibility, but hey lets just eschew it and look for something else? Or are you implying that we can’t be addressing the education issue while looking for and doing other things? You claim the main driver of CAM use is dissatisfaction with the limitations of SBM (which I am about to challenge). Well, you should know better than most that SBM is always seeking to improve and have fewer and fewer limitations so that is already and constantly being addressed. You know that medical education is putting more and more poper emphasis on (for lack of a better all encompassing term, but please know I am not as simplistic to limit it to this) “bedside manner.” So why can’t we be addressing education as well? Because you don’t like that idea? Without having a better one yourself (save for accepting the more benign CAMs so we can look more credible in vigorously denouncing the more dangerous ones)?

    For example, If we have never considered the key role of unmet medical needs in CAM use (and I cannot recall anyone on SBM explicitly doing so, while there is often the unspoken assumption that conventional medical care should be enough for anyone ) we will never work out why the above plan is most unlikely to work very well.

    As per the NCCAM website “who uses CAM most:” (4)

    People of all backgrounds use CAM. However, CAM use among adults is greater among women and those with higher levels of education and higher incomes.

    Then take the results of survey data which is used by both the University of Maryland Medical Center (5) and the American Acadamy of Medical Acupuncture (6) which states:

    55% of adults said they believed that it would help them when combined with conventional medical treatments.
    50% thought CAM would be interesting to try.
    26% used CAM because a conventional medical professional suggested they try it.
    13% used CAM because they felt that conventional medicine was too expensive.

    And suddenly your incessant pestering that it is unmet medical needs that drive CAM use look pretty darned shaky. People who have extra money to spend and think it “might be interesting to try” or that it could help when combined with real medicine are the largest consumers of CAM. A huge chunk of it is because mislead (to be charitable) physicians recommended it. Only a minority because they couldn’t afford real medical care. Poor people try and use real medicine because they see it works better than the garbage they can’t afford to waste their money on.

    But perhaps you would like to link me to a source that demonstrates it is dissatisfaction with the medical care they receive that is actually a larger contributor to usage.

    We are in effect requiring that young children of varying levels of interest and intelligence are to be raised to a level of scientific sophistication and personal conviction such that later on in life they will tolerate ongoing symptoms and threats to life rather than respond to strong instinctive impulses and external urgings.

    No, we aren’t, as evinced by my anecdote about my hippie friend. But, why is it an unreasonable (though very long term) goal to try and actually educate as many people to utilize critical thought and rationality as decision making tools rather than emotions and primitive urges? Your argumentation here is ludicrous to me.

    We are also not allowing for the fact that very little personal CAM use is based upon a conscious scientific decision — all that is needed is sufficient reason to think that it is worth a try and that there is nothing much to lose.

    No, we aren’t. As Dr. Gorski has said, you seem to be continually blind to the fact that these criticisms are well known and addressed by us. We want to create a culture, a system, and a knowledge base wherein people will realize that it isn’t “worth a try” and that there is something to lose. A battle that is counteracted by the quackademic and cultural narrative I noted above. We aren’t trying to solely make everyone scientists like ourselves as the only means to achieve the goal, but to espouse the proper narrative and condemn our colleagues who should know better from fueling said narrative.

    So surely we should be considering whether there are other more direct ways of achieving our ends, perhaps thinking again about what our ends should be, even what is achievable given the terrain we have to work within. You seem to have reasonable aims, from your experiences with your friend.

    I feel honored to finally elicit a positive response from you. My friend warrants a different tactic and expectation than my colleagues or the popular media. You may be right that we don’t explicitly enough express (and perhaps at times even know) what our short term and interim goals are or should be. But you seem to act like the only people on the planet approaching the issue is us. No, we here have a niche that suits us well. Ben Goldacre does a different thing. So does Edzard Ernt and Simon Singh. PZ Myers does his thing and so does James Randi and they intersect with and even reference us as well.

    Once again, you charge us with not doing what we never professed to want to do. And you then have no concrete ideas yourself, merely criticisms like a mother-in-law backseat driving. I have actually outlined exactly what I do, what I would like to do, and how I have been doing it here many times. Dr. Novella has his SGU podcast, goes on TV shows, makes educational videos, runs a skeptics society, and acts as a teacher to medical students and residents (just to name a few I can think of off the top of my head). I won’t belabor the point but each and every single author does many other things, in many different tacks, to different audiences quite regularly. But somehow that doesn’t matter – this site specifically is too strident and wrongheaded for some reason. Except when Dr. Hall posts about patient partnerships and you have absolutely nothing to say.

    Whatever they may say, most CAM users have some respect for science and are interested in its opinion on medical matters.

    Which is exactly why quackademia and the popular science narratives I outlined above are so dangerous. It allows and engenders conflation that no reasonable lay person can be expected to suss out.

    So again, find me a currently active CAM practitioner who is admitting to the world that his methods work as placebo. For the reason I gave they will never do so.

    While not perfect, I hope you can have the intellectual honesty to see that I have demonstrated why that doesn’t matter and is a complete straw man to the conversation at hand.

  26. David Gorski says:

    Indeed. There’s a new one right here:

    http://www.saturdayeveningpost.com/2013/01/02/in-the-magazine/health-in-the-magazine/placebo-power.html

    I might have to deconstruct it, either here or at my other blog, sometime this week. :-)

  27. nybgrus says:

    Yep, that is the one I came across as well Dr. Gorski. It offers an excellent example of the conflation of what placebo can and cannot due, all whilst using language which makes people think placebo is something truly amazing and powerful that is just waiting for medical science to harness the “power” of much like we are waiting for ITER to harness fusion.

  28. David Gorski says:

    That’s what I get for posting before I check the moderation queue. :-)

  29. pmoran says:

    David:“And why should we care if this was the case? Nothing is more destructive of the pseudoscientific content of CAM than that its observed effects (such as they are) are from placebo responses. If CAM admitted it was based mainly upon placebo responses almost all of the problems that it poses would disappear.”

    Again, you either haven’t read posts by myself, Steve Novella, Kimball Atwood, and others very closely or you’ve conveniently forgotten. We’ve discussed this matter again and again and again and again. In fact, in the summer of 2011 in the wake of Kaptchuk’s asthma/placebo study, we wrote a slew of such posts, and there have been more since. I might even do another one soon, as Sharon Begley has written a rather credulous article about placebo effects that I found the other day.

    Of course I know what is in those posts.

    My specific question was why we would not welcome CAM practitioners admitting that their methods are placebos, just as we have been trying to get them to understand all along? Why would that insight be merely something else with which to beat perceived opponents around the head, rather than as something to build upon?

    It was certainly correct to point out the weakness of the evidence for a specific physiological effect of placebo in the Kaptchuk study, also the dangers of relying upon placebos in serious illnesses like asthma.

    But this last point was beaten to death, and then hammered home some more, and then covered yet again, with considerable righteous indignation, even though it is not clear that anyone, anywhere is seriously suggesting using a known placebo alone in a potentially fatal condition like asthma. It is difficult to think of an element of CAM that would do that, once knowing that a method was placebo, and that their actions would be judged on that basis. After all, the Kaptchuk study itself demonstrated that medication is clearly superior to placebo in this condition (the weird thing was that it was less so than we might expect, but this rather interesting aspect was ignored).

    I think I commented along these lines at the time. I didn’t call it for its “straw man” aspects although they are considerable. We are all remarkably adept at detecting those in the writings of others, but not our own. The reason is that most human discourse requires approximations if it is not to be swamped by qualifications. So just about anything can be regarded as a straw man if some exception can be found to it.

    The question is how close any particular characterization of the beliefs of others is to the truth, and that requires open debate.

  30. Angora Rabbit says:

    On the subject of Dr. Oz, SBM readers won’t be surprised that, for our recent hire of a Nutritional Extension Faculty member, we asked the applicants to prepare and present, on 24hr notice, a one-page fact sheet and webinar to rebut the latest Oz fantasy. This is now built into the job description because our R.D./State Extension specialists tell us that their number one job is often to waste a day chasing and then rebutting the latest crazy fad promoted by Oz. The man keeps us employed but, honestly, there are better ways we’d like to spend our time. Like addressing real interventions that are proven to work.

    I can’t figure out how Columbia lets Oz get away with it either. A colleague there reports that Columbia now levies a tax to PIs both on floor space and on the number of employees per lab down to the bathrooms! I figure Columbia admin is putting up with him because they must be getting a healthy cut somewhere.

  31. pmoran says:

    Nybgrus, so those responsible for a massive investment of time, energy and other resources into “alternative” cancer treatments don’t actually have cancer? It is because they are women, and well-educated, with high incomes?

    And if you and Dr Gorski are still unable to find CAM practitioners who profess what you referred to as their present “mantra”, will that be retracted?

    Weing is closer to the truth, that they will retreat into mysticism, and other ploys, rather than admit that their methods are placebos.

    Nevertheless, I don’t think we, on our part, can avoid allowing that CAM practioners may be of benefit to some patients via placebo influences. To do so requires taking a very extreme and difficult position on the relevant science.

  32. pmoran says:

    And if you and Dr Gorski are still unable to find CAM practitioners who profess what you referred to as their present “mantra”, will that be retracted?

    Sorry, I don’t really expect you to go that far. I don’t care about this point to that degree. I do care about “why people use CAM” because that feeds into so many areas needing a sound understanding.

  33. nybgrus says:

    so those responsible for a massive investment of time, energy and other resources into “alternative” cancer treatments don’t actually have cancer? It is because they are women, and well-educated, with high incomes?

    That’s what you got from what I wrote? I really am going to have to stop wasting my time like that then.

    Where could you possibly have gotten that notion from? Seriously? You think rich, well educated women don’t get cancer? You don’t think that they could be (at least part of) what drives the CAM side of things? You are familiar with this thing called “supply and demand” and that when those with resources “demand” more – for whatever reason – there are typically plenty of people waiting to meet the supply?

    But yes, the data show us that in fact, 50% of CAM use is driven by the fact that “it would be interesting to try” and that those who have the money to spend on it do, and those that are just smart enough to think they know better than the average Joe spend it on CAM.

    A poor person with cancer isn’t likely to add on CAM to their treatment because they can barely afford the time and money to do the actual treatment in the first place. There is also data to show that providing actual medical care in poor communities vastly increases uptake of medical care and decreases CAM usage – i.e. meeting medical needs decreases CAM use in line with your mantra. I never said you were wrong, I merely said it definitely wasn’t the sole drive, and almost certainly wasn’t the main driver. You seem to have difficulty handling the multifactorial nature of the topic.

    There is lots of overlap and fluidity with CAM use and being able to magically snap your fingers and “fix” one aspect of it would suddenly make it go away (even if we suddenly had medicine actually meet all medical needs in a vacuum).

    And yeah, if you really want to get snarky about it – do you think that those in the Bravewell collaboration have cancer? Or any disease? Or how about the Sameuli’s at my undergrad alma mater? Do you think that the money, time, and resources they pump into the promotion of CAM is because they have a disease and their needs were unmet by modern medicine? You’re delusional if you do. They are a concerted effort by those who are highly educated, with lots of money, oh yeah – and the president of Bravewell is woman and the half of the Samueli duo is female as well.

    I mean really Peter, I don’t get where you are stuck on this. The motivation is ideology; and when you convince the right rich people it gets results (even when they regret it after as it costs their lives, like Steve Jobs).

    At this point, I am busy enough and definitely tired enough of rehashing these points over and over that I need to give it a break with you. No matter what evidence or citations I throw at you, or what logic and reason, or stories of my own experiences and those of others, you dogmatically stay on point repeating the “unmet needs” mantra endlessly, with absolutely no acknowledgement that you have even attempted to challenge your assumptions. And you don’t even need to challenge them – you just need to broaden your scope. You aren’t wrong you are just only partially right. For someone constantly telling us we are stuck to a dogmatic narrative, you sure seem to have exceptionally little else to say. At least I think about it and challenge my assumptions. You are so cock sure about your conclusion thanks to having thought about it for so long and having been there in the 60s and 70s that you don’t even allow the possibility you might be wrong. I do. But the incessant harping of one pmoran isn’t sufficient evidence to sway me. And I’ll reiterate – even if you were right that your manta of “unmet needs” was correct, I still wouldn’t see cause to change what I do. Because I (and this blog) are addressing other drivers. And doing just one thing to address the problem is both a waste of talent and stupid.

    And your argument is utterly pointless. Fine. Unmet needs. Got it. Check. You know the very nature of SBM is to constantly improve and meet more and more needs. Guess we are done here guys. Dr. Gorski – pack up shop. Nothing left for us to do here. Seesh.

  34. nybgrus says:

    magically snap your fingers and “fix” one aspect of it would suddenly make it go away

    …one aspect of it would not suddenly make it….

  35. windriven says:

    @Quill

    “Assuming that this soma refers to the fictional drug in Huxley’s novel, then I think this analogy is sort of backward. SBM serves up drugs that, like soma, have a real, consistent, measurable and large effect while Oz serves up various old oils in new bottles, some of which work wonders, others of which are waste of bottles. ”

    Admittedly it has been (whispers) forty years since I read Huxley but I clearly remember soma as being hallucinogenic. It was upon that recollection that I drew the analogy. If I misremembered (Rosanna Rosanna Danna voice:) never mind.

    Moreover, the point was that rational reasoning requires a discipline and effort that wishful thinking does not. Perhaps I expose a cynical bent inferring that most people gleefully opt for the easy over the correct.

  36. nybgrus says:

    BTW, Soma is a real drug.

  37. pmoran says:

    I have produced supporting studies, too, Nybgrus, but an almost mathematical level of logic says that people are not often going to invest in medical treatments without an ongoing medical need of some type. Hence the reductio ad absurdum in my last post.

    About the only exceptions that I can think of right now might be in the “wellness” and anti-aging sections of CAM. Even “wellness medicine” exploits that vague desire to feel better more of the time. This sometimes brings people into doctor’s offices.

    You also need a realistic appreciation of the limitations of present mainstream medical care, even when well applied. Not all skeptics have that.

    It only then becomes inescapable: — unmet medical needs are a necessary prerequisite for CAM use, and all those other factors merely influence whether any given individual will turn to CAM or not, in the latter instance simply enduring ongoing problems without further action, as most people still do.

    The reason for my boring, dogged, intolerable persistence is that an understanding of this will influence many matters — how we talk to CAM users, what strategies might best work, what constitutes realistic objectives etc.

  38. nybgrus says:

    but an almost mathematical level of logic says that people are not often going to invest in medical treatments without an ongoing medical need of some type

    For someone who keeps touting the notion that usage of CAM is nearly never predicated on critical thought or dispassionate scientific analysis that seems like a very odd thing to say. You also seem to ascribe wholly to rational choice theory which has been widely critiqued and fails in the face of this little thing called “marketing.”

    Once again, the “need” can be manufactured – and is to great success, regardless of actual need. You do at least give lip service to the noiton of the worried well and “wellness medicine.” Care to look at the data again and see how much of CAM usage falls under that umbrella? Unless you want to tell me that people see refloxologists because their hepatologist just can’t seem to fix their jaundice, or that the 50% of people who try CAM because it would be “interesting to try” have an unmet need for modern medicine to let them “try” things. Perhaps we should should just let people “try” our medicines and surgeries just for the interest of it to meet that need of theirs?

    You also need a realistic appreciation of the limitations of present mainstream medical care, even when well applied. Not all skeptics have that.

    Oh I do. I just also think that the gap can be narrowed from both sides of the equation.

    It only then becomes inescapable: — unmet medical needs are a necessary prerequisite for CAM use

    And yet you haven’t even remotely demonstrated this. Yes, unmet medical needs is a driver of CAM. I’ll even grant that it is not an insignificant driver of it. Heck, my own step-father – a critical care pulmonologist – says that “Homeopathy is a symptom of the failings of modern medicine.” I also think that unmet needs will be the last bastion of CAM use. But it is also one that we cannot address any faster than we are (i.e. that is already being worked on heavily). So how would you have us focus on it additionally?

    So what is left is the stuff that we are working on. The funny thing is, regardless of whether it is the major contributor, the necessary driver of it, or merely a side note… it wouldn’t change one iota what I think or how I do things. Nor should it.

    I’m the first one to tell me patients, “I am really sorry we don’t have anything to help you further right now, but there just really isn’t anything out there that can, and most likely anything else would be a waste of money and might possibly harm you” (or something to that effect). I then go on to stress that we can work together to help manage symptoms, come up with life plans to make the condition more tolerable, all the way up to palliation.

    But it gets da/\/\ned hard to convince someone of that when every fracking media outlet is blasting the new miracle cure, legit physicians are hawking bunkum, alternative practitioners are licensed, and garbage “alt meds” are on pharmacy shelves. I can easily convince almost anyone that a bleach enema is a bad idea and its just a few crazy people who advocate it. But I have trouble arguing against, “But Dr. Oz said it would help!” or “My other doctor said it might help!” or even better “My other doctor uses it all the time!” (and then I find out the other “doctor” is a naturopath, chiro, acupuncturist, or homeopath).

    As I said, you aren’t (that) wrong… you just aren’t contributing anything useful to the conversation we don’t already know. And you keep trying to get us to… I don’t even know what.

  39. pmoran says:

    But it gets da/\/\ned hard to convince someone of that when every fracking media outlet is blasting the new miracle cure, legit physicians are hawking bunkum, alternative practitioners are licensed, and garbage “alt meds” are on pharmacy shelves. I can easily convince almost anyone that a bleach enema is a bad idea and its just a few crazy people who advocate it. But I have trouble arguing against, “But Dr. Oz said it would help!” or “My other doctor said it might help!” or even better “My other doctor uses it all the time!” (and then I find out the other “doctor” is a naturopath, chiro, acupuncturist, or homeopath).

    I hear you. But note that your implied goal is that you MUST stop people using these methods. This is the perceived duty of the medical skeptic, and his worth is to be measured by that.

    The frustration thus derives from all the factors, including the unresolved medical needs :-) and sometimes sheer patient desperation that can make that hard, if not impossible with many patients for the foreseeable future. You will be lucky if your patients even tell you that they are using CAM, especially if they know you are a card-carrying, vocal medical skeptic.

    Might a slightly different goal help, one that adequately takes into account all the influences you are up against?

  40. nybgrus says:

    But note that your implied goal is that you MUST stop people using these methods. This is the perceived duty of the medical skeptic, and his worth is to be measured by that.

    My goal is to advise my patients as to the best possible course of action for the maximization of their health taking into account every facet I possibly can from scientific, to medical, to psychological, to financial, and anything else they may find relevant. You insinuate I’m raring to slap grandma in the face for taking gingko and seeing an acupuncturist. Nonsense. As I have said interminably – different tacks apply to different scenarios.

    To draw a parallel – imagine the earliest physicians who began to realize how bad smoking was for their patients’ health. It must have been hard to get them to quit… it is hard now and we have heaps and heaps of campaigns, laws, regulations, taxes, and education about it. Everyone knows it is killing them yet they still pay lots of good money to do it (especially in Australia where it is $18AUD+ per pack!). Can you imagine telling your patient it is bad, a waste of money, and to stop when you have all that advertising and even legit physicians claiming benefits of it?

    We changed the system and we changed the culture to making smoking uncool, disgusting, and absolutely not endorsed by the medical establishment… and incidence and prevalence of smoking plummeted. And continues to decline.

    Obviously it isn’t exactly paralell to CAM since the harms are (almost always) less and harder to detect (though wasn’t smoking pretty hard to detect the harms and prove? and it only raises your absolute risk of lung cancer by a few points at best, yet that is the major talking point, isn’t it?) But the point stands – changing the culture and education of the people made a profound change in smoking. Which, lets face it, offers placebo benefit (and non-placebo benefit) to people! It makes them feel better, more relaxed, less stressed… with nicotine to boot!

    Sheer patient desperation is always tough to deal with and I am always acutely sympathetic. But I make it a point to hone my history taking skills in order to elicit patient confidence so that when I specifically ask if they use any CAMs (and I always do) they tell me. In fact, I have had more than one “standardized patient” request to speak to me after my oral exams in order to compliment me on my interpersonal skills and completely non-judgemental attitude. I’d be willing to bet that Dr. Gorski’s patients like him too.

    So yeah, my goals to take into account all those things and it is not only insulting but downright naive of you to claim that I do nothing but re-read my comments here to my patients any time they admit to or ask about CAM use.

  41. RUN says:

    @Angora
    Do you have some of these fact sheets/webinars available to others? I hear things Oz claims, but don’t always have a chance to look up more info on it……

  42. kayyannne says:

    “That’s why one of my aims this year is to come up with ideas about how we can work to change this, because this matters, or should matter, to everyone. All of us will get sick at some point in our lives. Many of us will become seriously ill at some point in our lives, and all of us have known or will know someone who becomes seriously ill. All of us will require medical care, and many of us require chronic treatment for some condition or other. Blogging is important. Exposing quackery and medical pseudoscience is important. However, it isn’t enough.”

    I didn’t have time to read all of the comments, so I apologize if I’m putting forth an idea that has already been suggested. I’ve been thinking about this post, and I think a good idea would be for Ben Goldacre to make one of those PBS specials based on his books. You know the 2 and 3-hour long specials that they use for fundraising. He’s perfect for it, and has the enthusiasm that an audience likes. He also has his books that he can offer as a giveaway for subscribers.

    It’s just an idea that struck me, and I felt compelled to share.

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