Angry Responses to My Piece On Alternative Medicine

First of all, my deep apologies for not posting in so long. I’m going to get back to a regular schedule, I promise.

My long article on alternative medicine came out a few days ago in The Atlantic. In a nutshell, I explain why more and more doctors are recognizing that alternative medicine does a better job in some ways with many patients than mainstream medicine does–even though the core physical treatments of alternative medicine seem to rely mostly or entirely on the placebo effect. In particular, I make the case that alternative practitioners tend to invest more time and effort in helping patients adopt healthier lifestyles and attitudes than do mainstream doctors, and these changes are likely to do more for most people’s health and wellness on average than mainstream treatments.

Not surprisingly, several prominent medical-science bloggers have gone ballistic at the suggestion that alternative medicine might have something going for it. Here’s a brief list of links to some of the notable, highly critical responses to the article:

Steven Salzberg’s response
Steven Novella’s response
David Gorski’s response
Matthew Herper’s response

I responded at modest length to each of these posts in the comment sections under the posts (except for Salzberg’s post to the Atlantic, where my response is on a separate page. Salzberg and Novella, both highly respected scientists (and Novella is a physician as well) known to be strongly opposed to alternative medicine, were interviewed by me at length for the article, and their viewpoints were, I think it’s fair to say, well-represented in the article. (Neither has suggested otherwise.) I didn’t interview Gorski, but mentioned him in passing in the piece. Gorski is a physician-scientist who must be among the angriest voices on the planet with regard to alternative medicine–he is the hardest-core of this group of hard-core anti-alternative-medicine warriors–and he went after me some months ago with regard to my Atlantic profile of John Ioannidis, the highly acclaimed physician-researcher who has found so many problems with published medical research. Herper is, I believe, a lowly journalist like myself.

I’d like to make some relatively broad comments about these mostly angry responses to my article. I’ll start off by pointing out that while these folks imply (they of course don’t come out and say so) that they are representing mainstream medicine and indeed all of science and perhaps all of Western thought, they are not. As my article makes clear, mainstream medicine has been slowly moving toward increasing acceptance of alternative medicine. Increasingly, Gorski and other hard-core opponents of alternative medicine are themselves gradually being pushed toward the fringes of medicine. (Gorski concedes as much in his post.) Whereas I found top physician-researchers happy to say good things about alternative medicine wherever I looked, including at some the most prestigious academic medical centers in the world–I wasn’t even able to fit them all into the article–I had to work a bit to line up two highly respected, articulate scientists who were intensely opposed to it so I could fairly present that point of view in the article.

Don’t take my word for it–go out and ask physicians you trust what they think of alternative medicine. Yes, many still object to it, and most have some concerns and hesitations about it (as do I), but I’ve found that most have come to accept to some extent the fact that some of their patients, for whatever reasons, seem to get some real benefits from it, and often with problems that seemed resistant to mainstream medicine. Why would a caring physician, or any scientist, find this fact so hard to take?

Some of the attacks on my article also attempt to paint me as an alternative-medicine “apologist.” But what does that even mean? Am I imagined to attend meetings of my fellow apologists where we come up with our arguments together? Apparently I’m being assigned to some terrible camp for which I’m supposed to be judged, rather than for my actual argument. Are my attackers mainstream-medicine apologists? Do any of us have to stoop to name-calling to make our points? For the record, I’ve never had anything to do with alternative medicine in my entire life until I took on this article, either as a patient or a journalist, and I did my best to come into it with an open mind, and with no skin in the game. If I’m an apologist for this field, I’m an incidental one.

There are two main claims that underlie all the attacks on my article. They are: 1) Because physicians could in principle provide the sort of health-improving attention to patients that alternative practitioners by most accounts are today much more likely to provide, and because it is so difficult to clearly prove that alternative practitioners do in fact do a better job in this regard, it’s wrong to say that alternative medicine offers any advantage in this regard.  And, 2), because alternative medicine incorporates core treatments that don’t actually have the (implausible) direct physical effect claimed, but rather work by the placebo effect, alternative medicine is a fundamentally evil, anti-scientific entity (voodoo!), and therefore one must never suggest there is any aspect of alternative medicine that might be good.

I can only shrug at these notions. You’ll either buy them or you won’t. I don’t, and most physicians don’t, as far as I can tell.

Those two basic arguments underlie Gorski’s particularly rabid rant, too. But if you read it, you’ll quickly find yourself buried in a detailed, apparently point-by-point refutation of virtually everything I say in my article. He goes through the article paragraph by paragraph, sentence by sentence, finding in each the logical flaw, the fallacy, the error of argument. Do I compare A and B? Then I’m a fool because A and B are different! Do I contrast C and D? Then I’m a fool, because it’s a false dichotomy! Do I assert a point about science? What do I know about science, I’m a journalist, and therefore a fool! Do I quote a Nobel Laureate? Then I’m a fool, because I’m arguing from authority! Do I point out a problem with mainstream medicine? Then, fool that I am, I’m setting up a straw man! Do I cite a study? Then I’m a fool, because that study was trash, or I’ve misinterpreted it, or it doesn’t apply here! Do I say that randomized studies, the gold standard of medical science, can’t really settle the question of whether alternative medicine might ultimately do a better job in some ways? Then I’m a fool, because any question can be settled with randomized trials, and in fact the studies have been done!

A brief aside about studies: There are hundreds of thousands of researchers whose careers depend on producing studies, so I’m not exaggerating when I say there is a study, and probably ten or 50 or 200 of them, for just about any reasonable question you could possibly think of, with results for each question pointing in every possible direction. And in medical science sooner or later someone manages to cobble together a version of study for each question that can be called a randomized study. When someone like Gorski sets out to prove a point, or (as is more often the case) trash someone else’s, he’ll point to one of these studies and cackle, QED! And when his opponent, if she is playing the same game, disses that study as junk and plunks down a different study that points in the opposite direction, Gorski will declare that study invalid in some way. And soon the two will be slapping studies down in front of each other and tearing them up like a violent game of crazy eights. I never go there. In fact, I would prefer to not quote studies at all in my articles for that reason, but editors strictly require it–I have never been able to win that argument. But I do so knowing the Gorskis out there will claim they can trump my study with their study, or howl at every point that isn’t backed up by a study.

At this point, if I were anything like Gorski, I’d fire back by taking on every single point of his rant, and show why each is flawed, and why every one of my points should stand. I won’t play that game, because it accomplishes nothing. (Well, I play it a little, but try to keep it short, and to assert a broader perspective.) There is no argument in the world that a Gorski can’t tear apart point by point, and (you’ll have to trust me on this) no tearing apart Gorski could produce that I couldn’t in turn rip to shreds. You can see these sorts of mind-numbing, often semi-childish back and forths in many of Gorski’s rants, since his targets do sometimes take the bait, and you can frequently see them play out in the comments underneath his posts, since he draws a crowd that loves playing this game.

The basic problem here is simply that of being unable to see the forest for the trees. Science by tradition endeavors to break down phenomena into their simplest component parts, and many scientists, and fans of science, become so enamored of this approach (which certainly has its benefits) that they are incapable of approaching anything any other way. I suspect this is why when Gorski enters an argument, he immediately atomizes. What he won’t, and perhaps can’t, do, is take a step back from the dueling studies and the logic errors and the flawed reasoning and the inappropriate comparisons, and instead look at the big picture objectively, and ask, What’s really going on here? What might I be missing? Is there another way of looking at this? Does there seem to be some important, underlying truth that’s being suggested here, a truth that may differ from the “truth” I’ve been clinging to, at least to some extent?

In the case of this subject, that shouldn’t be hard to do. My point is incredibly simple. Our healthcare system has left physicians unable to lavish the time on patients needed to make patients feel fully cared for, or to invest time and resources in getting patients to adopt the healthy behaviors and attitudes that are so effective in lowering the risk of our most serious diseases and in relieving the pain and discomforts of many,  many disorders. (I’m not even really making a controversial point here–you can read much the same in the pages of the New England Journal of Medicine of the Journal of the American Medical Association.) Alternative medicine practitioners often focus on these approaches, and many patients indisputably report that they benefit from it. Why should we care at all about medical science if it isn’t dedicated to making us feel more well? But the enemies of alternative medicine are so blinded by their disdain for the “voodoo” element of alternative medicine–the fact that its core treatments depend on the placebo effect, and have no plausible mechanism–that they refuse to give an inch on any aspect of alternative medicine. Never mind that this placebo effect has been shown to accomplish wonders with regard to how patients feel, or that many and probably most of the drugs that physicians prescribe also don’t do much more than placebo for most patients, along with carrying a risk of horrific side effects. And again, you can look all that up in the medical journals.

What I’ve tried to do in my Atlantic article, and in most of my work these days, is raise questions in areas where people already think they know the answer, but may not. I try hard to resist the temptation to claim that everyone should simply embrace a different answer, but rather merely endeavor to show that there may be a different answer, or set of answers, that work, to some extent, in some situations, for some people. I want to provoke intelligent conversation on a subject where many or most people didn’t think there was anything to discuss. I want to open closed doors. But the Gorskis of the world treat intellectual doors as if it is their sworn duty to keep them tightly latched shut. They claim they’re defending science. I assure you they are not. Nothing more closely represents the spirit of science than open-mindedness and a determination to put biases aside and seek out the ways in which one might be wrong. Nothing is a bigger affront to the scientific spirit than to put all one’s might into trashing all arguments and evidence that threatens a preferred point of view. I estimate I’ve interviewed over a thousand scientists in my career, and the great majority of them were perfectly willing to confess their doubts, their hesitations, their concerns with being wrong, the questions that haunt their work and beliefs. The scientists who never give an inch when confronted with opposition to their claims and beliefs, who react with bile and disdain, who tear apart and take no prisoners, are as far as I can tell outliers, and are easily and best ignored. They can blog to their hearts’ content, and win a core of like-minded fans, but in the end they won’t do much harm. They’re noisy preachers to the choirs.

But here’s the biggest point I’d like to make about the alternative-medicine debate: Don’t take my word for it, don’t take the word of the Nobel Laureate or the top scientists I quote, don’t take the word of the alternative-medicine practitioners I quote, and please, please don’t take Gorski’s word for it. Go out and see for yourself. Talk to mainstream doctors, and alternative-medicine practitioners. Talk to people about their experiences with different types of treatments. Decide for yourself whether there isn’t something interesting going on with alternative medicine, something that seems to provide real help to some patients who were let down in some way by mainstream medicine. We don’t all have to agree on what exactly is going on here, or whether it is entirely a good thing. But I’ll bet you won’t end up thinking that, as Gorski and others assert, alternative medicine is a purely evil and harmful thing that must be crushed. But fair warning: You may end being called an alternative-medicine apologist. On the other hand, you’ll be in good company.

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33 thoughts on “Angry Responses to My Piece On Alternative Medicine

  1. Hello David and thanks for these observations on your Atlantic piece and the resulting excitement it elicited. You have struck a nerve, clearly! And yet it seems to me that your biggest crime here was to simply Ask The Question.A research scientist told me once: "For every PhD, there is an equal and opposite PhD." That truism now helps me in questioning virtually all "evidence" – both CAM and anti-CAM types alike. I am simply a dull-witted heart attack survivor who, suddenly alarmed by the fistful of cardiac meds I must now take every morning, began digging into disturbing issues around "marketing-based medicine" as practiced under the powerful influence of Big Pharma. Bingo! A skeptic was born. But it seems that self-described skeptics like Dr. Gorski are skeptical only about alternative therapies, not about how the practice of modern medicine may seriously need to improve. You hit the nail on the head when you talk of prevention. For whatever reason (lack of time, no billing codes, limited knowledge?) many MDs do not hammer home the important ways their patients can PREVENT heart disease for example (exercise, diet, quit smoking) in favour of pulling out their prescription pads to order statins as they have been trained to do by their drug reps. I've quoted your work a number of times in my own writing after hearing your Australian interview with Phil Dobbie. Keep up the good work, David!

  2. Anonymous says:

    David, I don't think you read these articles prior accusing the authors of not having read yours.Very few people have a problem with the idea that lots of people will take better care of themselves if they have an alternative medicine guru to hold their hand. But your statements, and your uncritical quotation of statements by others to the effect that modern medicine has had little or no effect outside of infectious diseases flies in the face of mainstream opinion and readily accessible facts. Deaths from cardivascular disease have dropped dramatically (some 50%) over the last decade in spite of less healthy lifestyles. Diagnosed with cancer today, your chances of being dead within 5 years have fallen by about a third relative to just 15 years ago. I could go on, but I think these are sufficient to make my point. Simply put, you casually and incorrectly dismissed the hard (and to a very significant degree, successful) work of thousands of researchers over the last 2 decades. That's what people are angry about, not the comments on accupuncture (which I have made use of myself).

  3. Hello Anonymous, thanks for writing. First of all, I appreciate the fact that you're trying to show me the error my ways, rather than simply flaming me. I only accused Matthew Herper of not reading my whole article, and I think my comment at his blog justifies that belief. I have no idea why you think I didn't read the articles that I've commented on, but in any case, for the record, I did read them before commenting. It sounds like you're saying I should have provided some sort of criticism of the quotes from the top physician-researchers and the Nobel Laureate I provided, or perhaps that I shouldn't have quoted them at all. I thought their comments should speak for themselves, without my providing any cheers or jeers, and they seemed like pretty credible and informative sources to me. I also quoted two of the world's foremost critics of alternative medicine, and let them make their arguments at length. I think readers can decide for themselves, without any need for me censor or critique anyone's comments. Do you look for that sort of balance in sources before you express your opinion? I hope so, and if not I highly recommend it, it can really open your eyes. No one knows what the decline in heart-disease mortality rates is due to. The best guess seems to be the drop in smoking and the improvement in emergency treatment of heart attacks. Few studies have attributed much of the mortality drop to the drugs that tens of millions are put on. Remember that changes in lifestyle will show up as changes in mortality years and decades later–that would jibe with a decline due to the sharp drop in smoking rates, and would suggest that the obesity problem is going to catch up with us. I believe it's fairly well accepted that cancer mortality rates are severely compromised by earlier diagnosis. I respect your opinion that medicine has been highly successful, but I disagree with it, as do many of the top physician-researchers in the world, and there is abundant study evidence to back this up. I am well aware that there is also evidence that can be interpreted to suggest otherwise, and believe everyone should decide for themselves. Personally, I don't go around telling others that their interpretation is flat-out wrong and mine is right, or try to make it seem that others don't know what they're talking about. I recognize there is room for disagreement here, as I would think any reasonable person would. I don't agree with your interpretation of what constitutes mainstream opinion either, but that can be a hard thing to quantify. I also don't do agree that I've done any of this casually, and can't imagine what you're basing that assessment on. What's more, I have dismissed absolutely nothing. I am a huge fan of medical science, and applaud its great progress in some areas, and its slow, difficult progress in others. That doesn't mean we have to have our heads in the sand about, or keep our mouths shut about, where medicine has had a real tough time helping patients as much as it wishes it could. Many physicians and researchers are very open about this, and it's shame you and many others want to treat it as an insult, or a dirty secret, or a lie. It's not. It's just the way science works.And finally, I wonder how you know what it is people who have been attacking my article are angry about. I can't read minds, and I'm betting you can't either. I don't agree with your assessment on that score. I do think some of these folks are probably annoyed that my article has some grim things to report about mainstream medicine, but my judgment is that what really upsets them is that I've found something nice to say about some aspects of alternative medicine, given that my loudest attackers have made little effort to hide their deep, passionate hate for alternative medicine.

  4. I’m a big fan of the clarity you bring to important issues. I have “Wrong” on CD and am on my third listen. A few comments.It can be difficult to create an RCT that meets Western criteria for demonstrating the efficacy of Eastern medicine/practices. I thought this comment in an NEJM editorial on “Tai chi for fibromyalgia” (http://bit.ly/jT6WZc) was apt (one of the authors of the editorial is Ted Kaptchuk): “The authors state that they tried to minimize any a priori differences between expectations for tai chi and the control intervention, which consisted of stretching and health education, and they report that expectations in the two groups were similar at baseline. However, it seems likely that when a persuasive and enthusiastic teacher of tai chi first explained its potential benefits to the class, expectations in this group were heightened. The authors dutifully suggest that a sham tai chi intervention would have been desirable as a control. Ideally, a placebo control matches all aspects of the therapeutic intervention except for the ‘active’ element of that intervention. But what is the active element of a complex, multi-component therapy such as tai chi? Is it rhythmic exercise, deliberate and deep breathing, contemplative concentration, group support, relaxing imagery, a charismatic teacher, or some synergistic combination of these elements? If so, would the matched control include awkward movements, halted breathing, participant isolation, unpleasant imagery, or a tepid teacher? Would the resulting sham intervention be credible, valid, or even genuinely inactive?”On an historical note, in the 19th century, physicians had little to offer by way of medical treatments. As my favorite historian of medicine, Roy Porter, once put it: before the 20th century, a doctor’s “pharmacoepoeia resembled a box of blanks.” Practitioners of “irregular” medicine (homeopathy, hydrotherapy, Thomsonianism, Grahamites) flourished. Homeopathy appealed to the wealthy (John D. Rockefeller, for example) because it was safer than the heroics (blood-letting and purges) of “regular” medicine.The resurgence of alternative medical practices in the 1960s coincided with a general criticism of Western values. Medicine had become bureaucratic and was associated with the authoritarian values the counter-culture rejected. By the end of the 20th century, criticism of the medical system was extensive. It was not cost-effective. It was not equitable. And it was not even particularly safe. This loss of confidence led many individuals to seek out patient-friendly alternative forms of healing. Medicine is not a science that exists in a vacuum. There’s always a social/historical context. Let's hope your critics are eventually able to wake up and smell the coffee.Thanks so much for your high quality investigative journalism. I look forward to reading much more. I particularly enjoyed your article in The Atlantic on John Ioannidis.

  5. David, I was going to let the whole "you didn't read it," pass, given the tone of my own response to you and given the fact that, as you say, I'm but a lowly journo.But just to be clear, I did read the whole thing, twice, before posting. And there were really two points I was making. First, that alternative medicine is not preventative. And second (and the reason for most of my tone) is that those two paragraphs represent one of my own worst fears as a journalist.You took the precise events I've spent the past decade covering (I wrote the first story on torcetrapib's failure; I broke that Merck/Schering-Plough were sitting on their artery imaging study of Vytorin; I had a bunch of nice stories in the Vioxx and Avandia messes) and you turned them into a straw man that medicines are not working at all. I do agree with a lot of what you wrote. But casually dismissing effective medicines and implying that alternative medicine is somehow preventative (very few things are; statins, a very healthy lifestyle, a PCSK9 mutation) really seemed pretty severe dismissals of science to me. You did it so casually, too.I did love the John Ioannidis profile.

  6. Thanks for writing, Matthew, and especially for being one of very tiny minority of people who are able to recognize that reasonable people can civilly disagree about this stuff. Disagreement is supposed to built into science, not treated like a scourge. If I was wrong in concluding you hadn't fully read my article before posting, then I apologize–I like criticism, and like all lowly journalists, I'd certainly rather be widely attacked than widely ignored (though I try hard not to pander that sentiment by striving to stir up controversy as a motive in and of itself). But one thing that really gets my goat is when someone tries to publicly dismiss something I've worked hard on and care about without taking the time to actually know what I've said. But I realize there may be other reasons why your post seemed to me misaligned with my article, and the fault could be partly or even entirely mine.Even a 7,000-word article can be far, far too short a vehicle to express what one wants to say. The section on the failings in modern medicine was sadly short and inadequate. It was in a sense a 3-paragraph version of the Ioannidis article, which was in a sense a 10-page version of my book, Wrong. The editors and I were very aware of the problem, but in the end we decided it was better to spend the space on the new points the piece was making. Please don't mistake the necessarily summary nature of that section for casualness. There is nothing that I or the Atlantic take lightly about pronouncing medicine to be of highly limited benefit in some regards. I spent a lot of time studying that question. If that claim weren't backed by an ocean of research, including the opinions of dozens and dozens of highly respected physicians and researchers, I wouldn't have advanced it.Of course, there is a lot of room for interpretation of this research, and opinions are just that. Even if two people were looking at exactly the same data about the returns of medicine with regard to chronic, complex disease, they could reasonably sharply disagree on whether the overall results have been magnificent or scant. I wouldn't try to treat someone like a fool or a wrongdoer for that disagreement. I think it's great when these issues get discussed and debated–that's actually my goal, not convincing people I'm right, because I'm almost never sure I'm right, far from it.I acknowledge your significant and excellent contributions to medical journalism–I've been reading your stuff for years, and have clipped many of your articles. And thanks for the kind words about the Ioannidis piece–which David Gorski still insists completely distorts Ioannidis' actual beliefs, because Gorski apparently understands Ioannidis' beliefs much better than Ioannidis does.

  7. I prepared this comment for the Atlantic article, but discovered I couldn’t post it there because I don’t have any of the accounts offered, and I don’t want to create more accounts.
Rather than waste my effort, I brought it over here.Then discovered it was too long!So in three parts it comes (from experience, Blogger will lose my comments if I post three in a row, so I’ll post #1 now and others later):I found this [Atlantic] article via Derek Lowe’s post ‘The Failure of Modern Medicine?’ at ‘In the Pipeline’.The Freedman [Atlantic] article is excellent. I’m not so taken with many of the comments [over at Atlantic]; they seem to be from folks whose views (for or against integrative/alternative medicine) are set in stone. Freedman’s article manages to evoke questions (for readers to ponder) without imposing answers. Without naming it, in his post Derek Lowe referred to alternative medicine’s secret ingredient, “which has been gradually removed from a lot of modern medical practice” (leaving his readers to head over to a linked article to find the answer). As a long-term consumer of both conventional and alternative/integrative medicine I immediately thought, “the secret ingredient is the personal attention and greater time spent with the patient”. Full marks to me, but it’s a “dah” question to pose to someone like me.To some extent the effectiveness of (at least some) pharmaceuticals and surgical interventions has created a problem for modern society. Many people have the attitude that modern medicine can fix everything. With this attitude, why bother to lead a healthy lifestyle when the alternative provides more fun in the short-term and doctors will repair the mess later? I have an overweight friend who is advised by his Dr to take fish oil capsules for prostate, and to exercise to lose weight. My friend ignores the advice because fish oil capsules are too expensive/inconvenient, and he doesn’t have time/inclination to exercise. Later, when he developed persistent nausea after meals, his Dr again raised the need for exercise, but also gave him a sample pack of prescription tablets to try. The tablets worked a treat, so exercise fell by the wayside. In Australia we have a Pharmaceutical Benefits Scheme (PBS), which subsidises the cost of many prescription medicines. I’m unsure if my friend’s prescription tablets are subsidised. I suspect he would continue to take them only if they are affordable, which means either they are on the PBS or the full price is inexpensive (given the Dr hands out sample packs it seems unlikely the full price is inexpensive). So our medical system gives my friend an easy fix. I presume the tablets fix only the nausea, plus perhaps they create some unwanted or, as yet unknown/undisclosed, side effects. If, instead, our system encouraged my friend to exercise (perhaps paying him to do so, plus enabling his Dr to spend more time/attention on why he doesn’t exercise – my friend is in his 60’s; in his youth he played elite sport, his three sons are all super-fit triathletes …), I suspect more than just his nausea would benefit.My friend is unlikely to visit an alternative practitioner, because he wants a quick fix. On the other hand, I prefer doctors who are interested in integrative medicine. My friend and I are examples of two types of patients; one wants a quick fix while the other would prefer to try anything that seems appropriate before resorting to pharmaceuticals or surgery. I suspect this in part explains why conventional doctors and integrative/alternative practitioners/doctors have different attitudes; they see different patients.

  8. First of all, I neglected to respond to Carolyn's comment above, the very first comment. Sorry about that! Thanks, Carolyn, and I agree with your suggestion that what really upsets people about my article, even though none of its individual points are particularly controversial even from the point of view of mainstream medicine, is that it is not rigidly anti-alternative-medicine, and many people are so completely locked into a deeply hostile position on alternative medicine that when they see an article that is moderately friendly to it they are driven to full attack mode, without ever taking a moment to consider what's really being said and whether any of it might actually make a little sense.Thnks, "Both Need Reform," for your comments, too. It's true that there's a self-selection issue involved in the patient bases of mainstream and alternative medicine, and your illustration is a good one. However, I do often run into people who consider themselves pretty firmly as one sort of patient, but who end up for various reasons becoming the other sort, at least temporarily. I find these stories particularly instructive in pointing out the contrasts between the two approaches. There's no strong pattern in how it all works out–some have their minds opened, others have their fears confirmed. (And by the way, I'm sorry posting at the Atlantic posed problems for you, and that you had to break up your post here–looking forward to the next 2 installments!)

  9. David:I'm not angry – certainly not with you. I do get angry, sometimes, when I learn about a scam that directly harms trusting patients, but let me not get sidetracked.I am puzzled at why I can't get some simple points across, to you or to others. So let me try again. I think a big problem is the use of the phrase "alternative medicine," which has been adopted by the Andrew Weil's very effective, and which cleverly co-opts the argument in his favor. You use it yourself when you write above "go out and ask physicians you trust what they think of alternative medicine."I would tell people no, don't do that. Ask your physician what he thinks of Ayurveda, or homeopathy, and see where that goes. That could provide you (the patient) some useful feedback.Exercise, relaxation, a healthy diet, and other lifestyle changes are not "alternative." They're just fine! If you ask your doctor what he thinks of "alternative medicine," and he interprets that as including diet and exercise, then he will probably say nice things – as he should. Andrew Weil wants to include many aspects of real medicine under the same umbrella term, and then (here's his rhetorical trick) he wants to invest various implausible treatments with the same respectability. But each treatment needs to be evaluated on its own merits.I don't want to make this too long, so let me just address one other point in your blog post here. You wrote that "there is a study, and probably ten or 50 or 200 of them, for just about any reasonable question you could possibly think of, with results for each question pointing in every possible direction."This is not true either – and it's a dangerous form of cultural relativism. In science (unlike, say, politics) there are correct answers and incorrect answers. Physics, biology, physiology, genetics – these all work in very predictable ways. We know a LOT about these fields, although it's true that there's much that we don't know. Scientists love to argue about the limits of our knowledge – we're constantly revising what we know, and that's where the debates occur. But we don't, for example, argue about whether DNA is the molecule that contains our genes. It is, full stop.We also don't argue about whether you can dilute a substance down below the value of Avogadro's number and still detect it. Homeopaths, though, when faced with this basic scientific fact, make the wild claim that water retains a "memory" of substances that were in it previously.But I understand that it is hard – impossible sometimes – for an outsider to wade into the literature and see a clear answer. I can't even do this myself when I venture outside my own fields of expertise. But it's just not true that you can find studies "pointing in every possible direction" for most scientific questions. And when studies do contradict one another, it's usually the case that one of them is wrong.

  10. I tried to post a response here earlier, but it did not go up – perhaps this comments section is moderated. At any rate, I wanted to point out that I am not angry, and I don't think it is accurate to say I have "gone ballistic" in my response. I'm certainly not angry with you, David. Primarily I am trying to figure out why the purveyors of treatments that we both agree don't work have been so successful at selling their treatments to an unsuspecting public.As I wrote in my first attempt, the use of the phrase "alternative medicine" to cover a wide range of treatments is probably their most clever strategy. Exercise, a healthy diet, and relaxation are not "alternative." By including these and other reasonable advice in the category, they somehow get away with painting other, completely implausible practices with the same brush.I'd like to modify your suggestion above to ask one's physician what he/she thinks about alternative medicine. Don't do that – that's buying into the marketing of this term. Instead, ask him/her what he/she thinks of homeopathy, or Ayurveda, or some other *specific* practice. Then you might get some useful advice.

  11. Apologies to you, Steven Salzberg, and to others who may find their comments not coming right up. Blogger has instituted a new spam filter that is sending almost all new comments to spam (Steven's 2nd comment went right up, I notice, so I guess it's not totally malfunctioning), and the filter can't be turned off. I promise I don't do any moderating of comments here whatsoever, except for the most blatant spam, eg of the online pharmacy variety. I have it set to post everything immediately. I'm trying to get in the habit of checking spam frequently to catch new, misfiltered comments and get them up, sorry if some of you find your comments temporarily held up–they'll go up!

  12. Jan (who commented a ways above): Thanks much for writing in, and your observations–and for the kind words about Wrong and my article on Ioannidis.

  13. Hello Steven,Again, thanks much for writing in. If you weren't angry, I apologize for lumping you in with the others. Actually, I have no way of knowing who actually felt anger and who didn't when they were writing these responses, and I probably shouldn't impute any emotions or internal mental states to their writing. (I've been amused at the sorts of emotions and personal characteristics and beliefs that some of my critics have freely and confidently attributed to me.) I guess doing so sometimes serves as a useful shorthand for summing up the overall tenor of a piece of writing, if at a cost in accuracy and precision, and perhaps in fairness.I have gotten a lot of criticism (as I suspected I would) over the use of the term "alternative medicine," and concede that there are problems with it. I figured I would get criticism about whatever I did to try to differentiate between, and somehow categorize and name, approaches to medicine that are different in some important way. But I saw it would have taken up precious article space and reader energy to explain all this. So I took the quick and straightforward way out and just used the common term "alternative medicine," trusting that, with a little explanation on my part, everyone would basically know what I was talking about, even if they didn't like the term, or found it an ill-defined or inappropriate categoy, or didn't like everything I lumped into it or what I left out of it. As with much about this subject, I think the fact that everyone seems vaguely unhappy with my choice suggests to me I probably did about as good a job as I could have, from a broad perspective. But yes, Steven, I do get your point, and would have preferred to avoid getting tangled up in the sorts of improper implcations that can go along with naming and categorizing things. And I have no quibbles whatsoever with your suggestion that when people consult others about their opinions of and experiences with different approaches to medicine they clearly spell out exactly which approach they're referring to. In my point of view, the differences between Ayurvedic medicine, acupuncture, massage therapy and hypnotherapy are not all that large in terms of what's really working for the patient–namely the attention of a caring practitioner, a focus on healthy behavior and attitudes, and the administering of a physical treatment in a way likely to promote a strong placebo effect. (And yes, not all "alternative" approaches always provide these things, and yes, many mainstream practitioners provide some or all of these things, but I'm speaking in rough averages.) But I recognize that not everyone–and possibly hardly anyone–fully shares my point of view on this, and it's fine with me to focus in on individual treatments and styles. (Continued on next comment.)

  14. (Continued from previous comment.) I absolutely disagree with the notion that science is just chock full of non-trivial questions for which there can be no debate. DNA is the molecule that contains our genes, stop, because of how we define genes; that's a great example of a trivial question. If we posed the question, Which molecules exert influence over how we turn out? then we might have a more interesting discussion. Few questions that aren't essentially definitions have answers that can't possibly be questioned. We can agree there are some interesting questions for which we have answers that seem overwhelmingly likely to be true, though people can reasonably argue over how overwhelmingly. Things that researchers once thought they knew for sure are now known to be at least partly wrong: In your field, perhaps the lack of important coding information in junk DNA and the non-heritability of epigenetic changes might be good examples of these kinds of surprises (though I don't pretend to know much about it, especially compared to you–if I'm wrong, I'll bet you can come up with others.). In a field I'm more familiar with, the desirability of avoiding all fats and the unlimited wholesomeness of carbs would be good examples.There is a wealth of evidence from mainstream, widely respected researchers that medicine is bombarded with a vast array of conflicting study results. You could write a book about it! (Oh wait, I did.) The first large randomized trial at mainstream medical institutions to test the power of third-party prayer in reducing heart-surgery mortality found that prayer worked. Other studies since have begged to differ. But now anyone who wants to tout the power of blind prayer (prayer when the person being prayed for doesn't even know about it) in surgery outcomes has a gold-standard study to quote. Fans of homeopathy have a big, mainstream review study to crow about, as you of course know. I know, I know, you and I and everyone else can show why each of these studies was flawed or fluky. But guess what? Those who disagree with us can tell us why the studies we quote are flawed or fluky.Studies are vital, but in the end we have to use good judgment. I can't tell you how many respected scientists have said that to me, in various phrasing. Some of us have better judgment than others, and more training in which to apply it, and less bias with which to distort it. I respect your judgment highly. (Continued on next comment.)

  15. (Continued from previous comment.) The issues I raise in my article come down to questions of judgment, and they're legitimate, difficult questions, even for most highly respected, mainstream physicians and researchers. I'm not suggesting an undetectably low level of ingredient can work miracles via direct physical action. I'm suggesting it can have a great placebo effect that substantially contributes to wellness, and is often applied by a practitioner who has the time and determination to really get to understand how their patients think, feel and behave and make changes in those areas to powerful health effect. Some are sleazy charlatans, yes. So are some doctors. Some doctors are magnificent changers of attitude and behavior. We may disagree on whether on average doctors or alternative practitioners are more likely to work for and achieve these changes in attitude and behavior. We may disagree on whether medications really do a lot for chronic complex disease. But these aren't disagreements in fact, by and large, they are disagreements in judgment. We can both have reasonable and opposing points of view on this score. I don't think it's to any scientists' credit to be dismissing my arguments as alternative medicine apologia. That's bias talking, not good science.Your implication that non-experts ought to recognize that they're easily confused when they try to stake out opinions on these questions is I think a very tricky and potentially dangerous one. Many people have written on this question, and there's no easy answer. Scientists know a lot more about this stuff than people like me, but that doesn't mean scientists are unbiased or have gotten off track through error, too narrow a focus, or other means. Einstein could have told you that–you could write a whole book on his goof-ups. (Oh right, someone did.) Sometimes a smart layman with good judgment, good general knowledge, and relatively little bias, and who is willing to do some research, can do pretty damned well on some not-hugely technical scientific questions, especially when they've taken the time to consult with a wide range of highly credentialed experts.Everyone has a right to judge how I did on that score, but I really think my claims merit more than outright, total dismissal.

  16. David Gorski says:

    It's very interesting that Mr. Freedman accuses me of being so very, very "angry" when only very rarely have I seen so much concentrated anger directed against me in a post as this, and, trust me, I've had some pretty angry rants directed at me. Indeed, I'm puzzled at the vociferousness of his reaction. Indeed, even though I've had anti-vaccine activists try to get me fired, I don't recall any of them ever calling me "rabid." I mean, seriously. I'm more than happy to have objective readers look at what I've written, compare it to what you have written here and in the comments of other blogs, and judge for themselves whose rants are the "most rabid."I also note that, contrary to Mr. Freedman's straw man, nowhere have I ever called him a fool in any of my posts, leaving me to marvel at his thin skin. Seriously. Go back and read if you don’t believe me. I’ve simply argued that Mr. Freedman drew spectacularly wrong conclusions from his research and that he framed his presentation to support those conclusions. Apparently he can’t distinguish between criticism of his sloppy arguments and criticism of himself. I also note that Freedman’s argument boils down to assuring us that, yes, he has done the research and that there is “no tearing apart Gorski could produce that I couldn’t in turn rip to shreds.” Trust him on that one, except that, for the umpteenth time, Mr. Freedman fails to produce any scientific evidence or examples to refute a single thing I’ve written and falls back on arguing from authority and straw men.Mr. Freedman won't believe it, but I'm actually not angry and was never particularly angry, certainly not at him. Frustrated? Yes. Exasperated at his poor arguments? Of course. Highly critical of the arguments he marshals to support his apparent fondness for alt-med, sure. But angry? Not so much. I daresay that Mr. Freedman hasn't seen anything I've written when I was actually angry.One notes that it's so much easier to dismiss your critic if you can somehow diminish him by trying to paint him as being driven primarily by emotion, such as anger. That's what Mr. Freedman does, rather than actually engaging with his criticism. One also notes that Steve Novella's latest response to him is every bit as harsh as anything I've written lately; http://theness.com/neurologicablog/index.php/follow-up-on-atlantic-article/Note it's chock full of references to Mr. Freedman's "flawed logic," his "apologist stance" to CAM, etc. He even points out that Mr. Freedman chose to use insults, referred to his arguments as "cheap rhetoric," and accused Mr. Freedman of "projection," none of which I did in my posts. None of this is any less harsh than what I wrote; arguably it's harsher in some ways. Yet Mr. Freedman continues to view Dr. Novella as a paean of civility and me as "rabid."I sense a disconnect here. Confirmation bias, perhaps, based on my original post about his Ioannidis article?

  17. Anonymous says:

    People using alternative medicine receive a treatment and recover – as Freedman asks, "Why would a caring physician, or any scientist, find this fact so hard to take?" Actually, it would be uncaring to encourage such patients to believe they are benefitting from an ineffective agent, rather than from the practitioner-patient interaction and the attention it fosters. To allow a person to continue in error about matters central to one's health is uncaring and dangerous. Attributing a good outcome to the wrong thing had terrible consequences, for instance, in the well-documented history of the disease scurvy, allowing that affliction to continue well into the 20th century. Preventatives that included "plenty of fresh produce and meat" were hit or miss, depending on whether they included citrus or the right kinds and amounts of organ meats. It was scientific, evidence-based research that eventually isolated vitamin C as an antiscorbutic. Was it "caring" to tell sailors to eat fresh vegetables and avoid damp air? Only to the extent that no better information was available. Was it "uncaring" – too cold and logical – to tell them fresh produce would do no good unless it included citrus? Today, there is no excuse for telling patients their health can benefit from a vial of water that once contained a very small concentration of an unproven substance. "Alternative medicine" that pushes a false explanation of recovery is, to put it bluntly, unethical. Better information – about chemistry, biology, psychology – is available. If a benefit is provided, and if that benefit comes from the care and attention of the provider, or the patient's subsequent commitment to healthy behavior and choices, then please say so. Encouraging patients to believe in the efficacy of a non-cure can come back to bite them – next time, when the attentive provider is not present, when the condition might be different or more dangerous than the patient imagines.Sometimes something seems to work and nobody really knows why. Why is this hard to take? Because it should be. It needs to be. Medicine needs to ask why. It's the only way for it, and for patients, to keep from falling into potentially fatal errors.

  18. Thanks for writing, Dr. Gorski. And please, call me Dave. I agree with most of what you say here. I'm being somewhat thin-skinned, have unfairly singled you out for overly harsh treatment, have not bothered to dispute the details of your critiques, and have engaged in unjustified imputation of particular emotions (namely, anger) to your writing when I of course I have no way of knowing what emotions you're experiencing. And yes, the word "rabid" is over the top. I apologize for all this. You may be right in suggesting this is a case of confirmation bias on my part, but of course I'd hardly know that myself. I don't argue the details that you've raised in your critiques because anyone can peruse your blog (or of any blog where sharp and detailed criticism is par for the course) and see for themselves how that game plays out. My belief is I lay out my case, you lay out yours, and readers can at that point make up their own minds without having to watch an endless volley of detailed back and forth in which absolutely no quarter is given, and where absolutely no one's mind is changed. The world of scientific findings was tailor-made to provide ammunition for those battles. (I'm not anti-scientific-studies, by the way, I'm pretty much the opposite, but I recognize how malleable and varied they are on any one question.) I prefer to stick to the bigger picture here, which is simple enough: Doctors don't have enough time for patients and are not reimbursed for or even especially trained for addressing their health-risk-raising behavior and attitudes; alternative medicine practitioners are (on average) more attuned to those goals; both mainstream and alternative medicine practitioners rely on the placebo effect, but alternative practitioners are able to achieve a stronger one for a variety of reasons; and the medications dispensed by doctors, particularly for chronic complex disease and for disorders that involve patient reports of pain and discomfort but that may be hard to treat or even diagnosis–the latter accounting for a large percentage of office visits and health complaints–haven't been clearly proven to do all that much for many or most patients on average, and can carry significant risks and drawbacks. A good placebo treatment and an extra dollop of care, attention and listening, in comparison, can often accomplish wonders, with no harm done (though I acknowledge there is a generally trivial risk of direct harm). These contentions don't come from the world of alternative medicine boosters–I spent relatively little time in that world in researching this article. They come from top medical journals and highly respected mainstream physician-researchers who were happy to acknowledge to these points pretty much everywhere I looked. I had to specifically seek out the dissenters who won't give an inch. It seems pretty clear from what I'm seeing on a lot of blogs and Tweets that many people are reading your and other critiques of my article without reading my article, come to believe that I'm quoting what they see as (and you more or less paint as) the usual nonsense about alternative medicine, and they're pretty comfortable having their beliefs confirmed this way. On the other hand, there are many people out there who (like me) have never been fans of alternative medicine, but who read my article and recognize that there are legitimate questions being raised here, and they, like me, are shaking their heads over the unwillingness of a small minority of physician-researchers to allow for a moment, in the slightest way, that this may be the case.

  19. Thanks for writing, Anonymous. You raise an important point: When a patient feels he has become more well because of a treatment that probably did not have a direct physical benefit, should physicians try to set the patient straight, and in general oppose such treatments? Reasonable people can disagree about this. Most of the physician-researchers I spoke with felt very, very strongly that physicians should encourage whatever it is that makes patients feel well, even when the mechanism of treatment is implausible (and is almost certainly the placebo effect), as long as the treatment doesn't entail significant risk of harm (or create excessive financial burdens). Some people like to argue that the risk is in patients neglecting mainstream treatments likely to be of real benefit, but I made clear in my article that I was applying this argument to alternative practitioners who either are MDs or who work under or in conjunction with MDs. I am opposed, and in the case of children intensely opposed, to neglecting mainstream standard-of-care treatments of disorders known to be very responsive to such treatments. Otherwise, I have to agree with the idea that whatever makes the patient feel better, medicine ought to tolerate, if not embrace. Most major medical schools are more or less in agreement with that philosophy today. But as I say, I can see how a reasonable person might assert otherwise.

  20. I think it's a great piece. And a novel one: So much of what has been written on alternative medicine is either credulous crap written by true believers – or smug oversimplified crap written by so-called skeptics. (Incidentally, why are "skeptics" these days spending all their time defending mainstream medical ideology, rather than doing the more difficult work of doubting conventional wisdom? A skeptic–skeptesthui, "he who looks around"–should be a freethinking doubter of all). In any case, no one can write anything that would make everyone on all sides of such a contentious issue happy. But it makes me happy – and I think most of us Americans who exist between those two extremes. This essay will be hugely helpful to my work. Bravo!

  21. Thanks, Nathanael, good of you to pitch in. I agree that the middle ground is where most of us live on this issue, and as far as I can tell that includes most physicians. And why wouldn't they? They want to see their patients feel well, and even if they see it as little more than some extra hand-holding and a placebo effect, if it does the trick then they're all for it, or at least not opposed to it. It's a little surprising how fully the extremists have been able to dominate the conversation. They've gotten under my skin a bit, as is plain from my apologies above. But a few more comments like yours and I'll have my equilibrium back.

  22. Paul H says:

    A few points come to mind here:Is it OK for health care professionals to tell their patients things that science tells us are untrue? Magic water can cure real illnesses? There are invisible and undetectable energy meridians channeling an invisible and undetectable energy flowing through them, and blockages in that energy cause disease? I am very uncomfortable with this. The state of science education is bad enough as it is, without undermining it by validating nonsense in this way. Do alternative health practitioners really give good advice on lifestyle, and on preventing illness? I know that in some cases they certainly do not. For example, in the UK undercover reporters who asked homeopaths for advice were told not to use vaccines, and even told that a homeopathic medicine could prevent malaria, without the use of antimalarial drugs, insect repellent or mosquito nets. I am aware of several cases of people with life threatening illnesses who have rejected potentially life-saving treatment and died because an alternative health practitioner told them that they could cure them with useless treatments. If patients need more time and attention from their doctors, would it not be better to work on facilitating this, rather than introducing treatments that are ineffective? How is it that people can afford to spend money seeing alternative therapists, but not to see a reputable doctor, a dietitian or a physical therapist?

  23. Hello Paul H., thanks for writing. By coincidence, I address some of your points in my previous comment just above, in response to a comment that came in just before yours. I don't think physicians (or anyone) should blatantly lie to patients. But as I note in my article, we don't know if either alternative practitioners or mainstream physicians believe in the treatments they offer, even when the evidence suggests they work only by placebo effect. Surveys suggest that mainstream physicians are well aware that they frequently prescribe placebos, but I know of no evidence that alternative practitioners don't believe in their own treatments. Is it doctors' duty to wake patients up to the fact that the treatments that seem to make them feel better are based on the placebo effect? I don't think so, and most doctors don't seem to think so, but I don't think it's an unreasonable point of view. I do think it's unreasonable to accuse anyone who differs with that opinion of being unscientific or an alternative-medicine apologist.I agree that a good solution would be to get mainstream medicine to focus on doing the things that patients respond so well to, including better use of the placebo effect, and especially to adopt healthier behaviors and attitudes. But as I discuss in my article, that's going to be hard to do, and may not make any economic sense. Alternative medicine, from a practical point of view, may be doing a decent job of plugging that gap until mainstream medicine figures out how to do better. I share your concern at practitioners of any sort steering people away from vaccines, or doing anything else to cause people to avoid any mainstream treatments that have significant benefits and few drawbacks. Again, I like the idea of seeing alternative practitioners who are MDs or who work under one or in conjunction with one. Alternative medicine should be an adjunctive therapy, not a substitutive one, in my opinion.

  24. Following on from my previous comment:I have a chronic health condition with no diagnosed cause. Along with years of conventional medical “care” (including investigating a psychosomatic cause) I’ve tried many alternative therapies, in particular hypnotherapy, acupuncture (several types including traditional Chinese), chiropractic, osteopathy, massage, meditation, various herbal treatments (traditional Chinese and others), and naturopathy. Along the way the odd homeopathic remedy was prescribed (by naturopaths); I took the remedy but noticed zilch effect (which is what I expected).
I notice that many alternative practitioners are as narrowly focussed as their conventional medicine counterparts (the conventional are confined within their area of medical specialisation). There is a lot of incorrect supposition (by a person who then becomes guru-ish) that becomes dogma within the closed-system educational seminars that support the alterative medicine industry* (and yes it is an industry, different from but no less an industry than big pharma). It’s interesting to read that this sort of cross infection is also rife in evidence-based medicine (in his November 2010 article ‘Lies, Damned Lies, and Medical Science’ Freedman refers to the perpetuation of flawed scientific results, “It’s like an epidemic, in the sense that they’re infected with these wrong ideas, and they’re spreading it to other researchers through journals”. Even in conventional medicine misinformation persists for years beyond its debunking, Freedman, “even when a research error is outed, it typically persists for years or even decades”.The idea that alternative practitioners treat each person as an individual is fallacious. They take more time in gathering information about the patient and their ailment, but it is my experience that once a judgement is made (about what ails the patient) the alternative practitioner’s toolkit is just as limited as the conventional medico’s (thinking of nails and hammers here). For instance, they have diets (salicylate free, anti-candida, alkaline, blood type …the list is almost endless), which are foisted onto just about every patient, (one after the other, or, one on top of the other, when the first suggested diet isn’t effective).* In Australia it appears to me that money and/or people behind practitioner-only nutritional supplement companies (the “big pharma” of nutritional medicine) wield a fair amount of influence in alternative medicine’s educational programmes. Some of these companies market products like homeopathic (6X) DHEA, melatonin and SAMe (the marketing screed advises these products treat a deficiency of DHEA etc.!). Not sure if the US has this phenomenon; it enables the companies to circumvent the ban on sale of full-strength DHEA etc. in Australia. Informed consumers purchase full-strength product from compounding pharmacies or from US, leaving the uninformed to blow their dough on the 6X version (at similar cost!).As with the above example about 6X products, there are alternative medicine practitioners/therapies that profit from a gullible public. Personally, I include the biofeedback machines – e.g. BICOM, QXCI, SCIO in this category, but others believe these machines work. Caveat emptor, I suppose.When people first become sick I suspect many have faith that there is an easy and quick fix (even for cancer). Few want to look critically at the credibility of treatments offered. For example, I suspect few people contemplating biofeedback treatment would read a site like this: http://www.scoon.co.uk/

  25. You make an excellent point here, BothNeedReform. Namely, there are good alternative practitioners and bad ones. Same with mainstream physicians. And even beyond that, some practitioners (of any stripe) will be good for some patients with some conditions, and bad for other patients with other conditions. I certainly hope no one thinks I'm arguing that all alternative practitioners are good and all doctors are bad. I'm only arguing there are some aspects of alternative medicine which, when delivered by a good practitioner, preferably under the simultaneous or parallel care of an MD, likely offer a higher chance of benefit to patients than what one is likely to encounter only from a mainstream MD. Your experiences illustrate quite well that there are many, many situations where patients are not going to do better with alternative practitioners, and many are likely to do worse.Judging alternative medicine by the credibility of its core treatments does not, in my opinion, do it justice. I argue that most of these treatments work mostly or solely via the placebo effect. But let's not be quick to dismiss the potential benefits of the placebo effect, or of the benefits that come from the high quality of attention to behavior and attitude that many alternative practitioners provide.

  26. Paul H says:

    Thanks for the reply, and for making yourself accessible to critics David. I greatly appreciate it. I think the power of the placebo effect is often exaggerated. There is a common belief that it can cure objective illnesses, like infections, broken bones or cancer, but there is little evidence for that. Studies that compare placebo with doing nothing (which eliminates regression to the mean) suggest that there is little difference except in conditions with a large psychological component.It's a shame, but the idea that the placebo effect is a magical healing power induced by belief does not seem to be really accurate.

  27. You're right, Paul H., I think it's important to not overattribute curative powers to the placebo effects. Its benefits are limited. But it can do fairly well with some disorders, with some patients, even when compared to mainstream standard-of-care treatments, and that's worth noting and perhaps exploiting. Not to mention the fact that it's cheap and has no side effects. There are legitimate ethical questions that need to be explored, too, of course. Let's not either dismiss or glorify the placebo effect, let's learn more about it and see where it can and can't provide benefits.

  28. The final of my 3-part comment:It’s lamentable when people with conditions that conventional medicine can treat, at least somewhat effectively, reject that treatment in favour of ineffective therapies that are marketed using misleading claims (and when it’s an adult who chooses to withhold at-least-partially-effective treatment from a child, in favour of quackery, it’s deplorable). But everyone has different opinions about what is a misleading claim (e.g. ‘memory of water’ theory of homeopathy), and not every patient has a serious physiological or psychiatric condition, (perhaps the unflattering term, ‘the worried well’, explains some of the placebo effect); if such a person believes something will cure them, and it does, what harm has been done to that person? (And, by solving a health-consumer’s problem and thus removing that consumer from the overloaded conventional system, hasn’t this achieved a good outcome for conventional medicine too?)From my experience, many people with intractable conditions spend a lot of money on ineffective therapies using either version of medicine.I’d like to see conventional medicine focus on cleaning up its own act rather than attacking the alternative. I think a lot of people turn to alternative because what conventional offers is so off-putting. After years of inefficacious consultations I’ve lost faith in conventional medicine, to the point where I eschew even the no-brainer stuff, like Pap smears, not because I don’t believe in the effectiveness of the screening but because I loathe the medical system; it is dehumanising. (I spent some time considering whether I really mean ‘depersonalising’, but I don’t; what a long-term patient experiences, thanks to repeated exposure to doctor-centric systems, is beyond depersonalising.) I think most people with serious health issues would, by preference, consult with a supportive and attentive conventional medical professional, if only there were more of them.AN ANECDOTE:This anecdote is in response to the comments by eleidth and patriciabee over at Atlantic (about the effect of acupuncture when used on a dog). It’s about a dog and homeopathic treatment:Around 12 months ago I paid a social visit to a homeopath’s home (the homeopath and I have a mutual friend). The homeopath described how her homeopathic remedy cured her ailing dog. Apparently the dog (old and very arthritic) was clearly unwell, so homeopath administered one of her homeopathic remedies until such time as the dog was on death’s door. She took the dog to a vet, who diagnosed what was wrong and prescribed antibiotics. Homeopath administered most of the antibiotics (several days of the prescribed course) but then decided the antibiotics were poisoning the dog, so (thanks to vet’s diagnosis, homeopath was now aware of the cause of dog’s malady) she administered a different homeopathic remedy (more suited to the dog’s condition than the first remedy). The dog recovered around a week after it visited the vet. According to the homeopath (who seemed blind to her flawed logic) the antibiotics played no part whatsoever in her dog’s recovery!I’m not suggesting the dogs referred to by eleidth and patriciabee were not helped by acupuncture (it appears they were helped), however, attribution errors are rife in alternative medicine (by patients as well as practitioners), which must enhance its favourable statistics.Attribution error seems to have boosted statistics for conventional medicine too if the likes of stents, antidepressants and some surgical interventions, in the end, prove to be no more effective than placebo, and the majority of drugs on the market do not work for the majority of people they are prescribed for.

  29. Thank you, BothNeedReform. It is indeed a big concern that people who have conditions clearly treatable by mainstream medicine end up falsely thinking they'll do better with an alternative medicine that does not in fact provide the same benefits. That's why I think it's so important to use alternative medicine as an adjunctive therapy, not as a substitute. Many (though not most) alternative practitioners are MDs, and many others work under or in conjuction with one. I've spoken to several people who've had disorders diagnosed with mainstream tests (like MRIs) and treated with mainstream treatments–all through an alternative practitioner, and after mainstream physicians had missed the diagnosis, apparently because they just hadn't spent enough time with the patient. Such anecdotes don't prove anything–there are plenty of anecdotes that suggest the reverse–but they can still be instructive.I do think there are situations where it's perfectly legitimate to make the choice to turn one's back on mainstream diagnosis and treatment in favor of alternative care, as long as it's an adult making an informed decision. Some elderly people with terminal cancer, for example, and who face under mainstream medicine the prospect of chemotherapy that is likely to take a lot out of them and not add many months of life to the limited time they have left, reasonably (I think) choose to go with alternative treatments that may not have much (or any) chance of prolonging their lives, but may leave them more comfortable in the time they do have. Of course, mainstream medicine can provide palliative care as well. It's a personal choice, one that I would respect either way.

  30. Anonymous says:

    I am extremely unqualified to attempt to write here as others have done. I really just wanted to express some thoughts about the placebo affect.There's a verse in the Bible that says 'a merry heart does good like medicine' so I figure that the affect on our wellbeing of our attitude and outlook has been observed for a long time. Hope can make us feel better, so can happiness and not giving way to despair. (Imagine you're lying in bed, crook with the flu, and someone dumps a kg. of gold on your bed. Feel any better?)I have a chronic illness myself, and am writing this from bed, so I'm not suggesting for a moment that we can just 'think' away our illnesses. But in the midst of them, we can change how 'terrible' we feel to a lesser or greater extent. Perhaps this is part of the improvement people feel with some medical practitioners? Would that be seen as different from an actual cure, especially in trials/experiments?I think it would be interesting to profile people's attitudes and levels of happiness/peace/confidence etc. along with whatever diets/health regimes/medicines are being tested in trials. I'm thinking of fads like the 'Mediterranean Diet' – how much was diet and how much was lifestyle, or family closeness and support, or community cohesiveness etc.? I also wonder if these positive attitudes or supportive/caring environments can also act as preventative medicine for some health problems?

  31. Thanks, Anonymous. I think you've gotten at a couple of important points here. One is the question of whether we ought to tease apart the outcome of "feeling better" (or feeling "less terrible," as you put it) from the outcome of actually "being" better in some objective way. It seems pretty clear that the placebo effect, or any treatment that aims at what we think or feel as opposed to trying to have what I call a "direct physical action," tends to be more about the former and less about the latter. One problem is that it's often (though not always) hard to measure health in a way that teases the two apart neatly, since often what we need to measure in health is a patient's report on how they feel–particularly if pain or discomfort is involved, as is often the case. Another problem is that how we think or feel sometimes goes on to have some sort of direct physical action on our bodies, so that the line can physically blur between the two.The idea that diets and attitudes and lifestyles can interact is also spot on, I think, and it's one reason that diet studies come up with so many conflicting results. Anybody hawking a particular diet can point to studies that make it seem as if their diet is unusually effective, but other studies will find otherwise. That's one reason I (and, increasingly, most experts on obesity and weight management) advocate a behavior-change approach, which takes everything into account. Focusing in only on what people eat, on the other hand, tends to be much less effective in the long run.

  32. Marlon says:

    Hi David, I just read your article in the Atlantic, I really enjoyed it, and I was really hoping you could help me find some of the studies that you referenced in the article (ALL of them in fact). I am an undergrad writing my thesis on the placebo effect and it would be incredibly helpful to my own research.

  33. changenaal says:

    Very interesting info !Perfect just what I was searching for! “The only gift is a portion of thyself.” by Ralph Waldo Emerson.

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