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You. You. Who are you calling a You You?

The YOU Docs, for those of you (YOU?) who are unaware, are Doctors Mehmet Oz and Mike Roizen, authors of books about YOU and a weekly newspaper column called The YOU Docs. It’s all about YOU.

There are two areas of the knowledge where I have more than passing understanding: infectious diseases and sCAMs. It always concerns me when I read nonsense in the few areas where I have some expertise. I have to wonder about the validity of other information in the paper like war and the economy. You know, important stuff. It could probably be argued that since the YOU Docs are in the “How We Live” section, the same section that carries horoscopes, the movie and TV reviews, the weather report — the fiction section — it should not taken seriously. After all, it is usually adjacent to the People’s Pharmacist, and my father always told me that you can judge a person by the company they keep.

The YOU Docs had a column with the headline: “Research backs acupuncture for a range of ills“. More fiction? Research backs acupuncture? News to me, but they are, after all, YOU Docs, and therefore may have information not accessible to mere docs with a small ‘d’. I grant up front to the authors that it is hard to be rigorous, or even coherent, in a 452 word essay. I am over 3,200 words for this entry. There are also no references, so I have to assume I found the correct research mentioned by the hints in the text.

They start with the usual appeal to antiquity:

Acupuncture has been around a long, long time: Archeologists have unearthed 5,000-year-old stone needles in Inner Mongolia.

If it is old, it must be efficacious. People would not use ineffective treatments for centuries, would they? This, of course, assumes that the Chinese, and other ancient healing modalities, had at their disposal an organized, consistent way to keep track of data to judge the efficacy of a therapy. While the use of acupuncture may stretch into antiquity, clinical and epidemiologic studies from ancient times are non-existent. The ancients only had anecdotes to guide them, and if there is no other lesson to be learned from SBM, the three most dangerous words in medicine remain “in my experience.”

One indirect way to evaluate the benefits of acupuncture and Chinese medicine in general is life expectancy. In 1900 it was 30 years. Good job traditional Chinese medicine. Now life expectancy is 71. Why?

“This can be attributed to the advancement of science and technology, especially in medical science,” said Zhao Baohua, vice-director of China Association for Aged People.

Goodness gracious. Reductionist Western Medicine more than doubling life expectancy. If only they had relied on acupuncture, perhaps population control would not have become such an important issue in the Peoples Republic.

As an aside, I cannot find anything but secondary references about the 5,000-year-old stone needles used for acupuncture. How it is ascertained that these needles were not used for sewing and were in fact used for acupuncture I cannot discover. A 5000-year-old package insert? I find one argument that these 5,000-year-old needles were used as scalpels and not for acupuncture.

The YOU Docs proceed to

But we like this popular form of energy medicine because it’s backed by an impressive body of 21st-century research. Energy medicine? Yes, it seems to change the electric currents or nerve impulses in your body.

That is what is nice about alternative medicine, a lack of consistency in terminology. Usually the term ‘Energy Therapy’ refers to energies that no one has ever measured, not altering nerve conduction. The NCCAM definitions are as good as any:

Energy Medicine

Energy therapies involve the use of energy fields. They are of two types:

Biofield therapies are intended to affect energy fields that purportedly surround and penetrate the human body. The existence of such fields has not yet been scientifically proven. Some forms of energy therapy manipulate biofields by applying pressure and/or manipulating the body by placing the hands in, or through, these fields. Examples include qi gong, Reiki, and Therapeutic Touch.

Bioelectromagnetic-based therapies involve the unconventional use of electromagnetic fields, such as pulsed fields, magnetic fields, or alternating-current or direct-current fields.

Usually I do not think of nerve impulses as being part of energy therapy, but that just may be me.

So as I am given to understand the YOU Docs, the mechanism of action of acupuncture is to alter nerve impulses. It would also suggest, then, that the cause of the diseases treated by acupuncture is due to altered nerve impulses, or perhaps the acupuncturist is only treating symptoms and not the underlying disease. All those diseases treated by one intervention that alters nerve conduction. And I thought aspirin was the wonder drug that works wonders. The YOU Docs have a different understanding of physiology than I learned at school.

What is the data to support the effect of acupuncture on diseases and symptoms by altering nerve conduction? It would be simple enough. Pick a disease or symptom. Nerve impulse measured before treatment. Acupuncture. Resolution of disease or symptom. Nerve impulse altered.

There is one study, small (which I could not get before the post went up), that demonstrates this effect in diabetic neuropathy. There are studies that show alterations in nerve function in rats and MRI studies that show CNS changes with acupuncture. But the simple temporal relationship that would suggest a cause and effect does not exist for any other process treated by acupuncture.

BTW: electroacupuncture doesn’t count as acupuncture for the purpose of this discussion. That is not acupuncture as defined in the article. To the best of my understanding the ancient Chinese lacked electricity.

This therapy involves inserting hair-thin needles into specific points on the body to treat countless problems, ranging from easing chronic pain and insomnia to reducing the side effects of cancer treatments and helping smokers quit.

Note “specific points.” A consistent result of recent acupuncture studies is that the effects of acupuncture do not depend on where the needles are placed or even if the needles break the skin. I realize that it is a short article, but we are only a few paragraphs in and it appears the YOU Docs lack a good command of the literature concerning acupuncture. I may be picky, but precision of understanding is important in medicine. You wouldn’t want your, oh, I don’t know, heart surgeon to say, “We are going to bypass one of your arteries, somewhere there in your chest.”

As to smoking cessation? Not so much.

The significant short-term effect was lost with the random-effects model for pooling, or by removing the outlying study that led to heterogeneity. The long-term result shows no effect of acupuncture compared with sham acupuncture. There was no consistent evidence that acupuncture is superior to no treatment, and no evidence that the effect of acupuncture was different from that of other anti-smoking interventions, or that any particular acupuncture technique is superior to other techniques.

The YOU Docs go on to give specific examples of acupuncture efficacy, managing, with awesome consistency, to get it wrong every time. I come to this with a slightly unforgiving attitude. I am a specialist. What defines a specialist is, in part, is mastery, or an attempt at mastery, of the relevant medical literature. I also work in a teaching hospital. I expect my residents and medical students, when reading a paper, to get the basic concepts of the paper correct and understand some the nuance of the papers they read. It is expected that the teaching attendings, when quoting the literature, will get it right, understand the nuance of the medical literature, and not cherry pick.

Just months ago, a Hong Kong University study of 60 insomniacs found those who got acupuncture fell asleep faster and were more likely to stay that way than those who got a fake version of the treatment.

I guess they are referring to “Electroacupuncture for primary insomnia: a randomized controlled trial” which, while not being acupuncture, does meet the criteria as mentioned for being the correct reference.

The authors conclusion of the study?

MEASUREMENTS AND RESULTS: Self-reported questionnaires, 1-week sleep diaries, and 3-day actigraphy were collected at baseline and 1 week after treatment. The Insomnia Severity Index was used as the primary outcome measure. Both groups showed significant improvement compared with the pretreatment baseline. One-way analysis of covariance adjusted for baseline scores showed that there were significantly greater improvements in sleep efficiency by sleep diary and actigraphy in the electroacupuncture group. However, no significant between-group differences were observed in the Insomnia Severity Index and other outcome measures. The proportions of subjects having less than 30 minutes of wake after sleep onset and a sleep efficiency of at least 85% at the posttreatment visit were significantly higher in the electroacupuncture group. All adverse events were mild in severity.

CONCLUSION: We found a slight advantage of electroacupuncture over placebo acupuncture in the short-term treatment of primary insomnia. Because of some limitations of the current study, further studies are necessary to verify the effectiveness of acupuncture for insomnia.

Not exactly a ringing endorsement of acupuncture for insomnia.

Of interest there is another acupuncture study for insomnia that used sham acupuncture and it was equally unimpressive.

RESULTS: No statistically significant differences were observed between the groups relating to parameters associated with the definition of insomnia. The treatment group experienced that it was easier to wake up in the morning compared with the control group (repeated-measures analysis of variance, p = 0.04). Both groups showed a statistically significant recovery in subjective sleep parameters during the study period (weeks 1-6) compared with baseline values (week 0).

CONCLUSIONS: Only modest evidence was found supporting the hypothesis that AAT may have an effect on insomnia. Least improvements were found in total sleep time and number of awakenings, 2 parameters directly associated with the definition of insomnia. AAT may have a role in the treatment of insomnia, especially in combination with other treatments such as cognitive behavioral therapy. This study provides an example of how to perform studies using alternative therapies for sleep disorders.

Funny. The treatment group woke up easier and that was a benefit for those suffering from insomnia how?

One difference between the two insomnia studies was that the second study used auricular acupuncture. They stuck the needles in the ear. So what nerve or nerves associated with sleep would warrant sticking needles in the ear in one study and sticking them in another site in a different study. According to the YOU Docs the needles were supposed to be placed in ‘specific sites’. What anatomy and physiology could the two studies have in common? Maybe in this context specific refers to anywhere on the patient. Or I am I trying to find a logical consistency with tooth fairy science?

And, as a final note, a Cochrane review of acupuncture and insomnia says

The small number of randomized controlled trials, together with the poor methodological quality and significant clinical heterogeneity, means that the current evidence is not sufficiently extensive or rigorous to support the use of any form of acupuncture for the treatment of insomnia.

The YOU Docs say “We like this popular form of energy medicine because it’s backed by an impressive body of 21st-century research.”

I guess it doesn’t take much to impress the YOU Docs. Actually, the totality of acupuncture studies are impressive in the same way a large pig farm can be impressive.

The YOU Docs continue.

Arthritis relief: British researchers who analyzed five well-designed studies of 1,334 people with bum knees have confirmed that acupuncture relieves debilitating joint pain related to arthritis.

What made these studies ‘well designed’? If the authors considered the acupuncture to be adequate it was well designed:

we defined acupuncture as ‘adequate’ if it consisted of at least six treatments, at least one per week, with at least four points needled for each painful knee for at least 20 min, and either needle sensation (de qi) achieved in manual acupuncture, or electrical stimulation of sufficient intensity to produce more than minimal sensation.

The definition was, it seems, mostly based on the authors’ opinion. The references do not suggest the definition is derived from rigorous testing. There is, by the way, no interest in whether the same specific points are used, just that a sufficiency of needles were used. There is more to a well-defined study than the authors opinion as to what constitutes adequacy of a clinical trial. How about sample size, blinding, etc.? Multiple needles would lead to one adequate outcome.

How good was the pain control? As the authors state in the discussion,

The size of the effect on pain was not dramatic: recalculating the data as standardized mean difference, the effect size compared to sham acupuncture is 0.4 which is considered ‘moderate’

Another ringing endorsement for the efficacy of acupuncture.

The Annals of Internal Medicine meta-analysis of acupuncture for knee pain comes to an alternative conclusion.

Sham-controlled trials show clinically irrelevant short-term benefits of acupuncture for treating knee osteoarthritis. Waiting list-controlled trials suggest clinically relevant benefits, some of which may be due to placebo or expectation.

Given the great heterogeneity in the studies of acupuncture and arthritis one can probably come to any conclusion you desire if you pick the right subsets of studies. Another group of British scientists (they call themselves Oxford Scientists) did a systematic review of systematic reviews of acupuncture and concluded:

Qualified support for acupuncture was originally reported in 12 out of 35 systematic reviews, and strong support was found in another six. Applying stricter inclusion criteria, however, showed that none of the 35 reviews supported acupuncture, predominantly because there were too few patients in the randomized, double blind studies. Six reviews with more than 200 patients in randomized, double blind studies had good evidence of no benefit. Systematic reviews of acupuncture have overstated effectiveness by including studies likely to be biased. They provide no robust evidence that acupuncture works for any indication.

I guess the Oxford Scientists don’t know an adequate trial when they see one.

The YOU Docs continue:

Squelching pain: In a landmark German study of 1,162 back-pain sufferers, twice as many got relief from acupuncture as from conventional fixes such as drugs or physical therapy. Acupuncture also has been proved at least as effective as pain drugs not only for treating migraines, but for preventing them, too.

This refers to the Archives of Internal Medicine where back pain patients had ‘real’ acupuncture, fake acupuncture or standard care. The sham acupuncture was twirling a toothpick on the skin. Really.

The ‘real’ acupuncture (both individualized and standardized placement of needles, that pesky need for ‘specific’ acupuncture points keeps disappearing) and the toothpick had the same improvement in pain.

Would you conclude that this is a landmark study showing the efficacy of acupuncture or conclude that whatever led to the pain improvement, it was not specific to acupuncture? Or do twirled toothpicks alter nerve conduction? If treatment and placebo have the same effect, one usually concludes that the treatment doth not work. Unless you never bothered to read past the press release.

Also, in the landmark study

Rates of adverse experiences differed by treatment group: 6 of 157 participants for individualized acupuncture, 6 of 158 for standardized acupuncture, and 0 of 162 for simulated acupuncture.

So if you were an ethical doctor who reads the literature carefully, if offered two treatments of equal efficacy but one treatment had no side effects, would you not choose the treatment with the least side effects? If you are going to offer advice based on a landmark study, and want to maximize efficacy and minimize side effects, how could you not recommend twirled toothpicks as the acupuncture modality of choice?

Migraines? The Cochrane review, if you want to believe them, demonstrated

Fourteen trials compared a ‘true’ acupuncture intervention with a variety of sham interventions. Pooled analyses did not show a statistically significant superiority for true acupuncture for any outcome in any of the time windows, but the results of single trials varied considerably. Four trials compared acupuncture to proven prophylactic drug treatment. Overall in these trials acupuncture was associated with slightly better outcomes and fewer adverse effects than prophylactic drug treatment.

When compared to sham acupuncture, ‘real’ acupuncture is no better for migraines. Do you get the impression that acupuncture is no more than an elaborate, nonspecific placebo effect and only has results with subjective endpoints and only clinically irrelevant short-term benefits?

The YOU Docs go on (with an increasing lack of confidence in the authors. If I can find so much in error in a few short paragraphs, why bother to read on? I do it for you. But not YOU. My caps lock is not stuck).

Reducing treatment side effects: Dozens of studies show acupuncture helps quell pain, nausea, fatigue, hot flashes and dry mouth in cancer patients undergoing chemotherapy, radiation or both.

And dozens do not.

Three RCTs compared the effects of manual acupuncture with sham acupuncture. One RCT showed favorable effects of acupuncture in reducing hot flash frequency, while other two RCTs failed to do so.

or

There was no difference between combined acupuncture and acupressure treatment at P6 and at the sham point for the nausea score.

Just where is this “impressive body of 21st-century research” supporting acupuncture? Acupuncture research is mostly a collection of poorly done studies that demonstrate marginal effect and a few definitive studies that show no efficacy. The body of 21st century research does not support acupuncture, at least if you bother to acquaint yourself with the details of the studies. As a rule of thumb, when there are multiple studies hovering around efficacious, some showing benefit and others not, it is unlikely that any clinically relevant effect is occurring.

“How can one therapy do so much?”

Well, because it doesn’t.

Eastern and Western medical philosophies merge when a licensed acupuncturist inserts those sterile, disposable needles into your skin.

The needles may be sterile, but the photographs all too often show the bare fingers right at the insertion site. Search Google images of acupuncture. If you like sterile technique, the photos will give you the heebe jebees. Looking at Google images it is not surprising that there was at least one reported outbreak of MRSA due to poor technique. Acupuncture technique evidently doesn’t bother itself with the impressive body of 21st-century research on germ theory and infection control.

The YOU Docs conclude

You don’t have to believe in it for acupuncture to work. Case in point: Veterinarians know that acupuncture often helps ailing horses, goats, cats and dogs (including Titan, the world’s biggest Great Dane) in measurable ways, such as being able to walk and run again. With animals, there’s no placebo effect. It either works or it doesn’t. Same for people. Many skeptical people who’ve tried acupuncture as a last resort become believers when they see results.

I am not as well versed in veterinary literature, although I cannot imagine that acupuncture should be any less effective in animals than it is in humans. As one review suggests “on the basis of the findings of this systematic review, there is no compelling evidence to recommend or reject acupuncture for any condition in domestic animals.” Why the lack of a firm conclusion? “The methodologic quality of these trials was variable but, on average, was low.”

I guess only the YOU Docs find the veterinary research part of an “impressive body of 21st-century research.” The authors of the review did not. I will refer you Dr. Ramey for reviews on animal acupuncture and animal placebo for a more expert evaluation.

“It either works or it doesn’t. Same for people.” For acupuncture, it’s the latter. That statement, from the YOU Docs, is as simple a dismissal of evidence and scientific based medicine I have ever read. Anecdote rules!

In the end I am left wondering.

Did the YOU Docs read the references and not understand them?

Did the YOU Docs read the references and choose to interpret them in an original way to ensure that the conclusion ‘acupuncture works’?

“You keep using that phrase. I do not think it means what you think it means.” – Inigo Montoya.

Did the YOU Docs not read the references and relied on second hand reports?

It is a good thing the YOU Docs are not rotating on my service this month. Such scholarship would be difficult to award a passing grade, even for a 452 word essay, since it was wrong about almost every specific. However, I am one of the grumpy, old school docs who expect MDs to get it right, even if limited to 452 words.

Addendum

I am ever so proud that I made no L. Frank Baum references for this entry. But allow me to recommend Wicked, the Life and Times of the Wicked Witch of the West. I read it right after I having read the Wizard of Oz to my eldest. The sequels are awful and the musical is worse, but Wicked is a wonderful book.

Posted in: Acupuncture, Science and the Media

Leave a Comment (52) ↓

52 thoughts on “You. You. Who are you calling a You You?

  1. Scott says:

    The two insomnia studies scream “multiple comparisons” to me. I don’t have access to the full texts, but I’d be very curious to know if they properly controlled for the multiple comparisons they certainly did. I kind of doubt it, given the general level of scholarship in acupuncture and other sCAM studies.

  2. Gary Scott says:

    Maybe a more appropriate place for the “YOU” docs in the O would be the sports section next to all the articles on steroids, doping and infidelity.

  3. Lawrence C. says:

    It always concerns me when I read nonsense in the few areas where I have some expertise. I have to wonder about the validity of other information in the paper….

    It concerns me, too, which is why I became concerned when I read this:

    The ancients only had anecdotes to guide them….

    Only? Well, no. There was in fact a great deal of what we might call collected literature in that day, including generations of notes and observations from the people that tried to treat diseases and heal people. Historians know there were quite a few libraries outside of the Imperial collections of considerable size and scope that contained what later westerners would generally call materia medica. The problem is that, of course, paper and parchment have this annoying tendency to disintegrate and also to attract the interest of new political and religious movements that like to burn it all. What’s left from BCE times is essentially a scattered collection of references to other works that no longer exist (at least no one seems to have located them yet.)

    The conclusion one can draw is that “the ancients” of China kept track of things in as systematic a way as was possible. Rational folks like to speculate for fun or academic purposes on what all might have been in these collections but, no surprise, the sCAM folks almost claim to know not only something of what was in them but also and almost miraculously say that they are following this ancient wisdom.

    This is sort of like saying one knows a whole subject because you’ve read the index cards in one tray of an old card catalog. But it doesn’t mean that “the ancients” only had anecdotes to guide them. Both assumptions are wide of the historical record.

  4. Lawrence C. says:

    Hmm. I wrote “Both assumptions are wide of the historical record.” For clarity I should note that only one of those assumptions is actually dangerous to health and prone to wide abuse and it ain’t Dr. Crislip’s.

  5. Joe says:

    @Lawrence C. on 15 Jan 2010 at 12:31 pm “The ancients only had anecdotes to guide them….

    Only? Well, no. There was in fact a great deal of what we might call collected literature in that day, including generations of notes and observations from the people that tried to treat diseases and heal people.”

    I think you will have a difficult time establishing that the literature of the time was anything more than a collection of anecdotes. Otherwise, you are suggesting that scientific studies were performed in ancient times; and then that approach was lost for millennia.

  6. Scott says:

    Expanding a bit on what Joe said, collecting information doesn’t allow it to rise above the level of anecdote, no matter the volume. What distinguishes data from anecdote is that it is rigorously, carefully, and scientifically collected. This allows selection effects to be considered, confounders addressed, and effect sizes measured. These are impossible with even the largest collection of anecdotes, and therefore reliable conclusions cannot be drawn from anecdotes – no matter how many of them you have.

    This is the reason for the saying, “the plural of anecdote is not data.”

  7. Lawrence – thanks for the information. However, keeping careful notes of anecdotal observations is still anecdotal. As far as I know there is no record of any ancient culture utilizing blinded controlled observations.

    And that, I am pretty sure, is what Mark was referring to.

  8. Sid Offit says:

    “This can be attributed to the advancement of science and technology, especially in medical science,” said Zhao Baohua, vice-director of China Association for Aged People.
    ———————-
    So we’re supposed to believe medicine doubled the life span of those living in China because Zhao Baohua says so? Where’s the evidence?

  9. overshoot says:

    If it is old, it must be efficacious. People would not use ineffective treatments for centuries, would they?

    That reminds me — how do tiger gonads, rhinoceros horns, etc. stack up as remedies for erectile disorders?

  10. Lawrence C. says:

    Joe notes: “I think you will have a difficult time establishing that the literature of the time was anything more than a collection of anecdotes. Otherwise, you are suggesting that scientific studies were performed in ancient times; and then that approach was lost for millennia.”

    Actually it works both ways, as one cannot definitively say that (a) it was all just a collection of anecdotes or (b) that it was a “scientific study” of some kind. The fact is, we just don’t know the methodology of collecting information on treatments and diseases in BCE China. The “card catalog” kinds of references we’re left with suggest that at least in some cases there was a pretty rigorous examination of treatments for a variety of problems, but again, these are basically just reference notes from which inferences can be made.

    The one sure conclusion that one can draw is that anyone claiming to be working from “ancient Chinese knowledge” is either a charlatan or has access to a really, really interesting set of otherwise unknown documents. I suspect the former.

    Steven Novella added:

    Lawrence – thanks for the information. However, keeping careful notes of anecdotal observations is still anecdotal. As far as I know there is no record of any ancient culture utilizing blinded controlled observations.

    And that, I am pretty sure, is what Mark was referring to.

    Yes, that is the current consensus and I do think that is what Crislip is writing about. I wanted to expand on that to remind folks that the whole area is largely a giant unknown and speculation on what may or may not have been collected and how is largely based on old “card catalog” entries. But as lawyers like to note, absence of evidence is not evidence of absence.

  11. weing says:

    I have to disagree with you. I saw “Wicked” and I loved it. The book is great though.

  12. BillyJoe says:

    Mark,

    “Migraines? The Cochrane review, if you want to believe them, demonstrated:

    “Fourteen trials compared a ‘true’ acupuncture intervention with a variety of sham interventions. Pooled analyses did not show a statistically significant superiority for true acupuncture for any outcome in any of the time windows, but the results of single trials varied considerably. Four trials compared acupuncture to proven prophylactic drug treatment. Overall in these trials acupuncture was associated with slightly better outcomes and fewer adverse effects than prophylactic drug treatment.”"

    That was in the RESULTS section.
    But look at the spin the authors put on these results in their CONCLUSIONS:

    “AUTHORS’ CONCLUSIONS: In the previous version of this review, evidence in support of acupuncture for migraine prophylaxis was considered promising but insufficient. Now, with 12 additional trials, there is consistent evidence that acupuncture provides additional benefit to treatment of acute migraine attacks only or to routine care. There is no evidence for an effect of ‘true’ acupuncture over sham interventions, though this is difficult to interpret, as exact point location could be of limited importance. Available studies suggest that acupuncture is at least as effective as, or possibly more effective than, prophylactic drug treatment, and has fewer adverse effects. Acupuncture should be considered a treatment option for patients willing to undergo this treatment.”

    This is obviously what the YOU doctors read and believed.

    HINT:
    It is a good idea when you read clinical trials to read the RESULTS of the trial before you read the author’s CONCLUSIONS. That way you will be able to detect those numerous occasions when the authors CONCLUSIONS are NOT JUSTIFIED by the RESULTS”

    If you read the full extract, the authors even go on to say that, because the effect of acupuncture has now been well established, future trials should be concentrate on finding the best acupuncture protocol, in which case the sham acupuncture control can be dispensed with!!!

    Good one!!!

    Yes, even Cochrane can get it wrong sometimes.

  13. crazyred says:

    Perhaps they will next say that accupuncture will help you ‘defy gravity’ or some other ridiculous claim.

    I agree that the book was great (I liked ‘Son of a Witch’ less; the middle was hard to trudge through, kind of boring, and I have not read the final one yet) and I too agree with weing, in that the musical was quite enjoyable.

    I don’t understand how a physician can wholeheartedly support CAM approaches to disease management (such as Dr. Mercola and Dr. Oz). Some of it reflects a paranoia of the pharma industry (they’re all out to harm all of YOU and I will save YOU with herbs and tiny needle sticks (if the herbs don’t cook your liver first), with a healthy dose of my personally branded therapies that cost more than most generic pharmaceuticals). It breeds mistrust of mainstream medicine and I think makes some adherents less likely to reach out to their doctors when something is going on. I am able to access some articles by virtue of my job that these doctors reference, and I really don’t come to the same conclusions. Cherry picking is an excellent way to describe the conclusions that CAM supporters come to.

    As part of my work to get my undergrad biochem degree, I had to read and analyze publications from research and report my observations. If this was required coursework for a BS (haha I know), I really have to sometimes wonder how these CAM physicians made it through medical school.

  14. BillyJoe says:

    From my previous post:

    “If you read the full extract, the authors even go on to say that, because the effect of acupuncture has now been well established, future trials should concentrate on finding the best acupuncture protocol, in which case the sham acupuncture control can be dispensed with!!!”

    Sorry I forgot the quote relating to this.
    Here it is:

    “Although future sham-controlled trials might find ‘specific’ effects over sham interventions, we think that such studies should not have the highest priority unless they also address other important questions. Other aspects that deserve further research include questions such as which types of acupuncture work best, what is the optimal frequency and duration of sessions, and so on.”

  15. daedalus2u says:

    If ancient Chinese investigators of acupuncture were scientists and used the scientific method, they would have found what present day scientists have found, that toothpicks that do not break the skin work just as well as needles, and that it doesn’t matter where the needles (or toothpicks) are poked against the skin. There is no hint in the ancient Chinese acupuncture literature that ancient Chinese practitioners were aware of these properties of acupuncture. There is no “toothpick style” of acupuncture.

    I suppose it is possible that the ancient Chinese literature was published simply to perpetuate the fraud that acupuncture is different than placebo, and the truth of acupuncture was handed down as an oral tradition in secret. But there is no evidence that is the case. All the evidence there is points to the ancient Chinese having the flawed idea of acupuncture that you would get by looking at a series of anecdotes, not from a scientific investigation.

  16. Joe says:

    @Lawrence C. on 15 Jan 2010 at 3:52 pm “Joe notes: “I think you will have a difficult time establishing that the literature of the time was anything more than a collection of anecdotes. Otherwise, you are suggesting that scientific studies were performed in ancient times; and then that approach was lost for millennia.”

    Actually it works both ways, as one cannot definitively say that (a) it was all just a collection of anecdotes or (b) that it was a “scientific study” of some kind.”

    Which seems more plausible to you: A) The Ancients did scientific experiments and got results that we cannot get today? Then they lost the knowledge of scientific method. How do explain that the ‘newly rediscovered’ method does not support acupuncture when you think that older, proper tests did?

    B) The Ancients followed the prescientific standard of the time and got anecdotes that amount to nothing?

    Saying both possibilities are equally likely since the records are lost is like saying extraterrestrials may have built the great pyramids since we have no documents saying they did not.

  17. JerryM says:

    The YOU Docs say “We like this popular form of energy medicine because it’s backed by an impressive body of 21st-century research.”

    I guess it doesn’t take much to impress the YOU Docs. Actually, the totality of acupuncture studies are impressive in the same way a large pig farm can be impressive.

    Any study finding any effect for acupuncture is impressive.

  18. EricG says:

    great article. sometimes a good bludgeoning-by-evidence is needed.

    as a side, posted the quote:

    “One indirect way to evaluate the benefits of acupuncture and Chinese medicine in general is life expectancy. In 1900 it was 30 years. Good job traditional Chinese medicine. Now life expectancy is 71. Why?”

    on my face book and am now torso-meridian deep in replies. nothing like a little debate on a friday afternoon.

  19. Zoe237 says:

    “great article. sometimes a good bludgeoning-by-evidence is needed.

    as a side, posted the quote:

    “One indirect way to evaluate the benefits of acupuncture and Chinese medicine in general is life expectancy. In 1900 it was 30 years. Good job traditional Chinese medicine. Now life expectancy is 71. Why?”

    on my face book and am now torso-meridian deep in replies. nothing like a little debate on a friday afternoon.”

    That’d be interesting to read. I’m familiar with the history of science in general, but not so much medicine. What, besides vaccinations and antibiotics, lead to this vast increase in life expectency? And has this increase been declining in recent years or does LE continue to increase? And how were doctors in the say 19th century, before the increase (and before the industrial revolution), NOT practicing medicine? I’m fearful that this is a false cause fallacy being utilized by both sides. I’m guessing the increase in life expectency is due to many factors, of which modern medicine was one part. The industrial revolution really seemed to be a turning point.

    The overall push of history is progressive- two steps forward, one step back, a spiral, but altogether forward. The trend in medicine for at least the past ten years, maybe more, has been towards integrative medicine, and SBM is losing. I’m seeing integrative as a compromise position between SBM and CAM. Is this trend just a fluke or is it the future of medicine, in which the people who have been trained in the “old” way retire, kicking and screaming against integrative?

    BTW, I hate Dr. Oz. Some of my younger midwest in-laws were even talking about how much they liked him, but I kept my mouth firmly shut (I was already in trouble for saying the Bible was not the literal world of god, better not push it).

  20. Mark Crislip says:

    Health gains are always multifactorial. The big four reasons we live a long time are flush toilets, vaccines, good nutrition, and antibiotics.

    It depends on how broadly you define medical science. Knowing the life cycle of the mosquito, making safer cars, occupational safety, etc etc and contribute as well.

    Some how I doubt acupuncture and moxibustion added much.

  21. Not so long ago, Michael Roizen was a rising star of academic anesthesiology. I am embarrassed to say that he trained at the same hospital that I did, although it was a few years before I was there and I didn’t know him. There is little question in my mind that he knows that this stuff is BS (I doubt that Oz does). In Roizen’s case, we must wonder why he went off the deep end: Money? Craving a sort of celebrity? What a waste.

  22. BillyJoe says:

    Zoe,

    “I’m familiar with the history of science in general, but not so much medicine. What, besides vaccinations and antibiotics, lead to this vast increase in life expectency? ”

    Mainly the nes you mentioned I think. But it is truer to say that science has caused the increase via public health measures such as sewerage systems and reticulated water supplies and via medicine such as vaccinations and antibiotics.

    “And has this increase been declining in recent years or does LE continue to increase?”

    It continues to increase.
    http://www.google.com/publicdata?ds=wb-wdi&met=sp_dyn_le00_in&tdim=true&q=life+expectancy+graphs+world
    You can click to add any country you like. So far Australia has highest life expectancy of about 81, but I haven’t cliked on all of them yet.

    “And how were doctors in the say 19th century, before the increase (and before the industrial revolution), NOT practicing medicine?”

    They used treatments which they seemed to have pullled out of thin air (if not out of their asses!) such as bloodletting, purgatives and emetics to purge the body of evil humours and poisoning with murcury and arsenic. It may have been “medicine” but it was not “evidence based medicine”. In fact it killed people.

    “The trend in medicine for at least the past ten years, maybe more, has been towards integrative medicine, and SBM is losing.”

    So much the worse for medicine.

    “I’m seeing integrative as a compromise position between SBM and CAM.”

    You would be wrong. Integrative medicine is non-evidence based medicine getting a free ride on the back of evidence based medicine.

    “Is this trend just a fluke or is it the future of medicine, in which the people who have been trained in the “old” way retire, kicking and screaming against integrative?”

    I surely hope not. I think we are starting to see a fight back by EBM (or SBM).

    regards,
    BillyJoe

  23. pmoran says:

    WRT the Cochrane review on acupuncture and migraine prevention, why might not an elaborate placebo that may also often generate distractant/counterirritant effects and necessarily involves periods of enforced relaxation and even some endorphin release, perform netter than a drug that itself has only marginal effects over sugar-pill type placebos?

    I am not saying that it necessarily does. The evidence is not conclusive. Yet it is plausible that it could i.e. such a view is entirely consistent with the evidence, and favoured by some. Observe that a migraine diary is a somewhat more objective measure than others that more easily allow patient subjectivity and bias to leak through into the reporting of outcomes.

    It looks like a “BIg Pharm” bias when we dismiss such findings without adequate grounds. Most people think that doctors should be eager to look at anything might help patients in cost/risk/safety/benefit terms, and they have far fewer concerns as to HOW treatments might work. To them all treatments are merely something worth a try with the relatively benign chronic illnesses mentioned here.

  24. Zoe237 says:

    Is this trend just a fluke or is it the future of medicine, in which the people who have been trained in the “old” way retire, kicking and screaming against integrative?

    “I surely hope not. I think we are starting to see a fight back by EBM (or SBM).

    regards,
    BillyJoe”

    Haven’t skeptics been railing against chiro and acupuncture for thirty years? Has it made any difference? Given the demand, and the number of medical schools teaching integrative, I’m not sure at all. But this is a new interest of mine, so perhaps my thinking will evolve. Thanks for answering my questions.

  25. Zoe237 says:

    “It looks like a “BIg Pharm” bias when we dismiss such findings without adequate grounds. Most people think that doctors should be eager to look at anything might help patients in cost/risk/safety/benefit terms, and they have far fewer concerns as to HOW treatments might work. To them all treatments are merely something worth a try with the relatively benign chronic illnesses mentioned here.”

    Yes, that’s exactly where I’m leaning. I’m a fairly reasonable person. I have a clear bias against people making claims without evidence for those claims. I’ve been looking and reading, trying to see “what’s the harm” and understand why there is a network of people dedicating their lives to fighting acupuncture, homeopathy, chiropractors, and herbal remedies.
    So much so that anybody who uses a chiro is a gullible quack. I started out wondering if the editors were engaged in turf wars or biased against anything “natural” but I don’t think that’s true anymore. So now I’m wondering if I’m missing something.

    Besides this website, among tv doctors, newspaper articles, NPR (and I read/listen pretty widely)… I almost never hear anything against integrative medicine. It’s pretty much exclusively neutral or pro, so SBM is my first real intro to these ideas

    The reason I would never try acupuncture is that it has no biologically plausible explanation and I’m not the type to fall for elaborate placebos. I also have no real medical conditions, and neither do my kids. If my good friend has migraines, and wants to try acupuncture because nothing else is working, I might tell her she’s wasting her time, and I definitely see it as a big waste of money. But on my grand scale of things to worry about wrt medicine, that is WAY down there as far as I can tell. Maybe worth one blog post/year, not the 37 listed on the right. But this is where I’m leaning, not decided yet. I REALLY appreciate the posts here on other topics though.

  26. Lawrence C. says:

    Joe asks of me:

    Which seems more plausible to you: A) The Ancients did scientific experiments and got results that we cannot get today? Then they lost the knowledge of scientific method. How do explain that the ‘newly rediscovered’ method does not support acupuncture when you think that older, proper tests did?

    B) The Ancients followed the prescientific standard of the time and got anecdotes that amount to nothing?

    Given such a poor choice, neither.

    But why the unfounded assumption that I “think older, proper tests” supported acupuncture? I think no such thing and thus have not indicated such.

    Saying both possibilities are equally likely since the records are lost is like saying extraterrestrials may have built the great pyramids since we have no documents saying they did not.

    Who is suggesting equally likely possibilities? Not me. Since there is almost no evidence at all about “ancient” practices, little can be said about them that means anything. The false analogy quoted above is even faulty as a conversation piece as we do have a lot of ideas about how the pyramids were build, mainly developed by clever reverse engineering. The ancient Egyptian’s “builder’s manual” doesn’t exist but methods to build anything on the Giza plateau do and work well today. The same cannot be said for acupuncture.

    What is really scary is that the comments to this article are longer and more valid than the original 452 word endorsement of acupuncture by celebrity doctors.

  27. Charon says:

    Lawrence C.: I will not go as far as others and say anecdotes have no value. “My brother ate this mushroom and died” was probably a pretty valuable observation once upon a time.

    But I do have to agree that the plural of anecdote is emphatically not data. There is no evidence for the scientific method existing prior to the 16th c. (or classical Greece if you push it). “Absence of evidence is not evidence of absence” is a stupid comment that betokens a complete lack of understanding of (empirical) induction, Occam’s razor, and the scientific method.

    (I’ll note that in the 17th c., science replaced law as the gold standard of intellectual argument – a primary effect being that logic was raised above rhetoric. What lawyers like to say is pretty irrelevant to logical debate.)

  28. BillyJoe says:

    “I will not go as far as others and say anecdotes have no value. ”

    I forget who said it…
    “Anecdotes are the start of an investigation, not the end”.
    …but that about sums it uip for me.

  29. Joe says:

    @Lawrence C. on 15 Jan 2010 at 12:31 pm “[I] became concerned when I read this:

    The ancients only had anecdotes to guide them….

    Only? Well, no. There was in fact a great deal of what we might call collected literature in that day, including generations of notes and observations from the people that tried to treat diseases and heal people. …”

    So, when you wrote that you didn’t mean to imply that the ancients had something more than anecdote to work from? What was your concern, and what did you mean by “Well, no.”? The latter sure sounds like you think they had something more than anecdotes available.

  30. nobs says:

    Charon posts: >>”But I do have to agree that the plural of anecdote is emphatically not data.”

    That phrase is bandied about quite frequently here.

    While the plural of anecdotes CAN be data,…..

    The plural of data is not proof.

  31. Lawrence C. says:

    Charon harumphs:

    “Absence of evidence is not evidence of absence” is a stupid comment that betokens a complete lack of understanding of (empirical) induction, Occam’s razor, and the scientific method.

    You get all that from a stranger repeating a lawyer’s cliche? Fascinating.

  32. EricG says:

    @ zoe237

    “That’d be interesting to read. I’m familiar with the history of science in general, but not so much medicine. What, besides vaccinations and antibiotics…”

    I don’t think that anyone here would be reluctant to call out the quote for “correlation is not causation,” as has already been demonstrated by listing a mutli-factor approach to the increase in LE.

    Merely a quote to stir the pot and incite some discussion amongst friends – which worked quite well.

  33. BillyJoe says:

    nobs,

    “While the plural of anecdotes CAN be data, the plural of data is not proof”.

    That sits very neatly beside:

    “Anecdotes are the start of an investigation, not the end”.

    I’m uncertain which I like better.
    Yours is more accessible (following on from the almost true “the plural of anecdotes is not data”), whilst mine (well, not mine, but I’ve adopted it) is more pithy.

  34. BillyJoe says:

    Charon,

    ““Absence of evidence is not evidence of absence” is a stupid comment.”

    It is almost true, which is good enough depending on context.
    Let me offer the following:

    “Absence of evidence IS evidence of absence, it’s just not proof of absence”

  35. pmoran says:

    Zoe237: ‘my good friend has migraines, and wants to try acupuncture because nothing else is working, I might tell her she’s wasting her time, and I definitely see it as a big waste of money. But on my grand scale of things to worry about wrt medicine, that is WAY down there as far as I can tell.”

    Yes, the YOU doctor claims are pretty benign. Smoking cessation, osteoarthrtis, migraine, insomnia, chronic pain, treatment side effects etc. These are conditions that can be extremely difficult to treat, for which usual drug treatments can introduce unwanted additional problems, where little is lost if any one treatment does not work.

    We can be legitimately irritated by the imaginative scientific claims, and angered wherever we sense frank fraud.

    But does not the likelihood that some folk are being helped in ways that may not be easily reproduced within the mainstream suggest the need for SOME tolerance, at this point in socio-medical evolution?

    The extreme intolerance that some have towards “alternatives” under all circumstances is not based upon science, or upon perceptions of conscious fraud. It is based upon the not quite sound presumption that they cannot possibly be of use to anyone. This is ignoring, or at least a biased interpretation of, a lot of scientific data

  36. pmoran says:

    BTW, I wss once as rabid a skeptic as any, coming to this party through my horror at what some of my cancer patients were being told.

    But medicine is complicated. It comprises an infinite variety of clinical conditions and what is important in one may be of less consequence in others. I have been forced by emerging data to entertain the idea that this applies even to the “working better than placebo” model upon which SBM and EBM are based.

    Overgeneralisations and oversimplifications are the true enemy.

  37. BillyJoe says:

    PMORAN,

    “The extreme intolerance that some have towards “alternatives””

    I think they are a small minority.
    Most are merely after a level playing field.
    If you make a claim you have to be able to back it up with evidence, otherwise the claim must be withdrawn.

    Even Ben Goldacre, the Bad Science” guy, has voiced some support for Homoeopathy – if used as a placebo. I have some misgivings myself – there is the possiblility of collateral damage with homoeopathy being used to treat real illness or used instead of real vaccinations, for example.

    For many, the real issue is the scientific dumbing down of society – the belief in nonsense such as “qi”, “meridians”, “energy”, “vibration”, “chakras” etc etc etc cannot help but have a negative impact on society’s scientific sense and make it victim to all sorts of nonsense.

    BJ

  38. nitpicking says:

    The big four reasons we live a long time are flush toilets, vaccines, good nutrition, and antibiotics.

    I’m surprised at you, Dr. Crislip. As an infectious disease doctor, surely you would support the idea that window screen, air conditioning, and other anti-mosquito measures have saved more lives (one estimate: 1 billion) by largely stopping malaria and yellow fever in the developed world.

  39. BillyJoe says:

    When he said “we”, I think he meant “citizens of the USA”, though that would, of course, apply equally to all developed countries.

    Basically it’s:
    Public health: food, water, and sewerage
    Medicine: vaccines, and antibiotics

  40. Lawrence C. says:

    Joe asks again: “So, when you wrote that you didn’t mean to imply that the ancients had something more than anecdote to work from? What was your concern, and what did you mean by “Well, no.”? The latter sure sounds like you think they had something more than anecdotes available.”

    They probably did, but who can definitively say? “Only” isn’t called for in absence of a time machine. In any case, the concern is this: the one thesis for which there can be in principle no scientific evidence is the thesis that only scientific evidence counts.

    The evidence of things lost in “ancient China” is a fascinating topic but to say that “only” something exists from that time is to wildly assume so much that it would take a book to really explain.

    Come to think of it, there is a book that investigates this sort of problem, one by the Nobel Prize-winning French scientist Jacques Monod titled Le hasard et la nécessité. (I think there is an English translation available.)

    I would like to discus such things further but I have been recalled to duty, such as it is, and won’t be around for some time. Au revoir, médecins et scientifiques de saisir!

  41. nitpicking says:

    BillyJoe, you do realize that both yellow fever and malaria were once rampant in the USA? They weren’t stopped by antibiotics or vaccines–they were stopped by insecticides, window screens, and improved drainage.

  42. Zoe237 says:

    Not to impugn doctors, but indoor plumbing is clearly the greatest invention of modern man. Besides the iphone of course. :P

    I’m not sure the life expectency of 30 of ancient China is a good argument against acupuncture, either. It seems like it took scientific medicine a great deal longer than other scientific revolutions to surface after the englightenment.

    I’m wondering if acupuncture, reiki, faith based, Dr. Oz/Weil style healing is the entering of religion into medicine. As less and less people go to church, are they looking to medicine for some sort of unmet need? (I am completely anti-religion, btw). Because the supposed effectiveness of acupunture strikes me as an elaborate religious/spiritual ritual designed for placebo effect.

  43. Joe says:

    @Lawrence C. on 16 Jan 2010 at 8:27 pm Joe asks again: “… The latter sure sounds like you think they had something more than anecdotes available.”

    They probably did, but who can definitively say? “Only” isn’t called for in absence of a time machine. In any case, the concern is this: the one thesis for which there can be in principle no scientific evidence is the thesis that only scientific evidence counts.”

    “Probably” isn’t called for in the absence of a time machine.

    Do you have any evidence, scientific or otherwise, concerning non-scientific evidence that counts? It sounds like special pleading to me.

    I am reminded of the lawyers’ adage that when you can’t argue the facts, argue the law; when you can’t argue the law, argue the facts; if you can’t argue either- just argue.

  44. Dacks says:

    @Zoe237,
    “Haven’t skeptics been railing against chiro and acupuncture for thirty years? Has it made any difference? Given the demand, and the number of medical schools teaching integrative, I’m not sure at all.”

    I think it is important to remember that the integration (so to speak :)) of CAM into the mainstream culture isn’t happening in a vacuum. There is a lot of money to be made by practitioners who need little or no training before gathering customers. The startup costs are low, and a good marketing campaign is all that’s really needed.

    The government has been active in promoting CAM modalities through deregulation. In my opinion, we are still seeing the ripple effects of DSHEA ACT of 1994. The public interprets the decision by Congress to legalize supplements with no oversight as tacit approval of their efficacy.

    Likewise, the overall trend towards “integration” in hospitals, schools, insurance companies accomplishes two goals: more money for these institutions; and legitimization of these therapies, leading to – more customers!

    A good businessperson CREATES demand for his or her product. I think we are seeing capitalism in action, aided by (self) interested government participants. At least this is part of the story.

  45. Enkidu says:

    @ nobs: “The plural of data..”

    The word “data” is already plural. :oP

  46. Enkidu says:

    Hmmmm…. didn’t mean for that weird face to appear in my post above!

  47. cloudskimmer says:

    This article is too good to waste on a forum that consists, primarily, of skeptics. I’d really like it to be sent to the “doctors” in question, and find out what they have to say in response to their so-called evidence being shown as completely inadequate. And then, it should be sent to the publication where it was printed in the first place which should print it. Doctors who want to practice miracles instead of medicine, and maintain that evidence supports their beliefs should be able to respond to Dr. Crislip. And it would be interesting to read their replies.

  48. Mark Crislip says:

    No way am I going to say the plural of datum….

  49. BillyJoe says:

    Well okay then:

    Anecdotes ARE data, they just aint proof.

    Everyone happy now?

  50. yacman says:

    I’ve always been a bit skeptical when it comes to acupuncture. My (maleable) opinion is that it might have some palliative effects on pain, but I think it is unlikely to have any long term benefit. I talked to an acupucture therapist once who said that it “boosts your immunity.” I doubt it, and I don’t see a mechanism. I did read somewhere that it causes a local burst in opiod production and has benefit for recovering drug addicts–but this would be awful hard to demonstrate objectively and I wonder if it isn’t all placebo effect. It seems to me that one of the challenges is finding a negative control. I’m a little surprised, if true, that patients can’t tell the differences between a toothpick sham and a needle. It is a lot easier to control a pill study.

    That’s my thinking FWIW.

  51. BillyJoe says:

    yacman,

    I was about to reply at length but then I remembered Harriet Hall’s article on acupuncture. Here is the link, it will answer all your questions and more:

    http://www.sciencebasedmedicine.org/?p=252

    There’s also a pile of references at the end if you’re interested in studying it further. :)

  52. yeahsurewhatever says:

    I have to wonder about the validity of other information in the paper like war and the economy. You know, important stuff. It could probably be argued that since the YOU Docs are in the “How We Live” section, the same section that carries horoscopes, the movie and TV reviews, the weather report — the fiction section — it should not taken seriously.

    What paper is it you’re reading that still has a nonfiction section? I thought they stopped including those around the time Hearst bought everything.

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