Tag Archives: alternative medicine

Treating the parts that real medicines cannot treat – a place for placebos

As a skeptic I have a shameful confession to make: I once had an imaginary condition miraculously cured by a placebo treatment.

Some conditions have symptons but not signs. Symptoms are felt and reported by patients, signs can be detected using some form of test. Headache and nausea are symptoms of migraine, vomiting and pallor are signs.

About 10 years ago I went through some high-stakes changes and made a career-move which required full-on keyboard use.  But I developed Repetitive Strain Injury which affected my hands to the extent that I experienced pain up to my shoulders.  Lawyers have a field day with RSI, because some repetitive strain injuries such as Carpel Tunnel Syndrome have signs, but others are just painful with no measurable physical changes. The long and the short of my story is that I bought a wrist magnet and strapped it on my right arm. Within half an hour my right arm was considerably less painful than my left and over the next few days the pains disappeared completely. I was able to take up my new job with no problem at all.  A miracle cure! For a condition my doctor had been powerless to treat! Woo hoo!

Doctors are often exasperated by patients who turn up with functional conditions (ie ones which have symptoms but not signs) because there is nothing concrete to treat and no objective way to measure outcomes. In the worst case, they consider the patient to be a malingerer and even in good cases trust between paient and doctor break down and create a space for kindly Alternative Medical practitioners to step into. Functional conditions are for Alt Med of course because the intervention needed isn’t medical. It’s in the realm that Terry Pratchett’s Granny Weatherwax calls “headology”. The wrist magnet really did cure my RSI.  It worked, not because it improved the flow of fluids in my body, but because I thought it improved the flow of fluids in my body.

Placebos are a side-effect free way to treat conditions which can’t be treated using evidence-based medicine. Let’s be clear here: these conditions are honestly experienced by people of integrity. Just because their minds and bodies are lying to them, doesn’t mean they are lying to the doctors. But there are no symptoms that can be measured and treated so the medical model and the patients’ experience simply don’t overlap. This creates a gap in the market which alt med happily and sometimes effectively fills. But not all alt med is innocent and all of it is expensive and based on false models and premises. We need medical science to admit there is something going on here that needs treating, rather than dismissing functional conditions as hysterical, imaginary or psychosomatic.

Unfortunately, medics who accept that placebos may indeed be appropriate for these conditions cannot bridge gap by prescribing them, even if they will work where “real” treatments fail. Doctors consider it unethical to lie to patients, and I think most patients would agree with them. So at the moment there is indeed a place for alt med in providing these interventions.  Alt Med has no place in treating pathological conditions of course (ie “real” ones): flower drops and sugar pills cannot treat cancer, and magnetic bracelets can’t cure Carpel Tunnel Syndrome.

Is the NHS modernist or post-modernist?

Someone came here the other day using the following search term: is the nhs modernist or post-modernist. I’ve not blogged on the subject but it’s a peach of a question, so I’ll bite.

One of my dirty little secrets is that I don’t really know what modernism and postmodernism are.  I don’t feel bad about this because the definitions are so slippery: Wikipedia (yes, I know…) says this about them:

Modernism: … affirms the power of human beings to create, improve, and reshape their environment, with the aid of practical experimentation, scientific knowledge or technology. (My emphasis).

Post-modernism: is a tendency in contemporary culture characterized by the rejection of objective truth … It emphasizes the role of language, power relations, and motivations; the term “post-modernism” comes from its rejection of the “modern” scientific mentality developed during the Enlightenment. (My emphasis).

So I’ll take ‘modernism’ to mean ‘empirical science’ in this context, and plough on with the question.

The brief answer, of course, is that the NHS should be both. The scientific method is the best way to find out the truth about the physical universe (how drugs interact with the body); but hard science can’t cast much light on how people interact with each other individually or within organisations. So Western medical practice, which is delivered by complex organisations including the NHS, is a battle-ground for these two philosophies. In fact the history of the NHS over the past 20 years has been a matter of eroding the power of the clinicians and handing it over to the administrators. Whether this has gone too far or not far enough depends on who you listen to.

Empiricism lacks the nuances you need to explain how people and organisations behave, but post-modernism’s not the answer either: it  can and frequently does go feral. Post-modernism holds that all ideas are made up; indeed extreme relativists claim to believe that there is no underlying and testable truth in the physical universe and that scientific laws like the law of gravity are “social constructs”.  From this you get the kind of post-modernism which is mad, bad and dangerous to know, for example the idea that using the scientific method to uncover truths about the physical world is an act of oppression “because other methods are equally valid”.  Um. No they’re not.

You’d think this was ludicrous but Ben Goldacre and David Colquhoun have both commented at length on an article which has the following in its abstract:

[Our objective is] …  showing how health sciences are colonised (territorialised) by an all-encompassing scientific research paradigm … [and] showing the process by which a dominant ideology comes to exclude alternative forms of knowledge, therefore acting as a fascist structure.

Goldacre and Colquhoun rightly say that this would be laughable if it weren’t dangerous: medical practice strives to be evidence-based, and so it damn well should be. I want my treatments tried, tested and effective, and only a “scientific research paradigm” will do that.

However, the paper’s authors have a point, badly put though it may be: advocates of the scientific method are indeed snotty about other forms of knowledge.

Let me tell you about my friend Sarah.

Sarah’s widowed mother was dying and the doctors looking after her concluded that any attempt to resuscitate her would be needlessly cruel. The Registrar had just raised the topic of the DNR order with Sarah and her much younger sister when he was bleeped away to another part of the hospital. So the women took the heart-breaking decision themselves.

When I told a Senior House Officer about this he said “but they didn’t take that decision – the Med Reg took it”.

Viewed through rational, modernist glasses, my SHO pal is right: the choice was not theirs to make and therefore they made no choice. But even so, they experienced making it as surely as if the casting vote had truly been theirs. We need the NHS to bridge both perspectives. It seems that patients’ families will complain more about badly delivered care which produces good results than about a team who are kind but made mistakes.

The clinical aspects of the NHS should deliver empirical pills sweetened with subjectivist sugar. If they don’t, medical care seems hurried, emotionally brutal and harsh, and the patient can feel like an item on a conveyor belt, a statistic or an inconvenience. Many of these patients then seek and obtain kindlier treatment among the alternative practitioners. You see, practices like homoeopathy and acupuncture are what happens when therapies operate in a world where anyone’s ideas about what constitute medicine,  evidence and even illness and good-health are as good as everyone else’s.  There is no valid evidence-base, and treatments are chosen intuitively or anecdotally. However, the practitioners provide a service which is not available on the NHS: they sit and listen sympathetically for 40 minutes to the emotional needs of their patients. The emotional landscape is seen as the very fabric of the condition and is the starting point for holistic treatments. They are, quite literally, post-modernism in Practice.

However, those managing the trusts, hospitals and practices that comprise the NHS, should take the opposite approach. We need them to respect the needs and experiences of the different groups they deal with, but they should stiffen this touchy-feely stuff with policies and decision-making based on as much statistical evidence as they can get hold of.  And heaven knows, the NHS can provide huge data-sets.  In fairness I should say that I’m thoroughly impressed by the pragmatic intelligence of the NHS managers I have met, and rather them than me.

Is the NHS modernist or post-modernist? It’s too big an organisation for a single answer.

Which probably makes it post-modernist.

Damn.


If you’ve the time during your coffee break, then read more Ben Goldacre and David Colquhoun.

Alan Sokal is spectacularly good on just how sloppy post-modernist thinking can be.

And here are a couple of other good links while we are on the subject of alternative therapies and the scientific method:

Quacktitioners III – a little bit of ‘me’ time

Oh dear, this isn’t going to be popular. And the reason it isn’t going to be popular is because I’m suggesting that women go to alternative practitioners for the same reason that men go to sex workers – for rest and relaxation or, as the women’s magazines call it, “a little bit of ‘me’ time”. Hear me out before you dismiss me as salacious or simplistic: it’s a conclusion it’s taken me a couple of years to arrive at and it’s one I’d like to test in debate.

When we ask “what do alternative therapists offer that doctors don’t” the simplest answer is “45 minutes of undivided attention”. There are plenty of other answers the most worrying of which is “hope”, but this post is not about desperate searches for a reprieve from a death sentence, it’s about healthy people who go time and again to alternative practitioners. I know what they’re like. I’m one of them.

In my time I’ve spent thousands on alternative therapists.  I’ve had pins stuck in my flesh, candles balanced on my ears and my aura captured in photographs.  I’ve had my chackras re-aligned, the state of my gut diagnosed by the strength in my arms and been annointed with everything from marigolds to onions.  One osteopath refused to chant over me on the grounds that “it’s a bit too shamanic for Cheltenham” but he was willing to do it in Stroud. Make of that what you will.

It was all money fantastically well spent even though none of it cured anything, though the shamanic osteopath did free up a neck muscle which had gone into spasm. But I got a bargain every time, because what I was really buying was 45 minutes of uncritical attention.

Men go to sex workers for this, though in their case they want orgasms rather than attention, but then they’re from Mars. Vive la différence.

So here is my two pronged observation:

  • Firstly, that what pays alternative therapists’ rent and rates is a predominantly feminine need for someone else’s considered attention and non-threatening touch
  • And secondly that men tend to sexualise sensations, and women tend to de-sexualise them, and alternative therapists and beauty therapists offer some decidedly odd services in a women-friendly way

If you’re not sure about my second point, ask yourself why it is that if men want a massage or colonic irrigation or to be wrapped in cling-film or put in a sensory deprivation tank it’s sexual and they look around on the scene or go to a sex worker, but if women want any of those things it’s beauty treatment and they go to a health spa?

Please think about this for a while because it’s probably one of those things that you’ve taken for granted for so long that you’ve never realised just how strange it is. Yes, I know that health spas will happily take a man’s money and wrap him in mud and cling-film, but let’s face it, men who really want this sensation see it as a form of bondage (it’s called “mummification”) and find other fetishists or go to some highly specialised sex workers. And equally, if having your insides washed out with warm water is your thang, then women want Enya playing in the background and the gentle aromas of neroli and ylang ylang floating in the air and men, um, don’t.

But think how peculiar this is. Same physical sensation interpreted in very different ways. I don’t know about you, but I think that’s very odd and very interesting.

So, what do we do with this observation? I dunno, and there isn’t room here for my thoughts and speculations on the subject. But if the medical profession is serious about casting a harshly critical light on to alternative therapies, then it should consider what it is that people are buying, and if you ask me, it’s attention.

Personally, I think that the alternative practitioners are providing a service as necessary and helpful to society as the service provided by prostitutes, and while I’m certainly in favour of regulation, I don’t think banning either helps.

Quactitioners II – The mystery of medical history

The Jobbing Doctor has an excellent quote on his blog:

One reason why medical history is not much taught in medical schools is that so much of it is an embarrassment – Lewis Thomas (1992)

Thomas put his finger firmly on one of the problems with the debate between scientific medicine and alternative medicine: scientific medicine’s reluctance to face the fact that in the bad old days doctors were as ignorant and dangerous as anyone else. This is counterbalanced by the fact that alternative practitioners are reluctant to accept that modern evidence-based medicine is safe. Established orthodoxy has moved on and the rebels haven’t, and this is causing wires to be crossed.

It would assist the argument enormously if medicine owned up to its embarrassing history, and then disowned it, staking its claim to be the truly revolutionary movement and the real alternative to the dangerous practices of the past.

You’ve seen the full version of this grid before. However that was a 20th and 21st century version. This version shows the situation in the 19th century when there was little science, and practice was based on observation and experience rather than trials.

19th Century Medicine - and its Alternatives

Despite this, medics and sceptics frequently talk and write as if there have always been two separate paths – scientific medicine (good), and alternative medicine (bad), and I’m not convinced of this.

18th and early 19th century doctors were a dangerous bunch, as ignorant and hopeful as the herbalists and homoeopaths but with a fondness for powerful drugs, and frequently with an arrogant attitude. They killed millions of new mothers by giving them “child-bed fever” because they didn’t know that infection can be communicated by touch. They’d treat just about anything by drawing blood. Their favourite medicine was calomel which induced vomiting and acted as a laxative because it’s toxic. Their patients became addicted to opium in the form of laudanum. (When a showed a draft of this to a young doctor he pointed out that his predecessors used to massage women to orgasm to cure “hysteria”. It’s not called “doctors and nurses” for nothing). Dodgy sexual practices aside, it was no wonder that Samuel Hahnemann and Edward Bach devised gentler alternatives, even if the reason these alternatives did no harm was because they did no good.

So, if doctors were as ignorant as other practitioners in the 18th and early 19th centuries, what has changed? And what hasn’t?

The big change of course is that medicine now works. It cures diseases and in the main it doesn’t kill people. We now benefit from antibiotics, immunisation and increased standards of public health, not to mention treatments for everything from athlete’s foot to cancer. And all as a result of acute observation, empirical testing, double-blind clinical trials, and a widely-published and peer-reviewed evidence-base. The roll-call of conditions which are a thing of the past is awesome, and medicine has done away with these in the last 100 years or so.

By contrast, not much has changed in the practice of alternative therapies. This is partly because “traditional” is “good”, and partly because clinical trials are expensive and will either show that the interventions are not very effective (herbalism) or not effective at all (homoeopathy). Ben Goldacre rightly criticises homoeopaths for their lack of self-criticism and for treating their founder’s approach as dogma, and they most certainly aren’t the only ones. He contrasts this complacency and stasis with the continuous questioning of the scientific approach and the constantly moving medical frontier.

Another thing that hasn’t changed is the rhetoric of the alternativists. They still talk about medicine as if its practices were as dangerous and untested as they were in the 18th and 19th centuries. There are a whole bunch of reasons for this, including the difficulties the lay person has with medical science because of the poor quality of science education in our schools, the challenges in creating and interpreting drug trials (listen to R4’s excellent edition of More or Less on the subject), and the confusion that understandably arises about where and why to draw the line between things science can be certain about and things it can’t. Oh, and demonising doctors is good for business, of course.

But has the rhetoric of the doctors changed either? The science has, and the outcomes of the science most certainly have, but has the rhetoric? (I genuinely don’t know).

I’m asking because, as I said right at the beginning of this piece, if modern medicine admitted its murky past, it would make it much easier for us all to point out that the alternative practitioners are still living in it.

Quactitioners I – Sincerely WooWoo

Ben Goldacre’s recent Radio 4 programme seeks to place current food faddists (I assume he’s thinking of Gillian McKeith and Ian Marber) in the long tradition of American snake oil salesmen and mountebanks.  His programme discusses the history of these travelling showmen and also of food faddists turned businessmen such as Kellogg, Graham and the seller of Hadacol.  It’s a good programme, and I recommend  it.

However, it’s disingenuous of him to let his listeners infer that there are only two kinds of people providing health services – scientists and quacks.  He’s not alone: most of the sceptical commentators out there make a clear distinction between the good and the bad, the sheep and the goats, the disinterested practitioners of empirical science and the cynical and opportunistic pedlars of sugar-pills.  In fairness to Ben Goldacre, he’s more a much more subtle thinker than that, but even he tends to simplify the message to make it easy to convey.

It seems to me that there is no neat correlation between sincerity and science, and that it’s more useful if we consider that there might be four categories of people offering to help us with our health.

To make things snappy, I’m calling them the Good Doctors, the Celebrity Surgeons, the Profiteering Quacks and the Sincere WooWoos.

Sincerely WooWoo

  1. The Good Doctors are scientifically-minded as well as scientifically-trained, they are men and women of integrity who frequently work in shitty areas and research shitty diseases
  2. The Celebrity Surgeons specialise in “diseases of the rich”, as Tom Lehrer put it and can be found practising perfectly good plastic surgery in Florida and dentistry in Harley Street.  Big Pharma can come into this category of profit-motivated scientists.
  3. The Profiteering Quacks are the ones Goldacre really dislikes – they don’t let truth, logic or inadequate training stand in the way of getting tv deals and book deals and products on shelves – they know it makes cents.
    And finally:
  4. The Sincere WooWoos are good people let down by a lack of critical thinking. They are troubled by modern medicine, particularly the cynical and profitable kind, so they they train as homoeopaths or acupuncturists or naturopaths, and then the Hawthorne effect and the Placebo effect builds them an anecdotal evidence base which reinforces their sincere belief in their success

The problem is that the debate ends up at cross purposes.  Too many sceptics restrict their criticism to the profiteering quacks without addressing the question of what is troubling about modern medical and surgical practice.  And likewise, far too many alternative practitioners throw out the baby of medical science with the bathwater of the profit-motive.

Cross Purposes

People like Ben Goldacre and John Diamond rightly argue that Profiteering Quacks are dangerous and leech on the vulnerable and insecure simply to make money out of them.  But those of us who defend science and evidence-based medicine need to accept that the group that I have flippantly categorised as “Celebrity Surgeons” do exactly the same thing, the only difference being that their interventions which are frequently unnecessary do in fact work – think of Jordan’s boobs and Michael Jackson’s nose if you doubt what I’m saying.

It isn’t enough to attack the woolly-thinking which leads trusting people to accept alternative practices like acupuncture and homoeopathy, we must also understand what it is about these practices which attract patients and practitioners, and what it is about “scientific” or “western” practices” which repel them.

Good Reading:

Bad Science – Ben Goldacre’s blog in the Guardian – eg his column about Gillian McKeith
Snake Oil – John Diamond’s searing criticism of alternative practitioners

Good Listening:

Skeptoid – a weekly 10 minute dose of evidence-based good sence
Bad Science – Ben Goldacre’s infrequent podcasts

Farewell to flakiness – or why I’m not entitled to my own opinion

A FlakeI was raised by people of great personal and moral integrity with reasonable intelligence who had no exposure to science or scientific thinking at all. This didn’t stop them having Opinions on things so it is no surprise that they were Flakes one and all. Bless ’em.

Flaky thinking is cozy, it provides comfort blankies such as “everything happens for a reason”or “someone was looking after me that night”. It also provides explanations which appear to be simple and easy to understand: ” stimulating the body’s natural healing processes” or “bright lines of golden energy”.

I’m not going to rip into acupuncture, auric photography, biomagnetic bracelets, biorhythm charts, cranial-sacral therapy, earth energy lines, feng shui, food sensitivity analysis, homoeopathy, osteopathy, reiki or any of the other forms of flakiness which I’ve spent money on in my time. To be honest, I cannot be bothered. Either you consider me to be foolishly narrow-minded because I dismiss them or foolishly forebearing because I don’t critique them and we both have better things to do with our time than argue the point.

Let’s just say that I spent my money on all of the above, probably thousands of pounds now that I look at the list, but I don’t feel ripped off; every one of them brought me a good 40 minutes of someone’s undivided attention and a nice warm placebo effect. I was lucky; it was a life-style choice not a fearful attempt to ward off cancer. But I wouldn’t spend my money on any of them again.

So what undermined my warm fuzzy view that the word “energy” means something when used metaphorically, that there are forces which cannot be measured by science, and that there is more to life than meets the eye?

Lots of things. Feel free to skip the list and cut to the conclusions at the end of the piece.

  • I check out the Asthma UK site and realise the approaches described are infinitely more cautious, detailed, rigorous and robust than the approaches of the herbalists I’d instinctively turn to.
  • My father, with cancer, is dramatically better after a stay in hospital which grants him at least another year of good quality of life.
  • A crystal healer describes the “lovely warm lines of yellow energy” flowing through her treatment rooms. When I ask her if she can see them she says “no, but Gordon has dowsed them and told me where they are”. The inane warmth in her voice sets my alarm bells ringing.
  • I read The Selfish Gene by Richard Dawkins.
  • I have to describe my symptoms to the German pharmacist rather than selecting the herbal tinctures and ointments I’d choose in the UK; I find myself thinking “These German pharmaceuticals are very effective” and then realising that they might work well simply because they are pharmaceuticals and being German has nothing to do with it.
  • I work for a large petro-chemical company and find that the individuals there are responsible and serious people, and not in fact the spawn of satan who just don’t “get” it.
  • I acknowledge that the scientists working on GMOs are (a) intelligent and (b) not malicious. I think that they are wrong about genetically modified organisms being good for the planet, but acknowledge that if they are wrong then it’s not because they are stupid.
  • A friend sends me a link to DHMO.org and I realise just how easy it is to writes spurious science-speak which is manipulative and emotional.
  • A friend of mine compulsively adds and subtracts numbers to find co-incidences and meanings without noticing that if you manipulate any date enough you can reach the number 7, or 26.
  • I read something which explains that the phenomena described in all documented near-death experiences (tunnel vision, a distant light, etc) are also consistent with specific forms of neurological shut-down.
  • I develop an increasing respect for the methodologies in my own field, and by extension for standards’ based methodological approaches in others. In other words, I come to prefer rigorous testing to instinct.
  • I have a relationship with a statistician.
  • I come across evidence that a feeling that there a ghostly presence in the room can be reliably triggered by certain localised electro-magnetic phenomenon.
  • I read The Demon Haunted World by Carl Sagan.
  • I regularly flick through copies of the British Medical Journal and discover that the research studies are of varying quality but explicit about their limitations and scope.
  • Triptanes provide effective migraine relief.
  • I read Snake Oil by John Diamond.
  • I start a post-grad degree and within a few months become imensely more picky about authorities and references.

Ok. It’s not a particularly impressive list: a lot of it is based on a distaste for poor critical thinking in others which of course doesn’t demonstrate any improvement in my own, the books are pop-science even if the scientists are credible, the rest of it is un-referenced and at this distance in time I have no way of checking where I got the information about near death experiences and ghostly presences from.

But…

But I think that the real epiphany is that I am only entitled to an opinion on subjects where I have some expertise. Guess what – experts really do know better. It’s a matter of knowing my limitations. I cannot bake cakes, design power stations or diagnose illnesses. I have no choice but to delegate those tasks. Generic intelligence is not the same as experience, training or qualifications and this is hard for people, particularly those educated in the social sciences or humanities, to accept.

Not all experts are equal, of course. Gillian McKeith’s “doctorate” is a tad light-weight to say the least, though the woman is undoubtedly sincere. We cannot accept the word of experts unquestioningly. We must continue to challenge and ask the pertinent questions – how did you arrive at that conclusion – how large was your sample-size – how well conducted has your research been – where do you get your funding, and so on. But challenging does work: 20 years of hindsight bias, selective memory, anecdotal evidence and the placebo effect do not equal one double blind controlled trial. Sorry.

Some people argue that science is just as much a matter of belief as religion is. It isn’t of course. I’ve argued that you have to trust the scientists but as Reagan put it you “trust but verify”. You can by definition repeat and test a scientific experiment or demonstration. You cannot test bach flower remedies, post-modernism or god. In fact there’s even a commandment against it.

This of course means that the opinions of true experts whose conclusions are based on testable and repeatable methods vastly outweigh yours and mine. We are entitled to doubts, concerns, worries, uncertainties and even rage, anger and disgust. Those are emotions and emotions are not opinions. We must also remain entitled to challenge – that is what accountability is.

Comfort blankies - do not forget to boil them to keep them sterile, otherwise they can harbour germs.  Unfortunately boiling may damage the warmth and softness of your blankie.To some extent I do miss the warm fuzziness of flaky thinking, but on the other hand if you acknowledge that real life is unfair, that shit happens, it becomes much easier to deal with. Nastier, but more straight-forward. There are a few flaky things I still adhere to: meditation, NLP and yoga specifically, though I’m not going to defend them here. The only school of “alternative” thought which I have not yet found to be intellectually undermined is the Buddhist approach to re-incarnation. To be honest, I doubt it’s got any validity to it, but does have the merits of being (a) internally consistent and (b) not yet countered by harsh scientific enquiry. However you look at it, the idea that bad things happen to good people for no reason is a nasty one.

I had been going to illustrate this with one of the Cadbury’s Flake ads but I couldn’t find the girl painting a picture in a poppy field in the rain, so I decided to show you this instead which did at least make me laugh.