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What’s with the new cough and cold products?

One of my earliest lessons as a pharmacist working in the “real world” was that customers didn’t always act the way I expected. Parents of sick children frequently fell into this category — and the typical vignette went like this for me:

  1. Parent has determined that their child is sick, and needs some sort of over-the-counter medicine.
  2. Parent asks pharmacist for advice selecting a product from the dozens on the shelves.
  3. Pharmacist uses the opportunity to provide science-based advice, and assures parent that no drug therapy is necessary.
  4. Parent directly questions the validity of this advice, and may ask about the merits of a specific product they have already identified.
  5. Pharmacist explains efficacy and risk of the product, and provides general non-drug symptom management suggestions.
  6. Parent thanks pharmacist, selects product despite advice, and walks to the front of the store to pay.

In many ways, a pharmacy purchase mirrors the patient-physician interaction that ends with a prescription being written — it’s what feels like the logical end to the consultation, and without it, feels incomplete. It’s something that I’m observing more and more frequently when advising parents about cough and cold products for children.

My Beautiful Baby is Sick!

New parents discover quickly that their child can instantly turn into a pint-sized “Patient Zero“, attracting what can feel like years of continuous cold symptoms. It’s true, kids get about six to eight colds per year, on average, and each can last up to two weeks. Compared to adults, colds are different in children. Runny noses are the most common symptom, and fever is frequent, too. Other common symptoms include sore throat, cough, difficulty sleeping and reduced appetite. Ear complaints are also common.

The Treatments — and the Science

While there are hundreds  of cough and cold products available, there’s actually very few differences between brands. Each manufacturer puts together their own concoction based on a small number of approved ingredients. The main differences between Benylin, Triaminic, or Dimetapp are packaging, flavouring, and marketing — the chemical ingredients are usually the same. For example, dextromethorphan is the typical cough suppressant. So a “DM” cough syrup is pretty much the same, no matter who makes it.

Cough and cold products have been sold for decades, long before rigorous proof of efficacy was required for regulatory approval. Consequently, clinical studies that support these drugs are (in general) of poor quality. When we look for studies of treatments specifically in children, the data are even more limited. Research results are complicated by different age groups, irregular dosing, lack of placebo control, and very small patient numbers.1 It turns out that the current recommended dosage for children, typically determined during clinical trials, is based mainly on expert opinion. When these products were originally approved, it was assumed that children were just “small adults” and that research in adults could be applied to children. Dosages were estimated based on ages — not weight, which would be more relevant.1

But children are definitely not small adults. Differences exist in how children absorb drugs (e.g., stomach pH) and where the drug distributes in the body (e.g., body fat percentage). Their ability to metabolize drugs can differ, too. Consequently, drugs can behave in different and unpredictable ways, compared to adults. Few studies have examined how cough and cold products behave in children, so their absorption, distribution, metabolism and elimination are poorly understood. An FDA expert advisory panel commented that it was inappropriate to extrapolate data from adults to children.2

The data may be summed up by their absence — there’s very little evidence to demonstrate these products are effective in children, and there’s some evidence to suggest that they are probably ineffective. Yet cough and cold products have a long history of use in children, with very rare reports of toxicity, usually due to inappropriate (excessive) dosing.3 In general, these drugs have a wide “therapeutic window,” meaning that large overdoses are required before serious side effects are expected.

But when you’re treating a mild, self-limiting condition with ineffective or unproven products that have a remote (but possible) risk of harm, the appropriate question should be “Why medicate?” And that’s the questions regulators around the world have been asking.

Regulatory Actions

Depending on a particular government’s policies on self-medication, and their own interpretation of the data, evaluations can differ, which I’ve pointed out before. In the case of cough and cold products in children, major regulators have all taken action to discourage their use:

  • In 2008, a Food and Drug Administration (FDA) advisory panel concluded that cough and cold products in children were ineffective and potentially hazardous. The committee recommended that they should be relabelled to indicate “do not use” in children under the age of six. Following this announcement, product manufacturers voluntarily relabelled their products to state “do not use” in children under the age of four.
  • Health Canada determined that cough and cold products should be relabelled to caution against use in children under the age of six. Products developed for this age group are no longer permitted.
  • In Australia, cough and cold products are now labelled “do not use” for those under the age of 2, and are available only with a prescription. They continue to be marketed and sold with labelling for children aged 2–12.
  • In the United Kingdom, products for children under the age of six are withdrawn. Medication for children aged 6–12 will continue to be available, with new warnings on the label.

(For those interested, here is a nice summary of actions taken by the TGA and other regulatory agencies regarding cough and cold medicines in the treatment of children.)

Remarkably, the restriction of these products may already be having an effect. A paper published this week in Pediatrics draws a relationship between the restriction of cough and cold products, and a decrease in emergency room visits for adverse events from their ingredients.

The Market Reacts

As someone who wears both a “pharmacist” hat and a “sleep-deprived parent of sick child” hat, I recognize the sense of urgency: a sick child is no fun for the parent or the child. Parents want to do something, anything, to help their child sleep/breath/stop coughing — so they head to the pharmacy with the intention of finding something to help. But what happens now that the traditional products are restricted, or otherwise labelled to caution against use?

The supplement/natural health product industry has responded quickly, bringing products to market that take advantage of regulatory double standards. In the USA, it’s the Dietary Supplement Health and Education Act (DSHEA). In Canada, it’s the Natural Health Products Regulations. As I’ve pointed out here before, these regulations reduce product safety standards, and all but eliminate the requirement to demonstrate that a product actually works. So what’s filling in the empty shelf space in pharmacies? Herbal, homeopathic and other “alternative” and “natural” cough and cold products for kids. And they’re being positioned as safe and effective alternatives for children. The Globe and Mail noticed:

When Health Canada ruled in 2008 that children under age 6 should not be given over-the-counter cough and cold remedies, it probably didn’t realize it was creating a whole new market for medications aimed at kids.

Companies that use certain active ingredients in over-the-counter medications, such as dextromethorphan (used in cough remedies) and brompheniramine maleate (used in cold meds), now must carry labels indicating they are not to be given to children under age 6.

But the recent ruling, made because there is little proof that these products work in children and evidence they can cause rare side effects or lead to overdose, doesn’t apply to makers of natural or homeopathic medicine.

Now, many of those companies are rushing to fill the void and attract a following from confused parents looking for ways to help their sick children in the wake of Health Canada’s restrictions on traditional remedies.

It’s the homeopathic remedy manufacturers that seem to be making the biggest inroads:

Boiron Canada, part of an international homeopathic company, has begun promoting several products it says can relieve cold and flu symptoms and aren’t included in Health Canada’s restrictions on cough and cold medications.

Hyland’s Homeopathic Canada, a division of U.S.-based Standard Homeopathic Co., sells a flu-care kit that it says can relieve fever, chills, aches, congestion and other symptoms in kids.

Companies selling natural or homeopathic cold and flu medications for children highlight that they offer safe alternatives to over-the-counter medications that have been restricted for use in children by Health Canada.

Boiron makes Oscillococcinum, a product of fermented duck’s heart and liver that has been diluted so dramatically (1 part in 100, 200 times in a row), that in order to consume even a single molecule of the original fermented duck, patients would have to swallow a volume of tablets greater that the mass of the entire universe. The chance of effectiveness, or side effects, with these sugar tablets is equally remote. Boiron has several other products, including Stodal, a “toxin-free” homeopathic cough syrup without any demonstrated evidence of efficacy, either.

Hyland’s Homeopathics is the company that recently announced a recall of their teething tablets — it seems they didn’t dilute the ingredients enough, and some children displayed signs of belladonna poisoning. Hyland’s offers a variety of homeopathic products intended for children — again, all without any objective evidence of effectiveness.

Conclusion

Despite a long history of reasonably safe use, there’s no evidence that traditional cough and cold products have any effectiveness in children. Mild side effects are not uncommon, and fatal side effects are exceptionally rare, but possible. Given that colds are generally mild and resolve on their own, and that no product has ever been demonstrated to have a meaningful effect on the duration of a cold, over-the-counter products, “natural” or not, are unnecessary for children. Rest, adequate fluid intake, and acetaminophen or ibuprofen for the feverish child, may be all that is required.

Homeopathic and other “natural” remedies have emerged as the only marketed alternative — not because they are effective, but because of regulatory double standards and loopholes allow the sale of these products without demonstrated efficacy (or even any medicinal ingredients at all). With the medicinal products pulled off the shelf, they’re the only game in town now. And while homeopathy is admittedly safer than restricted products, given there’s no medicinal ingredients, and they’re not effective, all you can expect are placebo effects. Are parents aware the substitute remedies are just sugar and water?

Pharmacists have some challenges to manage. They may be concerned that the “traditional” products they’ve recommended for years are gone, and embrace the new remedies, without pausing to look for the evidence. Others may rely on marketing, anectodal reports of efficacy, or just read the parent’s desire to have a product – any product, as justification for selling them. And in some cases, they may just recommend these products because it’s profitable to do so.  As a pharmacist, I admit that it’s more time consuming and less profitable to reassure an anxious parent that the cough and cold product they’re seeking isn’t necessary. But it’s far more ethically acceptable to me than to sell a homeopathic nostrum or unproven “natural” remedy that has no demonstrated evidence of efficacy, just so parents have the illusion they’re doing something to ease their children’s symptoms.

References

  1. Sime S. The Safety and efficacy of cough and cold medicines for use in children. New Zealand Medicines and Medical Devices Safety Authority. Report for the 13 December 2007 MARC meeting. Available here: [Return to text
  2. Nonprescription Drugs and Pediatric Advisory Committee Meeting. Minutes from October 18-19, 2007. Dated October 31, 2007. Available here: [PDF] Return to text
  3. Health Canada’s Decision on Cough and Cold Medicines. Health Canada. December 2008. Return to text

Posted in: Homeopathy, Legal, Science and Medicine

Leave a Comment (57) ↓

57 thoughts on “What’s with the new cough and cold products?

  1. Ken Hamer says:

    Am I missing something here? I’ve always taken “cold medicines” with the sole intention of mitigating the symptoms. I’ve never expected the products to “cure” anything. I just want to feel better while my *body* gets better.

    For “curing” colds I heartily recommend copious amounts of orange juice and white chocolate chip and macadamia nut cookies. Repeated trials have shown that a cold treated this way is gone in 7 days. Colds not treated last a full week.

  2. Amy Alkon says:

    Like Ken, I take cold medicines (Mucinex during the day, Benadryl at night most recently, when I had a cold accompanied by sore throat and stuffed nose) not to “CURE” the cold but to mitigate the symptoms.

  3. Reductionist Nurse says:

    I used to work in the health dept of a local grocery store. Many times I saw people select the Sleep Aid medicine and I would politely point out that the active ingredient Diphenhydramine hcl was the same as the big bottle of benadryl but at most half the price.

    I also saw people pick up the airborne and I would caution them to check the active ingredients and suggest a couple vitamin pills for a fraction of the cost as well.

    In both cases my advice was always ignored by stubborn older women who knew exactly what they wanted, which was to spend more money rather then think for 10 seconds.

  4. kongstad says:

    I guess it must be a cultural thing.

    In Denmark there are almost no cold remedies, besides cough syrup, but most people I know of know that cough syrup doesn’t actually work.

    As the father of to children, the youngest 4 months, I’ve had the doctor on the phone a couple of times, trying to get her OK for giving paracetamol for my feverish child (not at four months, older), to help him fall a sleep, I’ve administered it a couple of times even when the doctor I got hold of advised against it.

  5. Nescio says:

    Ken and Amy, I think the point is that many of the older products do not mitigate the symptoms as they are claimed to, or at least there is no scientific basis for the claims that they do, in children or in adults. The perception that they do may be largely due to the placebo effect. The same may be true of decongestants like phenylephrine.

    I suspect that it is the sedating effect of these products, certainly diphenhydramine and perhaps dextromethorphan, that account for their popularity. Giving these products to children might be considered the modern equivalent of giving them laudanum or brandy.

  6. Ken Hamer

    “Am I missing something here? I’ve always taken “cold medicines” with the sole intention of mitigating the symptoms. I’ve never expected the products to “cure” anything. I just want to feel better while my *body* gets better.”

    My understanding from the article as well as discussions with our pediatrician is that there is very little evidence that children’s cold medicine provides symptom relief to children. There is some evidence that it does not provide symptom relief. Conversely there is an increased risk of dosing errors, accidental poisoning, ER visits when children’s cold medicine is used.

    Scott Gavura
    As a parent, I really sympathize with the parents in the article. It feels surprisingly awful to hear your child hacking away and not sleeping, then of course there are the really bad coughs where they cough until they vomit. It’s just not good. My pediatrician really had to be quite firm with me in advocating to not use CCM. I believe that phrase that sticks in my mind was “We have seen some bad outcomes”. It also helped that she offered some specific home remedies, that really do seem to help the cough and don’t have the same risks as CCM*.

    Have a (cold) humidifier in the room with the child. Offer warm drinks with honey and lemon (That one didn’t work, can’t get them to drink it.) Take them into the bathroom and run a hot shower to to create a steam room.

    Just from experience I’ve also found freeze pops and knox chicken soup helpful.

    Just my opinion, but I think if you are communicating with a parent who has a child with a bad cough cold you will have more luck if you can tell them something to do or buy to help the problem symptom. If they have come into a pharmacy they are expecting to buy something to help their child. Better to sell them a humidifier or some freeze-pops saying “These are the best things I know for a cough. They are what I do for my children.” Than to suggest they go home and wait it out or use their own sugar and water. I will admit, this may sound unduly crass. It’s probably my retail/e-commerce past speaking. Also, some people response surprisingly well when given an explanation for a home remedy. “The water in the freeze-pop hydrates the throat, the cold is soothing, etc.” But perhaps I am being presumptuous and all they tactics are already being used. (Sorry for that, if so.)

    A side note – even in sleepless child-cold induced desperation, I have not knowingly used homeopathy on my child. Even aside from knowing the basic science doesn’t work, I don’t like the safety standards for the industry. I don’t feel that I know what is actually in the product. The belladona incident would be an example of that.

    Now it’s time for me to search up the pediatrician phone number and try to get an appointment. My child has a fever and sore throat and I must do something about it. :)

  7. Oh shoot, sorry for the extensive italics, I must have forgot a

  8. doh – I must have forgot a .

    …she walks away feeling foolish.

  9. hat_eater says:

    Some really old folk remedies, like spitting on a white stone or tying a red ribbon to the cot had the unintended but beneficial effect of soothing the parent without harming the child. Today, we need pills and syrups for that. I’ve found that some plant extract syrups (Pinus, Plantago) seem to work (in soothing the parent) and have no known adverse effects. And kids like them to boot. I remember I loved them as a child. They still bring fond memories.

  10. Dr Benway says:

    I guess it must be a cultural thing.

    In Denmark there are almost no cold remedies, besides cough syrup, but most people I know of know that cough syrup doesn’t actually work.

    Vikings fight colds with the power of their own awesomeness.

    But seriously, I think you’re right about the “cultural thing.” Humans have overcome superstitious thinking many times before. A more rational response to some problem just needs to become widely accepted as the normal thing to do. Sure, there will always be some with OCD or whatever who need moar superpowers. We can probably live with that.

    Too bad marketing professionals don’t have any professional standards against reinforcing popular yet false beliefs.

  11. While your article makes some good points I think it is rather confusing that keep using using the terms cough and cold medicines rather then the actual ingredients.

    Later in the article you do state that acetaminophen or ibuprofen can be used for fever, but I think its way too late, they have already been lumped in as questionable with all the other cough and cold remedies.

    It would be a far more interesting article to look at each ingredient and to explain the current research (or lack thereof) on effectiveness.

    I’m sure we’ve all heard by now that DM isn’t as effective as it once was against most coughs. But what about psuedoephedriphine vs phenylephrine, Diphenhydramine, Guaifenesin, codeine cough syrup, etc.

    I know you are trying to make a point about over medicating your child, but I think you’re missing the bigger opportunity to educate the readers about what really is effective and what isn’t. If somebody is reading this blog I think they already buy their medications based on what the active ingredients are rather than a brand name.

    1. Scott Gavura says:

      Fair enough, but a thorough review of the major “traditional” ingredients is a post in itself. Luckily, I’ve already done one, here.

    2. Scott Gavura says:

      @Benjamen:

      Fair enough, but a thorough review of the major “traditional” ingredients is a post in itself. Luckily, I’ve already done one, here.

  12. Grimalkin says:

    I’m currently pregnant. About a month ago, I caught a cold. It started about halfway through my workday and I was caughing and sneezing like crazy and feeling pretty miserable. When I announced that I seemed to be getting sick so I would go home to get some rest, I encountered what seemed like an endless line-up of co-workers feeling sorry for me because I’m pregnant so I “can’t take anything.”

    I grew up in a family where the strongest medication you could expect when sick was a TV and a warm blanket. I hadn’t even heard of cough syrup (in a non “teenagers getting drunk without having to buy real booze” context) until about two years ago when I had a really bad cough that just wouldn’t go away and my doctor recommended that I try it. So I went to the pharmacy and asked for a recommendation and bought what was suggested. I gave it two good tries but found that it tasted horrible and really wasn’t mitigating my cough at all (it actually made it worse for the half-hour or so after I took it), so I tossed it. I very rarely take anything like aspirin either, prefering to lie down for a bit if I have a headache…

    So it was rather surprising when it was assumed that I would be experiencing some great suffering because I wasn’t able to take something that I had never bothered to take anyway. I just did precisely what I always do: went home as soon as symptoms started, bundled up under my warmest blankie, and lay in bed watching TV and drinking juice/tea until I started to feel better. As a general rule, I don’t go back to work until a full day _after_ I feel like I could go back to work. It’s never taken me longer than 3-4 days to shake a cold and this time, like every other time, I was miserable but I got through it and caught up on all the movies I’ve been wanting to see.

    It’s definitely a cultural thing, because I’ve been getting two messages since I came to North America: 1) All symptoms, even the perfectly bearable ones, must be medicated, and 2) Whatever you do, don’t use vaccines or antibiotics because these are evil and will kill you. I grew up in a culture that went in the exact opposite direction: I always had all my vaccines and I’ve kept up with all my boosters (I still have/use the vaccine tracker the hospital gave my mom when I was born so I can make sure I know exactly what I’ve had and what I need), and I don’t mess around with not taking antibiotics if I need them. But for the rest, I really have to be close to death’s door to bother taking anything.

  13. lizditz says:

    Seattle Mama Doc has a post on the safety and efficacy of Vicks Vapor Rub to treat congestion etc. in children over 2. The discussion is good too — SMD’s mom even chimes in.

    If I were a pharmacist I might work up some handouts:

    For children under one: effective, safe home treatments for colds and runny noses (ie, don’t use honey or Vicks’, upright sleeping, cold vapor, hydration suggestions)

    For children over one but under two: effective, safe home treatments for colds and runny noses (ie, don’t use Vicks’, but do use use honey for coughs; upright sleeping, cold vapor, hydration suggestions)

    For children over two: effective, safe home treatments for colds and runny noses (use Vicks’ (and som how-tos, like on the back but not on the chest) do use use honey for coughs; upright sleeping, cold vapor, hydration suggestions)
    For children over two: effective, safe home treatments for colds and runny noses

  14. hippiehunter says:

    Number 5. Unethical pharmacist suggests homeopathic remedy for child. ( In my town every pharmacy sells watereopathy)

  15. lizditz – Oh, I forgot the vicks rub. I am a big fan of it for colds, for myself and my children (both over 2).

    On the other hand, I thought the plug-in vicks vapor thingies were awful. They seemed to have some chemical smell that aggravated my asthma, this could be a individual sensitivity, though.

    Dr Benway – Interesting thought regarding culture and rational thought. It makes me wonder what actions could be taken to lead a culture in that direction.

    “Too bad marketing professionals don’t have any professional standards against reinforcing popular yet false beliefs.”

    Having worked with marketing people I can assure you that many (not all) have a professional standard that they must take advantage of popular beliefs of any kind to sell the clients product. If there is not a popular belief handy, they will create one.

  16. maxwellsdemon says:

    I’m curious as to how effective the typical cold/cough OTC drugs are supposed to be for adults. I’ve never found them particularly useful for alleviating symptoms, myself, and I’ve wondered if I’m just weird or if they’re not particularly effective for anybody.

  17. Thanks Scott! I’ve added Science-Based Pharmacy to my RSS reader.

  18. Stuartg says:

    It’s not only pharmacies where the scenario plays out!

    Parents often bring their child to Emergency with coughs and colds because their family doctor (correctly) didn’t prescribe.

    I’ve seen doctors there spend over 30 minutes explaining that medications have not been shown to be effective in coughs and colds in children, that the best approach can be just cuddles and distraction. I’ve also seen those parents leave dissatisfied because they did not receive a prescription.

    Presumably the third stop is the pharmacy for over the counter medications.

    Thanks for the different viewpoint.

  19. ConspicuousCarl says:

    This is normal human behavior, and not just when people have sick kids. Try selling computer or radio equipment to people who think they know what something is going to look like before they even know what it is going to be.

    In a way this makes sense for simple things. You can’t go out and look for something without first forming a search image of what you are looking for. But once the subject forms a search image (such as a wire with a plug on the end, or a pill in a box), they are on a quest to find that item, not on a quest to get advice. When the person looking for something doesn’t actually know exactly what they need, they end up in this weird position in which they demand advice while also being certain to some degree that they know what they need.

    It would make more sense to go out seeking solutions or advice to achieve a specific goal rather than seeking a pre-imagined object, but for whatever reason it seems like we just aren’t structured for that. I think this is one of those cognitive biases which are always with us even when we are trying hard not to do it, so it should be no surprise that “average” people are especially bad when under stress or the influence of customary practice.

  20. B Hitt says:

    The fact that there is nothing in the world known to prevent a cold or shorten the duration of one is something that really needs to be more widely known in the public. People could avoid wasting a lot of money and effort.

    The OTC cold products are one thing, but the more pernicious and all too common manifestation of the “but I need something” type of bad thinking is people demanding antibiotics from their doctors and the doctors who oblige. That’s a public health powder-keg. My father-in-law (a hospital administrator) takes a course of Z-pak (azithromycin – heavy artillery, approximately $infinity a course) that he gets from one of his not-so-evidence-based doctors every time he sneezes or has a scratchy throat, and hands them out like candy to family members. I’m trying to get him to stop doing that and he seems receptive, but his thinking is “when you run a shoe store, you and your family get all the best shoes for free, so when you run a hospital . . .”

  21. lizditz says:

    MicheleinMichigan

    I thought the plug-in vicks vapor thingies were awful.

    I wasn’t thinking of those (it was probably the camphor that made you wheeze) but either the steam humidifiers (produces hot moisture) or the ultrasonic humidifiers (cool mist; many people with asthma prefer)

    I was prone to croup as an infant and through elementary-school age. By the age of seven I knew to get myself in the shower & then stay in the steamy bathroom when I awoke in the night.

    Very small n case observations: today’s young parents (study participants* are all college educated) lack practical nursing skills, such as dealing with croup; soothing a snotty, congested baby; preventing diaper rash; and dealing with minor injuries.

    I’m not sure how to ameliorate this situation.

    —–
    *my children and their friends with children. N= about 10

    1. Scott Gavura says:

      OK from a quick scan of the above, follow-up requests include:
      - A review of the effectiveness and safety of “traditional” (i.e., medicinal) cough and cold products in adults
      - A review of the effectiveness and safety of Vick’s Vapo-Rub in all age groups
      - A review of the safety of all of the above in pregnancy and breastfeeding.

      Did I miss anything?

  22. Dr Benway says:

    Very small n case observations: today’s young parents (study participants* are all college educated) lack practical nursing skills, such as dealing with croup; soothing a snotty, congested baby; preventing diaper rash; and dealing with minor injuries.

    Probably a side effect of modern mobility. Fewer grandmas, aunts, and other extended family informally passing on useful guidance.

  23. pmoran says:

    While no one wants to foster a “treatment-is-always-needed” attitude in the public, it is big leap from that to “you will feel no different whether you take any treatment or not”.

    That is not even a wholly sustainable scientific position on present evidence. People DO seem to feel better for “taking something”. Being “treated” probably also often satisfies deep human needs, ones beyond the mere relief of symptoms.

    The sheer size of the market for DIY and “alternative” medicine should be a warning that there are powerful forces afoot.

    One of those will certainly be the psychological gulf between — you know — the rather cool, sciency, working-better-than-placebo, “we know best” style of medicine, and the warm, nurturing, “take this and you will feel better”, patient-focussed one, one that is more validating of their self and their suffering –i.e. all such seemingly wishy-washy but potentially highly influential matters.

    Those who think it is easy to combine the best of the two approaches have probably never worked in general practice (or a pharmacy?).

    In fact, we now know that medical practices have themselves been responsible for a huge amount of this supposedly unnecessary medical activity, and still are. We have also observed how the mainstream’s possibly too rapid retreat into a (selectively) more science-based shell has been accompanied by a substantial upsurge in all alternative forms of medical care.

    The forces for rationality should be able to shape this massive medical consumption and keep it safer, but gee, let’s make sure we fully understand it before settling upon comfortable, simplistic characterisations of it. Otherwise we will be tilting at windmills of our own creation and expecting that to impact upon the real world.

    You might expect homeopathy to have died out well before now if all conventional medicine had to do was point out that it can’t do anything.

  24. Dr Benway says:

    pmoran, homeopathy, naturopathy, and chiropractic were declining up until Wilk v AMA and DSHEA.

  25. Harriet Hall says:

    I wrote about the option of not treating. See http://www.sciencebasedmedicine.org/?p=126

    It’s possible to say we can’t do anything to change the course of the illness but still to offer safe comfort measures and human sympathy.

  26. pmoran says:

    Dr Benway: pmoran, homeopathy, naturopathy, and chiropractic were declining up until Wilk v AMA and DSHEA.

    What are you suggesting? It’s a big world, and most of it would never have heard of either of these.

    People are doing what they are programmed to do, whether we like it or not. We may be able to influence the programming over time, but probably only in a major way if we are able to come up with more, and better, evidence-based solutions for their medical expectations. Until then it is not obvious how far any authority can extend over public treatment choices.

    In the meantime conventional medicine’s influence is entirely dependent upon public trust. That is a precious resource — it may need some nurture, in more senses than one.

  27. pmoran says:

    Harriet: “I wrote about the option of not treating. See http://www.sciencebasedmedicine.org/?p=126

    It’s possible to say we can’t do anything to change the course of the illness but still to offer safe comfort measures and human sympathy.

    I suppose “safe comfort measures” is what we are talking about once we eliminate inactive or unsafe pharmaceuticals. Can we not let the public choose their own, with some guidance broad controls?

    I am sure you would be a great doctor, better than I ever was, as when you are in the thick of it all in solo practice there are some things you never get the opportunity to learn.

    One thing I did learn from specialist practice is that no kind of medicine suits all. The down-to-earth, plain spoken, strictly EBM style practitioner attracted the equally down-to-earth, rarely complaining, at death’s door before going to the doctor, country folk from our surrounds.

    The “give the patient whatever they want”, prescribe a lot, investigate a lot, refer a lot kind of doctor attracted a different kind of patient altogether, that I will not attempt to desccribe as anything I said would look judgemental in comparison. You will know what I mean.

    I guess I am merely warning against trying to squeeze all of medicine into too restrictive a mould. There are very different needs out there.

  28. Dr Benway says:

    What are you suggesting? It’s a big world, and most of it would never have heard of either of these.

    There are two components to the alt med movement: human weakness and cons taking advantage. We can’t stamp out worry and wishful thinking, but we can hold health experts accountable to reasonable scientific standards.

    Well unless …

    - scientific standards can be refraimed as barriers to fair trade, effectively making it dangerous for doctors to call out quacks.

    - cons can sell pills without the expensive hard work needed to prove benefit

    - cons are allowed to become billionaires and so can force legislation that favors Oprah, Bravewell, and the Huffington Post –even within our medical schools.

    - doctors like David Gorsky and Stephen Barrett get fair gamed for simply writing about any of the above.

  29. Dr Benway says:

    pmoran, the “true” placebo effect that you distinguish from regression toward the mean, confirmation bias, natural course of the illness, and other non-specific confounds, has to do with the patient’s expectation of benefit from the therapy, if I understand you correctly.

    Well, that expectation arises from the public’s belief that doctors base their recommendations upon good science rather than just making stuff up.

    The public are aware that medicine saves lives. And they see the power of scientific investigation bringing things like the Internet and satellite communications. In comparison, magic and faith healing look like chumps.

    We can trade on that confidence. We can intentionally provoke an expectation of benefit and, if we’re lucky, the patient’s subjective sense of relief with be followed by genuine improvement in their condition, thanks to any of those non-specific confounds. But if we start using inert therapies regularly, the public will eventually catch on and that wonderful placebo response will gradually extinguish.

    tl;dr: honest docs provoke the best placebo responses.

  30. JMB says:

    I always thought there there were specific indications for the common over the counter symptom relievers. Of course, part of my idea was that by giving instructions on when the medicine was necessary, that I could divert the parent from administering medicine willy nilly to the child. For decongestants, I would instruct parents on symptoms of a sinus or ear block, and complete nasal block, and tell them that was when the decongestant was helpful (not just for a runny nose). For cough medicine, I would tell them only use it if the child was crying because of pain or vomiting resulting from repeated coughing. Since I was working the ER, it was rare to actually receive follow up, so it was hard to know if the education had any success in convincing parents don’t give the child a decongestant just because they have a runny nose. At least I didn’t get called to the commanders office for complaints because I would not prescribe medicine (which I did on occasion, especially antibiotics).

    I am out of my specialty here, so I can’t defend my rationale (other than CYA from the commander). At least for some, I think it reduced the administration of medicine to a child for cold symptoms. Only a small percentage of children suffering from a viral upper respiratory infection will actually experience those symptoms, and for that subset, decongestants or cough suppressants might be beneficial. So it was kind of a trick to get the commander off my back, but also try and convince the parent that the child probably wouldn’t need the medicine.

    I could never figure out such a strategy for antibiotics, and I just bowed to the pressure to give them out. Ironically, I eventually ended up on the other side of the patient doctor relationship on the issue of antibiotics for sore throats.

    I gave an infant mouth to mouth resuscitation for a respiratory arrest, and an anesthesia resident did as well. The infant was resuscitated, but in the next 24 – 48 hours both the resident and I became sick with sore throats. I passed out, hit my head, and was unconscious for about 30 minutes. So I ended up hospitalized on the VIP service (since I was on the faculty). The resident taking care of me checked the infant’s cultures, cultured my throat, and put me on antibiotics based on the culture and sensitivity results of the infant. He even checked with the anesthesia resident (who was staying home from work, but already on antibiotics). I was getting better fast until my culture results came back negative, and the professor emeritus in charge of my care discontinued the antibiotics. Well I got out of the hospital fast and got my own antibiotics, and that was the end of it. So you can say I got a dose of my own medicine of trying to be a purist (although I don’t know why the professor emeritus would have ignored the history, or for that matter, didn’t order a CT head for being unconscious for 30 minutes after striking my head).

  31. regarding placebo effect and CCM

    I would think that some symptoms are more prone to placebo effect than others. From personal experience (with my children*), the dreadful hacking at night at the end of a cold does not seem placebo prone. I’ve never noticed that a nose that is completely blocked was improved by anything other that something that is directly effecting the symptom (a hot steamy drink, a decongestant, etc).

    Perhaps with CCM and homeopathy we are talking more about placebo by proxy (sorry, I made that up, not sure of the standard word). The parents feel better because they have done something.

    *a very small sample for research purposes. :)

  32. “Very small n case observations: today’s young parents (study participants* are all college educated) lack practical nursing skills, such as dealing with croup; soothing a snotty, congested baby; preventing diaper rash; and dealing with minor injuries.

    I’m not sure how to ameliorate this situation.”

    In addition to Dr Benway’s explanation, I would add a couple potential reason for this. Young parents* today probably come from families with fewer siblings, so less opportunity to see parents care for a variety of childhood complaints and less demand to help out with those complaints.

    Also, I read an interesting book a while back on how the upsurge in parenting advice (books, media, etc) has undermined the benefits of the traditional older generation teaching younger generation parenting approach. I have seen this at play in the attachment parenting forums, where it seems new attachment parents are convinced that everything that their parents did must have been wrong. :) But, I don’t know that I completely bought into the author’s idea. I think a certain amount of inter-generational power struggle is traditional. :)

    *being an older parent of young children, I’m not sure where I stand in the nursing parenting skills continuum.

  33. pmoran says:

    Dr Benway: honest docs provoke the best placebo responses.

    I’d like to think so, too, but that is a “belief of comfort” not an evidence-based one. All the evidence suggests otherwise, that some form of manipulation of patient perceptions is required and at minimum the exploitation of prior patient conditioning. Is this “lying to the patient” , or a “mutually beneficial collusion”? And what is it when the patient himself seeks it out?

    Some of the apparent placebo response is reporting bias, so we don’t know how much is “real”. I am merely saying that if we profess to be science-based we have to allow certain critical questions the leeway that the science permits – also, that if we in the mainstream don’t have an answer to a medical need it is dog-in-the-mangerish to deny patients the possibility of even minor comforts elsewhere.

    If we are merely against fraud in medicine, and people becoming millionaires through quackery, let’s call ourselves something else, and discuss the at least equally notty problem of how to distinguish between conscious fraud, delusion and “true belief” within quack medicine promoters.

    And Dr Gorski and Dr Barrett get trashed partly because the song they sing is discordant with many people’s intimate experiences and beliefs. Some of that is inevitable if we want to support good science and effective medicine, but in at least Dr Barrett’s case they are also reacting to a “let’s stamp all this nonsense out” subtext (Recall the lost court action against the homeopathic firm), which even the more moderate elements of CAM thinks is going too far. In consequence Barrett’s web site is shunned by some of the people who might most benefit from it.

    Is there a better song? – let’s go to the actual evidence and see if there might be.

  34. pmoran says:

    Me:“Some of the apparent placebo response is reporting bias, so we don’t know how much is “real”.

    This might confuse, after following Dr Benway’s correct reference to many other confusing elements in assessing patient outcomes.

    I am not talking here about the “apparent placebo responses” wihin the placebo arm of placebo-controlled drug trials where spontaneous evolution of symptoms and other artifact can feed into the results.

    I have in mind studies specifically designed to elicit placebo responses, i.e. comparing placebo with a non-placebo state.

    With subjective conditions, there is always a response, but are the subjects really better, or just saying they are better?

  35. We would never give our kiddos anything homeopathic, but I know how desperate parents can become.

    Here’s how the trajectory plays out at our house in Geographic Isolation. (Where there are no weekend clinics. The choices are: ER and a mortgage-sized insurance co-payment or suck it up.)

    Friday all day-1700: toddler is rowdily fine
    Friday 1710: whining, lethargy
    Friday 1800: whining, lethargy, lack of appetite, slight fever, must be held every. singe. moment.
    Friday 2200: sobbing, concerning fever, cough, congestion, child is a barnacle.
    Tylenol and vaporizer are no help.
    Friday 2359: she is sleeping finally–noisily. On my shoulder standing in a hot shower. Shower water begins to cool….

    Saturday: (see Friday 1710-2359) still feverish plus extreme ear pain along with the above symptoms. Still giving Tylenol for fever and pain, also doing some driving around so child can sleep while the water heater recovers.

    Sunday 0900: same as Saturday except that the muscles around my left eye are twitching uncontrollably. We run out of coffee beans on this day.

    Monday 0830: call pediatrician who can barely hear me. My toddler looks and sounds like a spider monkey clinging to me.
    Monday 1300: visit pediatrician who prescribes something wonderful called Rondec, which is a decongestant/cough medicine. Everyone then gets good sleep and well-rested parents are more capable of caring for the recovering child.

    We treat Rondec like liquid gold and hoard the leftovers for some other weekend storm. This cold/congestion scenario is not uncommon, and we find that if we can decongest early on and thin the secretions, our children are shockingly more comfortable and everyone can rest.

    Is there some type of decongestant available OTC for toddlers? Is this what regulators pulled from the market? A safe decongestant alone might steer many parents away from snake oil.

  36. Dr Benway says:

    If we are merely against fraud in medicine, and people becoming millionaires through quackery, let’s call ourselves something else, and discuss the at least equally notty problem of how to distinguish between conscious fraud, delusion and “true belief” within quack medicine promoters.

    It’s the fraudsters and theocratic ideologues using healthcare as a wedge strategy that bother me the most. I’m particularly sick of the CCHR propaganda –e.g., “psychiatry: an industry of death.” But I think the DAN! doctors are even worse. Some are on faculty at good med schools. Ugh.

    Really good cons seem to believe their own bullshit. For people like LRH, Trudeau, Mercola, Adams, Holford, Hulda Clark, Gary Null, etc., it’s a waste of time trying to sort which part is delusion and which part is conscious fraud. The distinction has no meaning to them, and that’s their problem in a nutshell.

  37. Dr Benway says:

    And Dr Gorski and Dr Barrett get trashed partly because the song they sing is discordant with many people’s intimate experiences and beliefs.

    I think Tim Bolen is a more proximate cause. And behind him, I reckon it’s the Super Adventure Club –long-time friends of Hulda Clark.

  38. David Gorski says:

    Is there a better song? – let’s go to the actual evidence and see if there might be.

    So, what is the actual evidence?

  39. Draal says:

    Their ability to metabolize drugs can differ, too. Consequently, drugs can behave in different and unpredictable ways, compared to adults.

    I find that statement interesting. Can someone elaborate with a few specific examples? I’ve specialized in metabolic engineering of microorganisms so how metabolic networks differ is an interest of mine.

    1. Scott Gavura says:

      I find that statement interesting. Can someone elaborate with a few specific examples?

      @Draal:
      You can start here, and here.

  40. pmoran says:

    Dr Gorski: “So what is the actual evidence?

    Thanks, David – I certainly should be challenged – I admit I am still feeling my way here.

    At the time I had in mind the evidence relevant to placebo potential. This IS a key matter. The “zero benefit” that we sceptics like to feed into risk/benefit equations for CAM needs work. It applies often, of course, but not so clearly to many common relatively benign clinical settings. We must be sure of our ground on this.

    There are even more complex considerations. I have suggested that we sceptics can easily come across as wanting to obliterate CAM from the face of the earth, not minding if the odd personal freedom or value gets knocked about a little in the process. This inflames paranoia within CAM circles and elsewhere.

    Is that our objective? I can’t speak for others but I suspect that most, like me, don’t yet have any clearly defined, realistic objectives. We just know that there are a lot of aspects to CAM that we personally find intolerable and that’s why we’re here.

    Thus it is that for the entire duration of this blog visitors would have had to try and deduce our ultimate intentions from the nature of the articles, the comments, and the modes of expression that go unchallenged.

    Surely, then, they will have the impression that most of us see CAM as an entirely useless, somewhat pathological, utterly disposable aspect of human behaviour.

    Is that how we see it, and if so, is that in accord with all the evidence relevant to the phenomenon?

    For starters I would point out that a medicine of sorts flourished and was highly valued for probably hundreds of thousands of years despite having few really effective treatments. Over this period placebo-related behaviours would have evolved. Should it be any surprise that the same kind of medicine can still flourish, mainly in those areas where conventional medicine remains frustratingly weak?

    Why is this not to be seen as a healthy, entirely expected, even helpful in small ways and certain niches, social response to medical need?

    Remember it only looks bad because of some very recent developments in medicine. We now have some very good treatments for many conditions, making it tragic when simple folk make wrong choices. The fraudster is more obvious now, because of recently acquired scientific knowledge, methods and norms, which in turn serve to provide more reasons for tearing our hair out over silly CAM notions.

    Yet we probably can’t stop any of these entirely, whatever we do or say.

    How does that look to you? What kind of voice and what objectives might such an admixture of considerations support?

  41. pmoran,

    My granny used to put a teaspoon of cider vinegar into a cup of hot water and drink it in case it helped her arthritis. I can’t see anyone wanting to make that illegal.

    It’s people selling stuff and lying about what it can do that I have a problem with. Fraud might never be completely eliminated, but that’s not a reason not to make it illegal. (See also, Murder.)

  42. Pmoran, another factor is how some CAM proponents’ identities seem to be wrapped up in how hard they reject science-based medical treatments. In my opinion, the culture that rejects science and embraces CAM has increased in extremism over time. There is a world of difference between cider vinegar and chemically castrating children in a misguided and unsupported attempt to treat autism.

  43. Fifi says:

    Anthropologist Underground – “…another factor is how some CAM proponents’ identities seem to be wrapped up in how hard they reject science-based medical treatments. In my opinion, the culture that rejects science and embraces CAM has increased in extremism over time.”

    Unfortunately, this is a human/cognitive thing and not something specific to CAM proponents. The same thing can sometimes happen with people who consider themselves “skeptics” or supporters of SBM, and also with some doctors who take on SBM or being “more scientific than you” as their personal identity (or a symbol of their perceived superiority). Bill Maher is a good example of someone who sees themselves as a skeptic but is really more of a contrarian (a bit like Christopher Hitchens, who is a great writer but also heavily invested in ideologies). I totally enjoy a talented contrarian writer or performer but they are what they are, not what they want to believe they are and want us to believe they are. Anyone who thinks they’re rational and everyone else’s perspectives are emotional, clearly doesn’t actually understand how the mind works.

    The Edge did a great rundown of some of the biggest scientific “got it wrongs” and this very thing turned up (along with all kinds of other very interesting historical and not so distant scientific beliefs that have been overturned, which is no smear on science, it’s just how it works)…

    http://edge.org/3rd_culture/thaler10/thaler10_index.html#deutsch

    GEORGE LAKOFF
    Cognitive Scientist and Linguist; Richard and Rhoda Goldman Distinguished Professor of Cognitive Science and Linguistics, UC Berkeley; Author, The Political Mind

    Enlightenment Reason and Classical Rationality have been shown over and over in the cognitive and brain sciences to be false in just about every respect. Yet they are still being taught and used throughout the academic world and in progressive policy circles. Real human reason is very different.

    Here are the claims of enlightenment reason, and the realities:

    *

    Claim: Thought is conscious. But neuroscience shows that is about 98 percent unconscious.
    *

    Claim: Reason is abstract and independent of the body. Yet, because we think with our brains and thought is embodied via the sensory-motor system, reason is completely embodied.
    *

    Claim: Reason can fit the world directly. Yet because we think with brain structured by the body, reason is constrained by what the brain and body allow.
    *

    Claim: Reason uses formal logic. In reality, reason is frame-based and very largely metaphorical. Basic metaphors arise naturally around the world due to common experiences and the nature of neural learning. The literature on Embodied cognition has experimentally verified the reality of metaphorical thought. Real human reason used frame-based and metaphor based logics.
    *

    Claim: Emotion gets in the way of reason. Actually, real reason requires emotion. Brain-damaged patients who cannot feel emotion don’t know what to want, since like and not like mean nothing to them and they cannot judge the emotions of others. As a result they cannot make rational decisions.
    *

    Claim: Reason is universal. Actually, even conservatives and progressives reason differently, and evidence is pouring in that one’s native language affects how one reasons.
    *

    Claim: Language is neutral, and can fit the world directly. Actually language is defined in terms of frames and metaphors, works through the brain and does not fit the world directly. Indeed, many of the concepts named by words (e.g. freedom) are essentially contested and have meanings that vary with value systems.
    *

    Claim: Mathematics exists objectively and structures the universe. Mathematics has actually been created by mathematicians using their human brains, with frames and metaphors.
    *

    Claim: Reason serves self-interest. Partly true of course, but to a very large extent reason is based on empathetic connections to others, which works via the neuron systems in our brains.

    Given the massive failures of enlightenment reason, widely documented in the brain and cognitive sciences, why is it still taught and widely assumed?

    First, it did a great historical job back in the 17th and 18th centuries in overcoming the dominance of the Church and feudalism.

    Second, it permitted the rise of science, even though science doesn’t really use it.

    Third, unconscious mechanisms like framed-based and metaphorical thought are mostly not accessible to consciousness, and thus we cannot really see how we think.

    Fourth, applications of formal logic have come into wide use, say in the rational actor model of classical economics (which failed in the economic collapse of 2008).

    Fifth, we are taught enlightenment reason in our schools and universities and its failure is not directly taught, even in neuroscience classes. Seventh, most people just think and don’t pay much attention to the details, especially those that are not conscious.

    Much of liberal thought uses enlightenment reason, which claims that if you just tell people the facts about their interests, they will reason to the right conclusion, since reason is supposed to universal, logical, and based on self-interest. The Obama administration assumed that in its policy discourse, and that assumption led to the debacle of the 2010 elections. Marketers have a better sense of how reason really works, and Republicans have been better at marketing their ideas. The scientific fallacy of enlightenment reason has thus had major real-world effects.

  44. Draal says:

    “@Draal: You can start here, and here.”

    So the metabolic rates can differ with age (but the metabolic pathways do not). There’s a bit of a difference in how I typically use the word “metabolism” that had me confused with your original statement.

    The classical biochemistry textbook* defines metabolism as follows: “Metabolism is essentially a linked series of chemical reactions that begins with a particular molecule and converts it into some other molecule or molecules in a carefully defined fashion.”
    * J.M. Berg, J.L. Tymoczko, and L. Stryer. Biochemistry, fifth edition. W.H. Freeman and Company, 2002.

  45. Fifi – nice link – I forward to checking it out more thoroughly when I have time. Your comment on reason just blew my mind*, very interesting perspective, Thanks.

    *sorry, the surfer’s vernacular just seems to be the best description. :)

  46. Draal,

    The confusing OP statement is as follows: “Differences exist in how children absorb drugs (e.g., stomach pH) and where the drug distributes in the body (e.g., body fat percentage). Their ability to metabolize drugs can differ, too. Consequently, drugs can behave in different and unpredictable ways, compared to adults.”

    I don’t read “ability to metabolize drugs can differ” as exclusively (or even primarily) meaning “use entirely different metabolic pathways.” A toddler’s ability to walk differs from mine. That means they are slower,* have less endurance and more spontaneity; it doesn’t mean they fly.

    Differences in rates can certainly mean different outcomes. If starting product A participates in two pathways that convert it into either B or C, differences in metabolic rates between two individuals could make the difference between one ending up with lots of B and the other ending up with lots of C, even if the pathways they use are identical.

    Some painkillers used by humans are not prescribed by vets for dogs. They have the exact same effects and side effects, just in response to different amounts of drug. If I take X amount of drug per kilo it will relieve my pain; if I take 100X amount it will kill me. For a dog it’s reversed. X amount per kilo will kill it, while it would take 2X amount to relieve its pain. Not a good trade-off for the dog. (See http://logloglog.com/archives/2005/04/basket-2.html) One wouldn’t need to posit completely different metabolic pathways between dogs and humans to explain this; it could be a question of pathways operating at different rates. (I don’t remember which drug it was, so different pathways might also be involved in this example.)

    *Ok, “slower” might not always feel like the right word in this context.

  47. Draal says:

    “I don’t read “ability to metabolize drugs can differ” as exclusively (or even primarily) meaning “use entirely different metabolic pathways.” ”

    Like I said, it’s a matter of what definition is used. Different fields of study have their own jargon even if the word(s) are identical. So from my training, I read that statement different than you. And I’d didn’t say “use entirely different metabolic pathways”, now did I? Rather gene expression may be active for an infant and inactive for an adult which can lead to a new metabolite.

    I’m aware of competing pathways and differing expression levels of enzymes (particularly P450s) can lead to different levels for those of different ages. And that’s how something can be toxic for an infant (say, much lower clearance rate of a drug and/or it’s metabolites) but the pathways are still the same.

    I did come across one example were an infant has a particular enzyme expressed but adults do not which led to a

  48. Draal says:

    “Some painkillers used by humans are not prescribed by vets for dogs.”

    Animals also do not “complain” about the side effects and that’s why tylosin is used by vets but not physicians.

  49. pmoran says:

    @Fifi: I am not sure that neuroscience is a mature enough area of human knowledge to tell us a lot about how our minds work, and using the methods of science to undermine the validity of the knowledge they yield elsewhere seems a bit weird.

    Nevertheless, when given free reign, as they usually are , there is no doubt personal mind bents can lead us astray.

    For example, as mentioned here before, we sceptics like to see CAM as predominantly a scientific matter. After all, it is science, whatever that is, that tells us when treatments work or don’t work, also when someone is likely to be a fraudster, and it is science that tells us whether any CAM understanding of illness is likely to be true or not. It is also our passion.

    So CAM looks like an education problem. Make the public better informed and it will die out.

    It won’t. CAM doesn’t need science at all. The simplest of observations reveal that it is driven mainly by unmet medical needs and the power of testimonial. This is how medicine began, and it is where it returns whenever science is not providing adequate answers. The CAM user may value science highly, but still want the freedom to try out less kosher methods.

    This is the same conclusion as yours without needing to refer to the “scientific fallacy of enlightenment reason.”

  50. Geekoid says:

    Children’s remedies are a placebo…for the parent.

  51. Fifi says:

    Just to be clear – I’m quoting Lakoff for most of that post, sorry if that wasn’t clear. Everything under the link (all the mind blowing and well presented stuff) is Lakoff’s contribution to the list on Edge. There are a lot of other interesting ones by some exceptional thinkers there (along with the usual suspects, though the most fun one is the erroneous contemporary belief we hold that everyone used to believe the world was flat). Lakoff’s not writing about CAM in particular, just about the difference between how we think and how we like to think we think. I think he’s pretty spot on but I do have a confirmation bias and obviously new evidence may prove him – and me and my confirmation bias – wrong. Though I suspect if he is wrong, the new evidence won’t validate what he’s pointing out is a somewhat outmoded understanding of how the mind works but will point us in equally unexpected directions.

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