Quacks and their apologists often cite surgery and emergency treatments of traumatic injury and a few other catastrophic or potentially catastrophic events as the only “conventional” or “allopathic” methods that they consistently recommend. Explicitly or implicitly, for most problems they tout “holistic” or “CAM” treatments. In modern medicine, however, there are plenty of non-surgical and non-emergency treatments whose outcomes are so manifest that even the most exuberant advocates of implausible medical claims (IMC) seem careful to steer clear, lest they blow their cover. Where are the promoters or consumers of homeopathic contraceptives? Why haven’t we heard of a chiropractic adjustment for high blood sugar? How many pitches for Ayurvedic treatments of gout have you seen? There are exceptions, of course, the most notable being the nearly ubiquitous anti-immunization stance among IMC promoters.
Anesthesiology and Implausible Claims
In my day job I specialize in anesthesiology, a non-surgical field whose methods are so obviously effective that little is heard from the IMC crowd. Consider: is it likely that even the slickest of the current crop of snake oil salesmen, if they had the bad sense to try, could talk many people into accepting an implausible method for rendering the body insensible to pain? No, that would require a more effective form of persuasion, such as that used in China to promote “acupuncture anesthesia” from the mid-1950s until the end of the Cultural Revolution in 1976. That’s a story I’ll tell another time.
A few other implausible claims have crept into the broader realm of anesthesiology. Stimulation of the “pericardial 6″ acupuncture point on the ventral aspect of the wrist is said to prevent post-operative nausea. There is little basis for this, the Cochrane Review notwithstanding. Verbal messages, given to a patient under general anesthesia, are said to result in “faster healing.” The major proponent of this claim is Peggy Huddleston, a self-described psychotherapist with an M.T.S. (Master of Theological Studies) degree from the Harvard Divinity School. Ms. Huddleston appears to have parlayed the “faster healing” claim into a successful entreprenurial venture, featuring a website, workshops, CDs, and a book:
The book and the website are chock full of flattering endorsements. Most are from usual IMC suspects such as Andrew Weil, psychokinesis proponent Larry Dossey, Christiane Northrup (who wrote the book’s foreward), Therapeutic Touch guru Jean Watson, “medical intuitive” Caroline Myss and her patron, former neurosurgeon and “Holistic Person of the Year” C. Norman Shealy, cardiac surgeon Mehmet Oz, whose apparent scientific naiveté is more than matched by his expertise in making a buck from nonsense and banalities, and “mind/body” maven Joan Borysenko.
Some of the endorsements are from people who should know better, such as surgeon Susan Troyan and anesthesiologist Gerald Zeitlin, and four surgeons who appear on a series of “Testimonial” DVDs available for purchase on Ms. Huddleston’s website. I’ve met or worked with each of the MDs who should know better, and I’m guessing that none has bothered to consider Ms. Huddleston’s claims in more than a fleeting way. Rather, they are understandably more than willing to endorse a program that appeals to a few of their patients, particularly those who are frightened.
Plausible Claims, Prosaic Claims
Indeed, one of Ms. Huddleston’s core claims is entirely plausible:
…if you are facing major surgery, or a life-threatening condition, surgery can be frightening. The mind-body techniques you’ll learn here will give you ways to cope with your fears and actually feel peaceful during the hours, days and weeks before your operation.
Relaxation exercises, including visual imagery, really do help some people feel less anxious. It is even plausible that feeling less anxious can seem to reduce pain, because the discomfort of pain is reasonably construed as two distinct phenomena: the pain per se and the associated anxiety. To the extent that anxiety can be alleviated by non-narcotic means, it is reasonable to predict that narcotic requirements will be reduced. In 1977 a psychiatrist at the Massachusetts General Hospital made this point to a group of medical students, including me, in the context of teaching us to do hypnosis (so much for that being defined as “unconventional medicine” by virtue of its not being taught in medical schools).
It is also conceivable that a reduction in narcotic requirements might reduce the time a patient remains in the hospital after surgery, which is a recurrent claim in Ms. Huddleston’s book. This could be true because the need for pain medicine requires hospitalization only if the medicine must be given “parenterally,” i.e., by the intravenous or intramuscular route, and because ambulation and return of bowel function (in the case of patients who have undergone intra-abdominal surgery) occur sooner if the patient has had less narcotic. Ms. Huddleston’s claim that her method reduces hospital stays by an average of 1.5 days, however, requires more evidence than mere possibilities. More on that below.
Another of Ms. Huddleston’s claims is not only plausible, but is nearly self-evident and has been accepted for more than 40 years: meeting the anesthesiologist before surgery reduces a patient’s anxiety. Other assertions in the book are equally reasonable, if equally self-evident: talk with your surgeon, ask about alternatives, consider seeking a second opinion, discuss plans for post-operative pain medicines, ask about donating your own blood in advance in case you need a transfusion (although Ms. Huddleston is incorrect when she states that doing so confers “no risk to being exposed to disease,” because clerical errors in blood banking still apply), consider short-term psychotherapy if you’re really scared, and a few more. If these were her only claims, Ms. Huddleston’s book would hardly be worthy of a skeptical review here at SBM. It would also hardly be worthy of having been written.
No matter: a series of other claims impugns the book, among which a few examples follow.
…recent studies have documented that care, appreciation and love boost the immune system and enhance the functioning of the heart…Since the heart creates a large electrical field of energy that influences every cell, this has a very positive effect on the entire body.
Your illness or physical condition is already trying to “talk” to you, telling you that something is amiss. Your intuition knows what is out of balance and causing a health problem. Allow yourself to hear what it is.
While surgery will correct the physical problem, you’ll want to look for the underlining [sic] emotional component that may be causing it. Often there is one.
The key to her recovery was sending healing to her finger whenever the thought of it came into her mind. It was a simple but profound act. It re-established the natural flow of energy to her arm and finger. With time, this allowed her broken finger to mend as well as her broken heart.
Without touching the body, practitioners use their hands to influence the field of energy that pulsates in and around the physical body. Physicists call this a force field. A growing body of clinical research shows that Therapeutic Touch lowers blood pressure, reduces pain and helps wounds heal faster.
The results of Dr. Byrd’s [intercessory prayer] study are remarkable. If a drug study had these results, it would be hailed, becoming the drug of choice.
Lakota children could easily merge their beings with an eagle, soaring with it through the clouds.
If you can’t use anesthesia or pain killers, acupuncture makes even major surgery free of pain. For 5,000 years, acupuncture has also been used for the treatment and prevention of disease.
You’ll use less pain medication after surgery if your anesthesiologist says three Healing Statements to you during surgery. Medical research documents the dramatic benefits…Therapeutic statements will someday be a routine procedure…While there is ongoing scientific debate about how much an anesthetized patient can hear, one point is clear: We never stop hearing.
Many of these claims are familiar to SBM readers or are plainly absurd, and need not be discussed here. I’ve already promised to discuss acupuncture-as-anesthesia at another time. Here I’ll limit my comments to the last claim, which is both less familiar than the rest and the crux of the book. Here is her summary of “Healing Statements for Surgery” that Ms. Huddleston recommends be recited to patients under general anesthesia:
(Give this page to your surgeon and another to your anesthesiologist. Tape a third page to your hospital gown, so it is visible as you go into surgery.)
As I am going under anesthesia, please say:
#1. “Following this operation, you will feel comfortable and you will heal very well.” (Repeat 5 times.)
After saying the statments, please put on my earphones and start my tape player.
Toward the end of surgery, remove my earphones. Say:
#2. “Your operation has gone very well.” (Repeat 5 times.)
#3. “Following this operation, you will be hungry for ______________ .You will be thirsty and you will urinate easily.” (Repeat 5 times.)
#4. “Following this operation ____________________________________________________ .” Fill in your surgeon’s recommendations for recovery. (Repeat 5 times.)
Ms. Huddleston offers several references in support of this claim, most of which are either more than 40 years old, were never published, or are book chapters rather than scientific papers. Two exceptions are controlled trials that are about 20 years old. The first, of which I’ve only read the abstract, is a small study that reports shorter hospitalizations and shorter periods of fever in the study group. The second is slightly larger; its entire report is available online. It reports modestly reduced post-operative morphine use in the study group, but no differences in pain scores or nausea. It did not address duration of hospitalization.
What Ms. Huddleston fails to tell us is that there have been numerous other relevant studies, many of which preceded her book’s original publication in 1996 and almost all of which preceded her book’s 2nd edition of 2006. Although there are exceptions, the preponderant findings fail to support her claim. That aggregate result, as Steve Novella pointed out recently, is the real story here. There is also a body of literature demonstrating that various agents used for general anesthesia suppress recall and learning in a dose-dependent fashion, exactly as someone familiar with biology would predict.
Can Pre-Operative Psychological Intervention Reduce Hospital Stays?
What about the more plausible notion that pre-operative suggestions, particularly those aimed at reducing anxiety, can reduce the duration of hospitalization? In her book Ms. Huddleston offers two references. One reports an earlier return of bowel function in patients who have undergone intra-abdominal surgery if they had previously received a suggestion that their bowel function would return promptly. The control group received a non-specific “reassuring” suggestion, so it can be argued that the two groups had equivalent anxiety-reducing interventions. The study was small, and the identical number of 20 subjects in each group casts doubt upon its claim of randomization. Ms. Huddleston’s other reference has no abstract.
On her website, Ms. Huddleston cites three studies purporting to show that her own method leads to favorable outcomes, including shorter hospital stays. She provides abstracts for two of the studies (here and here), neither of which appears to have been subsequently published. The third, a letter published in the Journal of Alternative and Complementary Medicine, looked at non-surgical subjects and fails to support her claim, merely reporting “a tendency for a decrease in anxiety in the imagery group.”
There is, nevertheless, a body of literature that gives modest if inconsistent support for the notion that reducing anxiety may be helpful in various ways, including a reduction in requirements for pain medicine and reduced hospital stays. Do patients actually “heal faster”? Ms. Huddleston offers several anecdotes in her book to suggest that this is the case—with the word “heal” actually used in its literal sense—but there is no literature to support it.
An appendix in Ms. Huddleston’s book is titled “Vitamins that Speed Healing,” written by Judith Petry, MD. It sensibly advises against “supplements” that are known to delay blood clotting. It recommends vitamins A and C and bromelain to “improve the immune system” and “promote healing.” For these recommendations it cites “volumes of medical literature,” all from the 1960s and ’70s. I hope that few post-menopausal women will take the vitamin A recommendation seriously, because doing so over several years will likely result in an increase in the number of hip fractures.
It’s funny that Dr. Petry did not mention vitamins that probably do improve certain outcomes after anesthesia. It turns out that nitrous oxide, until recently a nearly ubiquitous agent in general anesthetics, increases plasma homocysteine levels by means that are entirely understood. It also turns out that this increase in homocysteine, a substance known to be a risk factor for heart attacks and strokes, confers an increased risk of post-operative myocardial ischemia (inadequate blood supply to the heart muscle). Finally, the pre-operative ingestion of three vitamins—folic acid, vitamin B6, and vitamin B12—prevents this effect by entirely known mechanisms. Although the use of nitrous oxide has diminished markedly over the past few years, precisely because of such findings, it still might be useful for some patients to be aware of the risk and its simple prevention.
Ms. Huddleston’s book, like much of the literature espoused by her champions, is a mixture of unremarkable suggestions and extraordinary claims for which there is no credible evidence. Her business appears to be booming: at about $500 a pop, she has grossed more than $3 million in 2-day Workshops alone, and she needn’t even be present. Her asking fee for a one-hour talk at Grand Rounds, according to Someone Who Knows, is about $5000. Her fee for a 50-minute phone call, by comparison, is a mere $155. I dunno how much she’s made from her book and her tapes, but she also invites websurfers to make tax-deductible contributions to her Foundation, in order to fund more promotional studies. Not bad work if you can get it.