May 05 2014

David Katz on Evidence in Medicine

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102 responses so far

102 Responses to “David Katz on Evidence in Medicine”

  1. superdaveon 05 May 2014 at 9:53 am

    Time and time again it seems like a major motivation for patients and doctors to turn to alternative medicine is just because the patient doctor relationship in alt med just seems friendlier, slower paced, more personal, and more relaxing.

    What can be done to improve these areas in SBM so that we can eliminate them as perceived advantages in alt med?

  2. Karl Withakayon 05 May 2014 at 11:18 am

    “Katz final big point is that the evidence-base for mainstream medicine is biased against the treatments he likes because they cannot be patented.”

    Isn’t that one of the reasons we have NIH research grants?

  3. Karl Withakayon 05 May 2014 at 11:26 am

    …Katz himself runs a federally funded clinical research laboratory.

    “The Yale-Griffin Prevention Research Center

    was established in 1998 through a grant from the Centers for Disease Control (CDC). One of 37 such centers nationwide, each of which represents an academic/community partnership, the Yale-Griffin PRC is the only center in the network based in a hospital. These centers engage in interdisciplinary applied prevention research in collaboration with community partners, federal, state, and local health and education agencies, and other universities.

    The goal of all PRCs is to develop innovative approaches to health promotion and disease prevention that will directly benefit the public’s health, first locally, and then nationally. PRCs use existing knowledge about health promotion and disease prevention to determine if it can be successfully applied in a community setting. Thus we are “research centers” not because we work in a laboratory, but because we measure effectiveness. “

  4. dwayneon 05 May 2014 at 12:13 pm

    One other thing.

    Even buying into Katz’s “alternative treatments as an alternative” step — once you move on to treatments that are not backed by evidence or plausibility, the physician is no longer an expert (nor is anyone) and becomes unnecessary. The patient might as well ask the dry cleaner or grocery cashier.

    Katz clings to the idea of the physician as providing expert advice and care, but, in the realm of the implausible and unevidenced, he holds no lofty position; he is just another guy.

    You can’t have it both ways. You can’t say, “Well, medicine is just a crapshoot. We can’t know this stuff. Now pay me a bunch of money to tell you what to do.”

  5. elmer mccurdyon 05 May 2014 at 12:48 pm

    superdave: perhaps patients could be issued guns before every consultation… or at least tazers… god, I think it would be awesome to be able to taze a doctor every time he acted acted like an asshole, or lied to me… or even just out of general principal for being a doctor…

  6. lourasauron 05 May 2014 at 2:20 pm

    I’ve had a horrendous time with a common puzzling medical problem: I felt sick in a nonspecific way for years, not able to think well, little physical or mental energy.
    I’ve made a lot of progress, by personal experiment and by finding out what researchers think. I found a good doctor who is science-based but also willing to be experimental.
    Alternative medicine is more like one of the pitfalls and seductions that are laid along the way for people with such puzzling problems.
    I *have* gotten useful information from other people with similar problems, filtering what they said for plausibility.
    I really would dread being treated with Dr. Katz’s “holistic” methods. Looking for answers in alternative medicine when a doctor is puzzled, rather than reading research and doing their own investigation in cooperation with the patient, seems like a lazy approach and a way of letting patients down.

  7. Paulzon 05 May 2014 at 2:43 pm

    It’s distressing that practicing physicians are advocating approaches like these. They will lead to vast harm.

  8. RickKon 05 May 2014 at 3:39 pm

    dwayne – Excellent (and amusing) point!

  9. BillyJoe7on 05 May 2014 at 6:07 pm

    Seems our little mascot is playing with guns and tazers now (whatever a tazer is!)
    …anyway…if I had a taser I know whose impertinent little butt I’d use it on every time he posted here. :)

  10. ccbowerson 05 May 2014 at 9:56 pm

    Taser, is a registered trademark, which was named as an acronym from modifying the title of a book “Tom (A.) Swift and His Electric Rifle.” I’m guessing a tazer is a bad knockoff he bought off the street, with a good chance of you getting the shock

  11. grabulaon 05 May 2014 at 11:35 pm

    “Using safe and effective treatments is all that matters – saying that your approach is “patient-centered” is just an attempt to grab the moral high ground and turn attention from this key issue.”

    A few months back when Will N and JoeinCA were arguing for patient-centric care, I couldn’t quite succinctly put my thoughts to words but the above does that, thanks Steve.

  12. BillyJoe7on 06 May 2014 at 8:01 am

    Here is a link to the David Katz article (not the original at HuffPo but reprinted at “The Health Care Blog”)

    http://thehealthcareblog.com/blog/2014/05/02/a-holistic-view-of-evidence-based-medicine/comment-page-1/#comment-583279

    There are a few considered comments by Andrey Pavlov (who posts at the SBM blog), as well a couple of inadequate replies by David Katz.

  13. Bill Openthalton 06 May 2014 at 8:48 am

    It would seem David Katz doesn’t know enough physics to understand homeopathy or “energy medicine” are impossible, and not enough psychology to understand how humans (including himself) are wedded to their irrational beliefs.

    He thinks he is open-minded, but what he actually says is “when I don’t know what to do I try and use magic”. I guess a substantial fraction of humankind is simply impervious to scientific thinking.

  14. chadwickjoneson 06 May 2014 at 12:29 pm

    Wow, the term “patient-centered care” is really beginning to lose it’s true meaning. Of course, hijacking the term for “Integrative” and “CAM” treatments is only ‘natural’.

  15. lourasauron 06 May 2014 at 1:06 pm

    It’s not true that there is no evidence for alternative medicine. There is anecdotal evidence, and lots of it.
    When you have lots of anecdotal evidence, it should be evaluated for plausibility in TWO ways, not just one.
    First, how plausible is it that it does work? That’s the scientific plausibility that Dr. Novella mentions.
    Second, how plausible is it that it doesn’t work? In other words, how well would it work as a placebo? Does it have that exotic appeal of an Ancient Traditional system, as in Chinese herbal medicine or acupuncture? Is someone trying to sell you something?
    With acupuncture, sticking needles into people would aid the placebo effect. And it has that traditional mystique. And, the scientific plausibility is very low except that it seems possibly effective for pain relief because the needles are stimulating nerves.
    I adopted a couple of techniques based on anecdotal evidence, that did work.
    One was a hypoallergenic elimination diet followed by food challenges. The anecdotal part is that many people say there are huge and surprising improvements when they eliminate foods that made them sick after food challenges.
    That has scientific plausibility (and now, some scientific support). It also doesn’t have much of a placebo aspect. It’s unpleasant to limit one’s diet – people tend to resist doing that – and if the food challenges make you sick, it’s very unpleasant indeed. Also, the it’s a self-help technique, so you aren’t giving anyone lots of money just to try it. And it has no magical cachet, no decoration with magical flourishes or words or comfort.
    If you have ever had a possibly dangerous allergic reaction to a food, the food challenges should be done under medical supervision.

  16. Bruceon 06 May 2014 at 2:01 pm

    Better people than me will address other issues in your post (e.g. a group of anecdotes does not make an evidence), but this is quite bad:

    “Second, how plausible is it that it doesn’t work? In other words, how well would it work as a placebo?”

    You are rephrasing a question and making a number of huge assumptions and unfounded logical leaps in one go. And to add to it you are assuming a placebo “works”. A placebo does not actually make someone better, it just makes some people feel better for conditions with subjective symptoms.

  17. lourasauron 06 May 2014 at 2:54 pm

    @Bruce,
    OK, how well does the interpretation of the mass of anecdotal evidence as placebo effect, work? That is the meaning I intended.

  18. Bruceon 06 May 2014 at 6:51 pm

    Which interpretation? Not sure what you are trying to say here. Let me start at your first mistake then:

    “It’s not true that there is no evidence for alternative medicine.”

    There is no scientific evidence for efficacy for alternative medicine. If there was strong evidence it would be a part of medicine, a collection of anecdotes does not equal compelling evidence, it just tells us that a number of people believed that it worked for them. Strong evidence needs to be strong, and anecdotes are the weakest of any kind of evidence you can present, no matter how many you have.

    You seem to then be advocating for the use of placebo medicine in some convoluted manner. Doing that is quite an ethical minefield and I am sure most doctors would rather not go there and would much prefer their patients using medical treatments that have been proven to work or were at the very least experimental.

    What you are suggesting is not a new argument that has not been discussed ad nauseam… you would do well to have a look at some of the other articles on this blog around placebos:

    http://theness.com/neurologicablog/index.php/well-it-worked-for-me/

    And maybe also reading SBM where these issues are discussed too:

    http://www.sciencebasedmedicine.org/ted-kaptchuk-versus-placebo-effects-again/

    http://www.sciencebasedmedicine.org/a-different-perspective-placebo-scam-and-advertising/

    and finally:

    http://www.sciencebasedmedicine.org/the-placebo-narrative/

  19. Bill Openthalton 06 May 2014 at 7:35 pm

    Iourasaur –

    If by “lots of anecdotal evidence” you mean “lots of seemingly correlated magical actions and perceived cures” you have a point. But this is not the kind of evidence that suggests further research might be warranted. It’s the kind of evidence to be dismissed out of hand.

  20. captian_aon 06 May 2014 at 7:41 pm

    laursaur,

    Warning. Post is, kind of, off topic.

    You would be incorrect that diet changes are not prone to placebo effect. People very commonly mistakenly attribute various symptoms to food they have eaten and at some point they become hopelessly attached to the idea of a food “allergy” and can no longer be objective in their observations. The problem of confirmation bias is particularly problematic. I suspect that the more laborious the dietary change, the more placebo “kick” that it carries. I think the bandwagon carrying the “i’m gluten sensitive” banner is filled with placebo success stories.

    Rotation diets are a terrible way to diagnose food allergies. Let’s use migraines for a real life example. Based on older literature, migraine patients are often told to restrict their diets, removing certain foods. Using the rotating diet approach to assess these foods will invariably result in false attribution: If you serially remove and then reintroduce one food every couple weeks, then inevitably your will get a hit with a food lining up with a migraine. This is inevitable given the variability of migraines. Once the food has been linked to the migraine in the patient’s thinking, then confirmation bias is set up and objectivity has been removed. Can you say Post hoc ergo propter hoc?. Wala! A food has just been falsely accused simply because it had the misfortune of being he food of the week on the rotation schedule.

    The current gold standard for diagnosing a food allergy is the double blind placebo controlled food challenge. This is rarely done in clinical practice because the logistics are horrendous, but any food sensitivity research done these days should have a DBPC design or it aint worth the paper it is written on. Of course not everyone has gotten the memo and I continue to see poorly designed food sensitivity/allergy research published outside of the allergy specialty literature*.

    If you feel better after removing broccoli from your diet then super, no big deal. But if you feel better after eliminating a major food group, then you are likely spending a LOT of time worrying about your dietary choices, spending more money on specialty foods (more effort spent, more money spent=higher placebo effect ), and potentially placing yourself at risk of dietary deficiencies. Suspected food allergies to a major food item should be evaluated by a competent allergist.

    Good luck
    Capt.

    Disclosure. I consider myself a competent allergist.

    *example: http://www.ncbi.nlm.nih.gov/pubmed/18813707. Migraine triggers diagnosed by patient survey

  21. grabulaon 06 May 2014 at 9:32 pm

    @Laurosaur

    ALL the evidence for acupuncture so far has shown there’s nothing to it. Dr. Novella posts a couple of links on it you should check out.

    Anecdotal evidence is really no good. It’s Ok to explore something due to mounting anecdotal evidence but for most altarnative modalities this had been done and has shown pretty conclusively that things like homeopathy and acupuncture do not work. In some cases for example homeopathy, we know on its face there’s no reason it would work, it’s just really clean water.

    The food challenge thing has come up before. It can lead people to some weird conclusions. For example my mother in law jumped on the gluten free concept and after excluding it from her diet she claims it was miraculous. However, she’s never bothered to be tested for celiacs. If there is an allergy there the right thing to do would be to see a doctor since they are trained professionals. You have a couple of good days AND just happened to be cutting out a particular food, what do you think your conclusion might be? The difference is seeing a doctor bypasses all the mistakes we as humans tend to make cognitively and direct, science based testing can determine most of the time exactly what or if there is an issue.

  22. lourasauron 07 May 2014 at 6:25 am

    We are talking about what you do when there is no established cure.
    The point I was making is, you do not just have ONE interpretation of the anecdotal evidence for these “alternative techniques” that you examine for plausibility. When you evaluate these techniques, you have TWO interpretations (at least) that are competing for plausibility.
    The first is the interpretation that “there’s something really in it”. It’s not just placebo effect or a fad or wishful thinking. The plausibility of that interpretation is “scientific plausibility”.
    The second is the skeptical interpretation. That interpretation also needs to be examined for plausibility.
    Take alien abduction accounts, for example. It’s hard to say much about the scientific plausibility. There may well be aliens somewhere in the universe. Maybe some aliens really do want to abduct people and do experiments on them. How can we know how alien minds would work? Maybe their alien crafts are very good at avoiding detection.
    But the plausibility of my skeptical interpretation of these accounts is much better, to me. That is, these accounts are very “psychological”. The tales of being intrusively examined and violated with anal probes etc., have a lot of psychological force. They seem like something that sexual abuse survivors might imagine. They happen at night when people are in a suggestible state – at a time when people are more open to experiences that they have suppressed while they are actively doing things during the day.
    So, I find those tales very easy to disbelieve.
    I am not going to get into an argument about acupuncture or homeopathy. I wasn’t defending either one. I used acupuncture as a demonstration of how you would evaluate something using BOTH kinds of plausibility. I’m quite familiar with the skeptical assessments of acupuncture. I was really disappointed when I found Dr. Katz’s foggy essay defending his use of homeopathy. I had hoped he was a doctor who was doing a good job of straddling the divide between strictly science-based medicine that tries only what has been scientifically proven, and alternative medicine. I don’t think so any more. As I said above, if I had gone to him with my very common problem – feeling chronically sick in a nonspecific way, with little physical or mental energy – if I had trusted him with my care, I would most likely have wasted a lot of time and money.

  23. Bill Openthalton 07 May 2014 at 8:07 am

    lourasaur –

    If “alternative medicine” is limited to plausible, but untested treatments, and if the patient is willing to serve as guinea-pig, and fully aware of the risks, then a doctor might want to try such treatments. I suppose if I were dying of a disease for which there is no cure, I might want to serve as test case for a new drug or treatment even if it hasn’t passed all the tests. But the vast majority of CAM is impossible (this is what is meant when “implausible” is used in a scientific setting), or like herbalism, a mixture of outdated knowledge, primitive pharmacology and nonsense.

    Taking money from patients for treatments that the doctor knows cannot work (such as homeopathy, reiki, chiropractic, faith healing, acupuncture etc.) is highly unethical. One could argue that hospitals obtaining patient dollars through CAM can subsidize costly real medicine while being better able to really help patients with a CAM infatuation, while avoiding the excesses certain CAM practitioners engage in (think Burzinsky). This doesn’t make it ethical, though I can understand why they don’t want quacks to rake in the money.

    Still, one really has to wonder if medical doctors whose scientific acumen is so low they subject their patients to nonsense such as acupuncture and homeopathy can be trusted to take proper care of their patients.

  24. lourasauron 07 May 2014 at 8:45 am

    @Bill,
    I agree, except that a doctor is generally better off looking at current research rather than fishing around in CAM. There are a couple of exceptions that I ran into, but generally the researchers are MUCH better equipped with info about plausible treatments than CAM practitioners.
    There’s a BIG problem with doctors not keeping track of research. I’ve run into it myself – doctors who “know” stuff that has been proven wrong by research. That’s a bad way to practice medicine. You can’t be an allergist like a traditional brewer, doing things the way your grand-daddy did. I exaggerate, but many doctors do rather little to keep up even with their specialty.
    It’s very challenging to read all that research. It’s even more challenging to try to really understand complicated things like the immune system, rather than just regurgitate research results. So I can see how doctors don’t do it. But they let their patients down that way.

  25. lourasauron 07 May 2014 at 9:32 am

    Another thing that has been very important for me when the established methods fail, is self-help. Dr. Katz didn’t mention that, and I can see how his methods could fail to help many people who could help themselves with determined experimentation.
    For example, I think that my common problem – feeling sick without specific symptoms, with little physical or mental energy – is often due to an allergy of some kind – either inhalants or food – that doesn’t show up on allergy tests.
    I think this because I have had those kinds of allergies both to inhalants and to foods. The typical symptoms of delayed-reaction food allergies – for which there are no currently-established medical tests – may satisfy the diagnostic criteria for chronic fatigue syndrome. At one time I could have been diagnosed with CFS.
    And I know how hard it is to figure out that kind of allergy. I know how likely it is that a doctor won’t mention that possibility. I know about the research that’s proved it can happen and is likely rather common.
    Diagnosing someone with CFS and trying symptomatic treatment, telling them to drink more coffee, try mild exercise, etc. , would be severely letting them down – if they really are suffering from an environmental sensitivity. And it seems likely that this is all that Dr. Katz’s “holistic” treatment would amount to.
    I found various allergies to foods and inhalants by a LONG process of experimentation. The technique of elimination diets followed by food challenges was a crucial part of this.
    I wrote a VERY long reply to “grabula” but my &^(*^* browser crashed and trashed it for me. So more on that later after I re-do it :(
    And in fact if a doctor treats something symptomatically and there’s a real environmental cause, they are running a SERIOUS risk of causing long-term damage. So the “conservative” approach isn’t necessarily safe.

  26. Bill Openthalton 07 May 2014 at 10:01 am

    lourasaur –

    Humans will be humans, and statistically speaking, half the population is below average :) . That applies to all fields of endeavour, and MDs are no exception. The fact that many MDs aren’t very good doesn’t make CAM practitioners any better, though.

    As they say in the classics — two wrongs don’t make a right, but three lefts do.

  27. Bill Openthalton 07 May 2014 at 10:49 am

    lourasaur –

    In the absence of physical symptoms, it is very difficult to determine which agent is the cause. Especially in the case of CFS, where the person is probably experiencing the symptoms when they go for treatment, and would have to report on a worsening of their condition — almost impossible.

    One thing to consider is that we really don’t know how energetic and motivated a person “should” feel. Oftentimes lack of motivation is caused by the circumstances people find themselves; the feeling of a lack of energy or inability to motivate oneself might simply be how we become aware of an untenable position within society. There need not be a physical cause such as an allergy — the brain reacting in a particular way to social circumstances suffices.

    This is something we don’t consider easily because culturally, we still see the mind as something immaterial.

  28. lourasauron 07 May 2014 at 11:01 am

    @grabula writes:
    “The food challenge thing has come up before. It can lead people to some weird conclusions. For example my mother in law jumped on the gluten free concept and after excluding it from her diet she claims it was miraculous. However, she’s never bothered to be tested for celiacs. If there is an allergy there the right thing to do would be to see a doctor since they are trained professionals. You have a couple of good days AND just happened to be cutting out a particular food, what do you think your conclusion might be? The difference is seeing a doctor bypasses all the mistakes we as humans tend to make cognitively and direct, science based testing can determine most of the time exactly what or if there is an issue.”

    First, I hope that as a skeptic you are also skeptical about your own skepticism – I hope you understand that your MIL may indeed have celiac disease or non-celiac gluten sensitivity, and it may indeed be important for her to eat a gluten-free diet. If she has celiac disease, eating a gluten-free diet might even save her from dying of cancer.
    It seems like your MIL didn’t really apply the elimination diet/food challenge procedure.
    The “hypoallergenic elimination diet” part is there because the immune system tends to do things to suppress immune reactions. So immune reactions will be more noticeable after the elimination phase. The elimination phase isn’t intended to be diagnostic in itself.
    The food challenges are a very important part of it. If people have a delayed-reaction food allergy, they are likely to get sick after food challenges. In 2003 when I did my first elimination diet where I had reactions to foods, I did about 10 food challenges where I got quite sick, starting within 1-2 hours after eating the food. I describe it as a “groggy stupor”, and I spent a lot of time in bed for about 4 days, after which the groggy stupor faded away.
    I have read a lot of research about delayed-reaction food allergies. There’s a lot of research supporting that this kind of food allergy does exist. These reactions have passed double-blind challenges, although not passing such challenges doesn’t imply that someone doesn’t have a real food allergy.
    Most of the recent research that I’ve read is about non-celiac gluten sensitivity. In reality, many of the people with NCGS have allergies to other foods as well, so the research on NCGS is research on delayed-reaction food allergies in general. A recent review article is at http://www.ncbi.nlm.nih.gov/pubmed/24533607 The authors are working to specify a better diagnostic procedure for NCGS. They say
    “a personal history of food allergy in infancy, coexistent atopy, positive for immunoglobulin G (IgG) antigliadin antibodies and flow cytometric basophil activation test with wheat and duodenal and/or ileum–colon intraepithelial and lamina propria eosinophil counts, could be useful to identify NCGS patients”
    It’s interesting that NCGS involves local eosinophilia. Chronic allergic rhinitis also involves excess eosinophils in the nasal tissues.
    There was a study showing FODMAPS cause symptoms for some people with non-celiac wheat sensitivity. However this study does not debunk NCGS as an immune reaction. Some people are sensitive to FODMAPS, others seem to have an immune reaction to wheat that isn’t a classical allergy. There is a good comment on the FODMAPS study at http://www.ncbi.nlm.nih.gov/pubmed/24275240 There’s also a reply by the authors of the FODMAPS study. They say they define NCGS as a non-immune reaction to food. In other words, a wheat allergy, even an immune reaction to wheat that doesn’t show up on skin and blood allergy tests, isn’t NCGS according to them.
    It’s very important that people get tested for celiac disease (blood tests or a biopsy) BEFORE going on a gluten-free diet. The reason is that the tests for celiac disease become negative after you have been on a gluten-free diet for awhile. To find out if you have celiac disease, you then have to do a “gluten challenge”, which involves eating gluten for an extended time. How much gluten you have to eat for how long, depends on the doctor involved. Celiac specialists tend to more often diagnose celiac disease, so they recommend eating more gluten for a longer time, to catch the marginal cases.
    However, if you really have celiac disease or NCGS, doing this gluten challenge is likely to be a grueling process. Once you have quit eating gluten, often a tiny amount will then make you sick and have other bad effects. A few milligrams or so of wheat could make you feel very sick, and the gluten challenge goes on for weeks or months.
    It’s important to know if one does have celiac disease, because the current treatment is to be strictly gluten-free for life. You have to carefully examine food labels for hidden gluten. Even if you have no obvious bad reaction when you eat gluten, you aren’t supposed to go back to eating it.
    You might suggest to your MIL that she try eating a little bit of wheat to see what happens. But even if she’s wrong about being wheat-sensitive, she can have a healthy gluten-free diet that doesn’t cost more than a gluten-containing diet. There are, however, some popular books about gluten sensitivity, written by doctors who make a lot of money by suggesting that people avoid grains in general or carbohydrates in general. Doing that may be very bad for one’s health.
    In 2003 when I first found out about my delayed-reaction food allergies, doctors didn’t yet know that celiac disease was fairly common in the USA. There was a big epidemiological study the USA in 2003 that found celiac disease at a rate of about 1%. Before that, it had been thought to be rare in the USA, about 1/5000.
    So I didn’t get tested for celiac disease before doing the elimination diet and food challenges.
    I did get useful information from other people with celiac disease and NCGS. I applied those plausibility filters that I mentioned to what people told me, and that did give me some useful information. So you BET I listen to other people’s accounts! Just as good doctors listen to what their patients say, as well as doing lab tests.
    Lastly, I’ve come to believe (and my doctors agree) that completely eliminating a lot of foods based on the results of food challenges, is likely a bad idea. I make an exception for gluten, because it can cause various harmful immune reactions, including the damaging autoimmune process in celiac disease. But with other foods, I think the best thing to do, is likely to eat very small amounts of the foods once every 4-8 days or so, taking various allergy meds beforehand to lessen the reaction. I have been doing this with the help of doctors. The gut has homeostatic mechanisms that react to food allergens by modifying the immune system in favor of tolerance. Current research seems to favor the idea that it’s good for the immune system to be exposed to food allergens in tolerable amounts.

  29. Teaseron 07 May 2014 at 12:38 pm

    DISCLAIMER: This comment is made only in the name of clarity. I did not intend to derail the conversation. I will not respond or defend the point beyond this one statement unless requested.

    @lourasaur

    I have to object to this statement:

    “There are, however, some popular books about gluten sensitivity, written by doctors who make a lot of money by suggesting that people avoid grains in general or carbohydrates in general. Doing that may be very bad for one’s health.”

    Eliminating grains from a diet is not a risk to one’s health. Eat vegetables, fruit, fish and organ meats for your nutrients and fiber. Grains are a poor substitute as a source of dietary fiber and nutrients in comparison.

    The minimum suggested carb intake is 130 grams.(The Institute of Medicine) Populations have thrived on < 50g/day. One starbucks grande caramel macchiato provides 34g of carbohydrate. It is very easy to consume excess carbs.

  30. pointsoflifeon 07 May 2014 at 5:32 pm

    “The proof of the pudding is in the tasting – Katz endorses homeopathy and acupuncture, and I reject them. ”

    I’m amazed at how an academic can reject a therapy that I and many others use in our daily general medical practices. Gee, I think “Acupuncture along with all of it’s variations” is the most powerful medicine in medicine.

    If someone rejects a discipline that you know for certain (beyond doubt) has a definite scientific therapeutic effect on pain, one would have to wonder the intentions of that person.

    What are your intentions?

    Since SBM or modern traditional medicine is not 100%, how do we help those who fail a therapy?

  31. BillyJoe7on 07 May 2014 at 6:06 pm

    laurosaur,

    It seems to me that, so far, you are practising science-based medicine. The things you have observed about yourself have led you to form what could be called an hypothesis, and you have followed this up with experiments to test this hypothesis. And you have read the literature. The next step is to convince someone to do a proper clinical trial to provide more reliable evidence for your hypothesis. Without this your “groggy stupor” could be all psychosomatic.
    So far I don’t see that you have been engaged in CAM.

  32. lourasauron 07 May 2014 at 6:14 pm

    @Bill
    If you have “CFS” that is caused by a food or inhalant allergy that doesn’t appear on allergy tests, then you can indeed sort it out by a process of experimentation. It may be very difficult. I had to do a LOT of experimentation. I had a severe problem with inhalant allergies that made me mysteriously sick for years. It was very difficult because my allergy testing for inhalant allergies, which had been positive at one time, gradually went negative … as I became sicker. So I had to figure things out by a long series of experiments. I got many medical tests from doctors, none of which helped me figure out the problem. By experimentation I figured out my allergies in stages. Then looking at the research, I found there’s a new clinical entity called “local allergic rhinitis”, which means that people have inhalant allergies with negative skin and blood allergy testing. So then I was on my way to figuring things out. Local allergic rhinitis seems to be actually fairly common, and a pilot study suggested that allergy shots can help.
    After a huge effort at allergen avoidance, my allergy testing became partially positive again. And I’m getting allergy shots with an allergist who is willing to give me allergy shots including allergens I didn’t test positive to, on the basis of symptoms, the limited research and past positive allergy tests.
    With “CFS”, people are very “fatigued”. They feel definitely sick. It goes way beyond just “being tired” or something that would come from depression.
    Also, one person who had been diagnosed with “CFS” had been told – by mainstream doctors – that she had the “immune system activation” kind of CFS. So it seems that medically you can tell that something immune is going on. “Immune system activation” doesn’t tell you very much, though. Is your immune system being activated by an autoimmune disorder? By a hard to diagnose allergy? Something else? It’s not an endpoint diagnosis. Another person with puzzling food allergies that don’t appear in the blood tests, who also has celiac disease, was diagnosed by a mainstream doctor with “mast cell activation syndrome”. Similarly, this is not an endpoint diagnosis. Why are her mast cells being activated???
    To really find the problem, in the absence of established lab testing, you have to get empirical, with techniques like elimination diet and food challenges and the experiments I did with inhalant allergies.
    It’s more commonly women who have these problems.

  33. grabulaon 07 May 2014 at 9:50 pm

    @lourasaur

    My point is only that self experimentation only goes so far and that without real medical training it may be hard to determine what exactly is wrong. I use my mother on law as the perfect example for a couple of reasons. First, she decided to make a change in her life a few years back and grabbed onto the concept of gluten free – through doing a little research on the internet. She went gluten free and claimed it made a big difference, so far that’s fine. However, she has never bothered to see a doctor and cannot therefore confirm gluten is definitely her problem. There are other issues that could be the source of any issues she may have that are incidental to her giving up products containing gluten.

    Second, as you mention, celiacs is serious, as are several other possible food related issues and self diagnosing is not helpful in these cases. By going in to see a doctor, she can literally confirm that she has celiacs, or they can begin scientifically looking into what may be bothering her.

    This is ultimately why I am not convinced that these diets are necessarily a good thing. People tend to be lazy, and their brains can lead them astray. A responsible individual would see a doctor if they felt they hadd a food related issue.

    The other problem and is apropos is that often times where certain kinds or components of foods are claimed to be the source of an issue, a diet change that generally becomes healthier than a persons current diet leads them to believe they’ve found an issue when it’s only their overall quality of life has increased and the ‘symptoms of life’ have eased somewhat. This isn’t inherently a bad thing but can lead to some extreme behaviour. My mother in law spends a lot of extra time and money working around her gluten issue, and has no idea if it is an issue at all.

  34. grabulaon 07 May 2014 at 9:52 pm

    @laurosaur

    “It’s more commonly women who have these problems.”

    I wonder if this is actually true or if women are just more apt to report issues?

  35. Steven Novellaon 08 May 2014 at 7:43 am

    POL wrote:”If someone rejects a discipline that you know for certain (beyond doubt) has a definite scientific therapeutic effect on pain, one would have to wonder the intentions of that person.

    What are your intentions?

    Since SBM or modern traditional medicine is not 100%, how do we help those who fail a therapy?”

    You confirm what I have encountered in many other proponents – you are “certain (beyond doubt)” that acupuncture works. Your certainty comes first, the scientific evidence is apparently irrelevant.

    I and others have thoroughly reviewed the literature. There is insufficient evidence to conclude that acupuncture has significant effects beyond placebo: http://www.sciencebasedmedicine.org/acupuncture-doesnt-work/

    My intentions are pretty obvious – just read anything I have written. It’s all pretty public.

    No, we cannot cure everything. That does not justify resorting to ineffective treatments or pseudoscience. But, there are always ways to help patients and to manage them, even if we don’t have all the answers.

  36. elmer mccurdyon 08 May 2014 at 11:33 am

    I’m actually not that little…

  37. DrJoeinCAon 08 May 2014 at 1:02 pm

    StevenNovella: You didn’t answer POL’s question. How do you help those who fail a therapy?

    Have you never seen someone who has benefitted from acupuncture for treatment of pain when other traditional treatments have failed? Would you deny a patient request for acupuncture for pain when other treatments have failed?

  38. steve12on 08 May 2014 at 1:26 pm

    “Have you never seen someone who has benefitted from acupuncture for treatment of pain when other traditional treatments have failed?”

    Anecdote, could have been placebo anyway, careful studies are the only thing that can adjudicate effectiiveness.

    “Would you deny a patient request for acupuncture for pain when other treatments have failed?”

    How exactly would a doctor deny a patient access to acupuncture? Who’s talking about denying anyone anything? We’re talking about what the science says and this is irrelevant.

  39. DrJoeinCAon 08 May 2014 at 1:31 pm

    Steve12: YOU didn’t answer either question, so why bother?

    Yeah, I’m asking for Dr. Steven’s anecdotal experience with patients.

  40. steve12on 08 May 2014 at 3:12 pm

    “Steve12: YOU didn’t answer either question, so why bother?”

    I’m not a clinician, I’m a scientist, so I can’t answer that. But I can tell you that the heart of the matter is wether a given treatment is effective, and this can only be adjudicated by careful experimentation, not clinical anecdotes.

  41. Hosson 08 May 2014 at 3:22 pm

    ChiroJoe(I’ve yet to see any evidence you’re a chiropractor, but its fun mainly because of your horrible CAM logic)

    “You didn’t answer POL’s question. How do you help those who fail a therapy?”
    Using treatments that have been disproven should never be used regardless whether or not all other proven effective therapies have failed. A treatment that has the same effect as placebo demonstrates a lack of efficacy.

    Plausible unproven treatments(not disproven treatments like acupuncture) appear to be, at least to this medically semi-ignorant person, the next logical step. The patient would of course need to be fully informed about the experimental treatment, and the patient may chose not to pursue additional treatment based on several other factors such as cost or a potential decrease in quality of life.

    “Have you never seen someone who has benefitted from acupuncture for treatment of pain when other traditional treatments have failed?”

    While on non-effective treatments, patients can report relief due to several factors including bias and placebo effects. I’ve seen people claim “benefit”(this is a crappy semantic way of claiming efficacy) from treatments that couldn’t possibly work.

    Here is a question for you. What methods or standards would you use to determine efficacy for relief of subjective symptoms? Based upon your response, I will apply your standards to several disproven therapies to demonstrate to you how inadequate your standards actually are for determining efficacy. Most likely if you disagree with the analysis, it’ll be because you’re applying an unstated double standard.

    By the way, your questions are horrible, and they require responses that address your unstated premises.

  42. DrJoeinCAon 08 May 2014 at 4:04 pm

    Hoss: “What methods or standards would you use to determine efficacy for relief of subjective symptoms?” The only standard for determining efficacy for relief of subjective symptoms is patient report. Does the patient report “relief?” Not only is that the only standard in clinical practice as well as in clinical studies, but it is the goal of treatment. So if you use a treatment and the patient reports relief and you “know” that it couldn’t possibly be “true,” then you should question what you know.

    This is a question for Steven who is convinced that acupuncture doesn’t work. My question to him was whether he has ever seen a patient who expressed that he got benefit following this treatment. You can continue to say the patient is fooling himself into believing he is better, in which case the question would still stand.

    Steve12: As always, clinical anecdotes from clinicians are welcomed.

  43. steve12on 08 May 2014 at 4:31 pm

    Steve12: As always, clinical anecdotes from clinicians are welcomed.

    Of course – they should be. I expect clinicians to discuss these.

    I also expect clinicians to know that efficacy cannot be determined from these. That requires careful experiments.

  44. Ekkoon 08 May 2014 at 5:06 pm

    @DrJoeinCA,
    I’m fairly certain people have pointed this out to you before but..

    “The only standard for determining efficacy for relief of subjective symptoms is patient report. Does the patient report “relief?” Not only is that the only standard in clinical practice as well as in clinical studies, but it is the goal of treatment. So if you use a treatment and the patient reports relief and you “know” that it couldn’t possibly be “true,” then you should question what you know.”

    This is most certainly not the “only standard in clinical practice” or in clinical studies. Temporary relief could be reported because the person is in a beautiful clinical setting, reporting to a kind, compassionate practitioner and wanting to give a good answer and report. It could be due to a variety of reasons, including this placebo response or regression to the mean. A good practitioner would also want to see validation in changes in diagnostic tests to confirm actual, postive changes, if tests are applicable, depending on the issue.

    Clinical studies are not interested in whether patients report relief. They are interested in the effects of an active treatment. People receiving nothing but a sugar pill could report some kind of temporary relief. A clinical trial is interested in more than this. This is why good, meaningful clinical studies actually measure something more than just some self-reported relief and they do so in comparison to people receiving nothing (some of which will also report relief). If a patient reports “relief”, that is not good enough, unless your only interest is producing a satisifed customer that will come back for a repeat visit/payment. If that is all that you are interested in, then mission accomplished! It might actually work to fool people who have mild, transient symptoms related to pain, discomfort, or mood but those same people would undoubtedly benefit more, and get their money and time’s worth more, if they received that placebo effect in addition to some active treatment effect.

  45. steve12on 08 May 2014 at 5:16 pm

    I was only reading Joe’s reply to me.

    “The only standard for determining efficacy for relief of subjective symptoms is patient report. Does the patient report “relief?”

    WOW! Is it 1688? It’s hard for me to imagine that someone could actually say this. It’s so ridiculous on so many levels. It’s not just the best way to determine efficacy. Nuh huh – it’s the ONLY way. Because experimentation has not really helped medicine at all. Medicine has progressed ONLY by accumulated anecdotes communicated between clinicians at their local barbershops.

    At least we now know he’s not an MD, DO, etc. Even a PA saying this is scary. My money is on ND or he’s making the whole thing up so that he can use that sweet, sweet argument from authority.

  46. BillyJoe7on 08 May 2014 at 5:34 pm

    Ekko,

    “I’m fairly certain people have pointed this out to you before but..”

    Yes it has, and in great detail, and in too many long in-depth posts.
    Dr Joe is a chiropractor – or at least he has three times failed to deny it – who champions the personal anecdote, eschews evidence based medicine, and denies the relevance of plausibility. He is ideologically motivated and will ever change his tune.
    The only purpose in replying to him would be to appeal to the fence sitters who may be reading.

  47. DrJoeinCAon 08 May 2014 at 5:43 pm

    Ekko: I remind you that we are talking about symptom relief. There are few, if any, studies of symptom relief that report results of “diagnostic tests.” If there is a study of whether or not a treatment provides relief of pain, the results measured are what the patient reports, whether the pain relieved, how long the relief of pain lasted, etc. Purely subjective patient reports.

    Steve12: Still not taking your medication, huh? Perhaps you would like to enlighten the class as to how to measure clinical efficacy for, say, a treatment for pain. What criteria would you use?

  48. DrJoeinCAon 08 May 2014 at 5:44 pm

    BillyJoe7: Says the ideologic skeptic…

  49. Hosson 08 May 2014 at 5:49 pm

    DrJoeinCA
    Thank you for responding.

    “The only standard for determining efficacy for relief of subjective symptoms is patient report. Does the patient report “relief?””

    Your reasoning is mind boggling to the point where I wonder if you’re being purposefully obtuse.

    The patient report gathers information about the effects of treatment reported by patients, which may or may not be real effects. Controls are necessary to isolate the different variables in order to determine efficacy. Your lack of controls and standards generates false positives.

    Based on your standard, a single patient report is enough to reject the null hypothesis. Your standard is heavily biased towards a type 1 error. Of course, you’re arbitrarily picking and choosing when and how to apply this standard.

    There are numerous anecdotal reports of faith healers relieving people of their lower back pain. Based upon your standard for determining efficacy, which only requires positive patient reports, faith healing is effective for relieving lower back pain. Now go ahead and tell us the standards you use to reject lower back relief from faith healing. Now tell us why you don’t apply the same standards for determining efficacy of other treatments for subjective symptoms.

    My guess is that you’re applying a double standard based on your perception of plausibility, which you’re grounding in anecdotal reports. You’re essentially creating a strong standard for stuff you think implausible with and a weak standard for stuff you think plausible. I think that can be describe as a natural thing the brain does, but when conducting science, its inexcusable for not controlling your own biases.

  50. Hosson 08 May 2014 at 6:14 pm

    Joe
    “I remind you that we are talking about symptom relief. There are few, if any, studies of symptom relief that report results of “diagnostic tests.” If there is a study of whether or not a treatment provides relief of pain, the results measured are what the patient reports, whether the pain relieved, how long the relief of pain lasted, etc. Purely subjective patient reports.”

    Which is why it is foolish to say that faith healing does not work. I know faith healing doesn’t work for objective things like curing cancer or AIDS, but faith healing does wonders for relieving subjective symptoms, just look at the anecdotes.

    Here is just a few “patient reports”.
    https://www.rhema.org/new/second/index.php?option=com_content&view=article&id=285:healing-testimonies&catid=54:prayer-and-healing&Itemid=108

    (I feel like an idiot for making a such a stupid argument.)

  51. steve12on 08 May 2014 at 7:15 pm

    “Steve12: Still not taking your medication, huh? ”

    Yeah – the eye-of-newt you prescribed wasn’t really working for me.

    “Perhaps you would like to enlighten the class as to how to measure clinical efficacy for, say, a treatment for pain. What criteria would you use?”

    There’s this wild, wild thing called a placebo controlled double blind study. It’s new, I know, but I’m going to make the prediction that it’s gonna be BIG! YOu just wait and see. It’s going to make demonstrating efficacy by clinical anecdotes look like a pile of puke.

    I just want to point out that no person with any medical training could ask such questions or make such outrageous statements as you are making. I find it funny that so many people come here and claim credentials that they don’t have. They think “Who’s to know?”, but they don’t realize that most of us can tell. it’s just not gonna work.

  52. DrJoeinCAon 08 May 2014 at 7:55 pm

    Steve12: See, the question I asked was “what criteria would you use?” And your answer was probably to another question. Try again. Or don’t. Do whatever the voices tell you.

    Hoss: And you could do a study of whether faith healing did in fact relieve back pain. If you did, the criterion you would use would be — patient report. Not blood pressure or pulse or temperature. Only patient report. What is the pain level when you started and what is the pain level after the treatment?

  53. grabulaon 08 May 2014 at 9:50 pm

    This is Joeinca ‘ s sacred cow. You have to understand, if he can’t rely on patients saying his woo works he had no way of defending his alternative practices. Double blind studies etc just get in the way with the truth. Add long as patients will pay to be fleeced, not treated Joe will defend anecdote to the end.

    These guys can’t attack the actual science. Like creationists shifting to abiogenesis, joes’ ilk attack the weakest link they think they percieve.

  54. DrJoeinCAon 08 May 2014 at 10:53 pm

    Grabula: Gee, if my woo works without side effects and makes my patients better, isn’t that what it’s all about? Or maybe you would rather treat patients and have them experience one or five serious side effects of the evidence-based medicine and wind up treating those side effects for more money. Or maybe even be one of the 400,000 who die from traditional medicine’s mistakes every year.

    Not really a tough call from my point of view.

  55. grabulaon 09 May 2014 at 12:01 am

    But see, that’s the problem Joe, it doesnt work. It’s what you keep failing to understand no matter how much evidence and rational thinking you are presented with.

    For example, acupuncture has to be shown through a mountain of evidence to not work, just sit through this blog for dozens of examples alone. Yet it’s a specific modality you continue to call to.

    Anecdotal evidence is works yet is literally all you have to fall to, to defend woo.

    Why not go to medical school, learn the science of Medicine and make a living legitimately instead of pushing nonsense?

  56. steve12on 09 May 2014 at 1:48 am

    “Steve12: See, the question I asked was “what criteria would you use?” And your answer was probably to another question. Try again. Or don’t. Do whatever the voices tell you.”

    What are you talking about? I answered: placebo controlled double blind study. That’s my criteria.

    And you’re still not fooling anyone “Dr” Joe.

  57. DrJoeinCAon 09 May 2014 at 2:10 am

    Grabula: See, the problem is that it does work. Really it does. You fail to understand that patients find relief of their symptoms from the use of acupuncture and other “alternative” treatments.

    You cite the studies which show it does not work, but, on the other hand, patients report high levels of satisfaction with acupuncture and report that it does work. When there is this kind of conflict, there are a couple of options.

    One option is to disbelieve the patients’ reports and try to find some other reason for their claim of being better. Maybe to claim that they don’t know what they’re talking about, regressed to the mean, are delusional, lie, or are “better” for some other reason than that the treatment actually worked. This option makes one somewhat uncomfortable since, after all, it is patient reports upon which the studies are based. On the one hand, you believe the patient reports during the studies, and on the other, you disbelieve the patient during clinical treatment. In addition, if you DID NOT have the studies and your patient came to you and said they got relief from acupuncture, you would have no reason to disbelieve them. It’s only because you rely on your interpretation of the studies that now you actually doubt the patient report.

    Another option is to question the studies. Maybe it’s not possible to do a reasonable study about acupuncture, a study that could actually control and blind for so-called sham treatment. If you interpret the studies as showing one thing, and yours and other physician experience is not in accord with those studies, it’s gotta make you think that there’s something non-Kosher going on here.

    There is a third option. That option is perhaps when patients have exhausted the standard medical treatments for their symptoms and are not better, maybe it would be reasonable to try a treatment which has no side effects, garners high patient satisfaction, is known to physicians to be efficacious in some patients for some conditions, and could work. This is certainly an option worthy of consideration, don’t you think?

    This is why I asked Novella whether in his migraine practice he has seen patients benefit from acupuncture and how he would treat patients who failed the standard treatments. There is some medical opinion that acupuncture is effective for treatment of migraine.

    Finally, there is nothing illegitimate or nonsensical about the use of acupuncture. Many family practice and pain physicians use it successfully, and their patients have positive experiences with it.

  58. DrJoeinCAon 09 May 2014 at 2:19 am

    Steve12: Do you understand what I mean by “criteria”? I mean, what parameters are you measuring to determine whether a treatment for pain is efficacious or not?

  59. grabulaon 09 May 2014 at 4:06 am

    Anicdotal evidence Joe, I know it’s hard to understand but it’s been explained to you already a thousand times on this blog. But what’s a little science when one can take the lazy path to making money off the ignorant?

    Dr. Novella in his patient way might attempt yet again to answer your ridiculously unscientific and horribly built arguments but the ultimate issue is that no matter how many times he answers you, you fall back on the danger garbage. It’s one argument you’ve mistakenly percieve as being strong in support of your woo. It seems no matter how many times is explained to you you’ll ask the same questions over and over, fir which I can only assume is a desperate attempt to gety some validation.

  60. BillyJoe7on 09 May 2014 at 7:44 am

    DrJoe,

    “it is patient reports upon which the studies are based. On the one hand, you believe the patient reports during the studies, and on the other, you disbelieve the patient during clinical treatment”

    This is false. Firstly, the patient reports are simply recorded. There is no imperative to believe them. Secondly, the trials actually demonstrate that what the patients report is false. This is because those treated with real acupuncture who report that they are better are equal in number to those treated with sham acupuncture who report they are better. So, not only do the trails not implicitly believe the patients’ reports, they actually demonstrate that those reports are false.

    “In addition, if you DID NOT have the studies and your patient came to you and said they got relief from acupuncture, you would have no reason to disbelieve them”

    False. If you are sufficiently informed, you will know that that there is every reason to disbelieve what patients report. And you would know the many reasons why this is so.

    “It’s only because you rely on the correct interpretation of the studies that now you actually doubt the patient report”

    Exactly. Now you’re on the money.

  61. BillyJoe7on 09 May 2014 at 8:00 am

    DrJoe,

    “Another option is to question the studies”

    Good luck with that tack. Unfortunately for you, there have been numerous well controlled, methodologically sound studies which all come to the same conclusion. Acupuncture does not work.

    “Maybe it’s not possible to do a reasonable study about acupuncture, a study that could actually control and blind for so-called sham treatment”

    You’re just demonstrating your ignorance here. Of course it’s possible to do sham controlled acupuncture studies. All the following acupuncture controls have been used and all have shown no effect from acupuncture: wrong acupuncture points for the condition being treated; not using acupuncture points at all; inserting needles superficially; not inserting the needles; using toothpicks.

    ” If you interpret the studies as showing one thing, and yours and other physician experience is not in accord with those studies, it’s gotta make you think that there’s something non-Kosher going on here”

    Correct. You’re on the money again: Personal anecdote is not reliable.
    This is exactly why clinical trials are done.

  62. BillyJoe7on 09 May 2014 at 8:03 am

    DrJoe,

    “when patients have exhausted the standard medical treatments for their symptoms and are not better, maybe it would be reasonable to try a treatment which has no side effects, garners high patient satisfaction, is known to physicians to be efficacious in some patients for some conditions, and could work. This is certainly an option worthy of consideration, don’t you think?”

    Except that this simply does not apply to acupuncture.
    Nor most CAM treatments.

  63. BillyJoe7on 09 May 2014 at 8:10 am

    DrJoe,

    “There is some medical opinion that acupuncture is effective for treatment of migraine”

    Yes, they conclude that sham acupuncture is as effective as real acupuncture. :)
    I kid you not. That was the conclusion of an actual clinical trial of acupuncture treatment of migraine.

    “Finally, there is nothing illegitimate or nonsensical about the use of acupuncture. Many family practice and pain physicians use it successfully, and their patients have positive experiences with it”

    Personal anecdote IS an illegitimate way to assess the efficacy of medical treatments.
    This is WHY we do clinical trials.

  64. Hosson 09 May 2014 at 10:08 am

    NotARealDrJoeinCA

    “And you could do a study of whether faith healing did in fact relieve back pain. If you did, the criterion you would use would be — patient report. Not blood pressure or pulse or temperature. Only patient report. What is the pain level when you started and what is the pain level after the treatment?”

    Congratulations for being one of the worse clinical study designers. Worse might be a little too strong, but definitely horrible. What do you think a faith healing study that collects patient reports without any controls would show? A positive effect with a high level of patient satisfaction most likely. The data collected is highly bias and uncontrolled, and the bad data cannot be used to determine efficacy. At most what you suggested was a poorly designed exploratory study.

    I think I’m likely wrong with your double standard relating to your perception of plausibility. I think the your double standard is applied to treatment of objective and subjective symptoms. I also think you’re too invested in your unjustifiable alternative medicine practice to raise the standards you use to evaluate treatments of subjective symptoms. After all, raising your standards would likely put you out of business.

  65. steve12on 09 May 2014 at 11:38 am

    Joe said:

    “Another option is to question the studies. Maybe it’s not possible to do a reasonable study about acupuncture, a study that could actually control and blind for so-called sham treatment. ”

    This could be a good point, but it works against you. The only problems that arise from having an unconvincing sham are when the acupuncture (AP) group outperforms the sham group, and someone appropriately raises the possibility of placebo being conveyed by AP and not sham, as the subjects can tell the dif.

    If the groups show equal effect, what possible interpretation would lead one to believe that AP works, but the ineffective sham has somehow obscured that truth?

  66. DrJoeinCAon 09 May 2014 at 12:22 pm

    Grabula: Oh, people are “ignorant” when they use acupuncture? So you don’t think that patients are entitled to make informed choices about their treatment? Or is it ok for them to make the choices but if they choose otherwise from you they are ignorant? Is that your point? I’m not sure you have evidence for that. In addition, many medical practitioners who prescribe acupuncture do not do the acupuncture themselves, but instead refer patients. So the medical practitioners do not make money from prescribing acupuncture. This of course is unlike medical practitioners who continue to treat the patient for months and months and see them back often because the patients are not improving. Rather than try something different, they continue to follow the cookbook despite the fact that it doesn’t work in a particular patient.

    BillyJoe7: So many inaccuracies it’s hard to know where to start. Let’s try, study results are based on what patients report. If you believe the study patient when he tells you he has pain relief and when he tells you that he has no pain relief and if you base the results of the study on these patient reports, why would you not believe the actual patient when he tells you the same?

    “There is every reason to disbelieve what patients report.” Really? Where do you get that from? If a patient tells you they are better, you disbelieve him, and if a patient tells you he is no better, you disbelieve him? Makes for a very confusing practice. Though maybe what you want to do is run through your list of what treatments “should” work and be done with it whether the patient claims relief or not. That just silly.

    I said: ”If you interpret the studies as showing one thing, and yours and other physician experience is not in accord with those studies, it’s gotta make you think that there’s something non-Kosher going on here.” And you fall back on your assertion that physician and patient experience is wrong, inaccurate, while the studies alone are accurate. Some people might question that assertion. Perhaps the studies, some of which are in conflict, are not accurate. So if the studies are conflicting and if personal and professional experience shows the practitioner that his patients get relief from acupuncture, why would this trained professional who relies on his powers of observation and diagnostic and therapeutic acumen then begin to doubt his abilities? Really, why? How did these powers of observation and doctor ability get lost all of a sudden?

    Hoss: The point is that the patient reports are used to determine whether a treatment for pain, for example, works or doesn’t work. That’s the criterion for all studies regarding treatment for pain. What does the patient report, pain relief or no pain relief? That’s how you measure whether the treatment is effective, by asking the patient. You do the study and ask the subject whether the treatment helped or not, and you believe what they say. Otherwise, if you don’t believe them, you can’t do the study, can you? There’s no objective measurement here; it’s all what the patient reports. This is the problem with BillyJoe7′s contention that he doesn’t believe what patients say. If you believe it during the study, why not believe it during treatment? And, by the way, there is no such thing as an “objective symptom.” Symptoms are by definition subjective.

    Steve12: Not quite sure what you’re getting at there. I think you would have a tough time doing a double blind study of acupuncture where the practitioner is also blinded.

  67. steve12on 09 May 2014 at 1:24 pm

    “Steve12: Not quite sure what you’re getting at there. I think you would have a tough time doing a double blind study of acupuncture where the practitioner is also blinded.”

    Good point – you couldn’t really double blind. But that also works against you for the same reason as the bad sham.

    What I’m getting at is that your objection that the experiments aren’t valid because of unconvincing shams or a lack of experimenter blinding don’t make sense with a null result.

    If it turns out that the study shows that AP didn’t work (i.e., pain relief was the same in the active and sham conditions), this was found DESPITE the unconvincing sham and DESPITE the lack of experimenter bias.

    Both of those problems bias the experiment toward better results in the AP group, not the sham group.

    You’re argument works against you Joe.

  68. DrJoeinCAon 09 May 2014 at 2:11 pm

    Steve12: Hmmm. I see all these arguments in favor of good “scientific” studies, when all the time it doesn’t matter whether the study has unconvincing sham and lack of experimenter blinding. Good to know that no matter how crappy the study is, as long as you get the results that support your position it’s ok. Who knew? I wonder what would have happened if the crappy study had found otherwise. Maybe it would have made the crappy study list along with the Chinese studies.

  69. steve12on 09 May 2014 at 2:32 pm

    More generalities.

    You’re not understanding (skocking).

    Of course it’s not a good experiment. But the reason WHY is important. And that requires looking at specifics, something you seem preternaturally unable to do. I’ll simplify

    In this case, no experimenter blinding and an unconvincing sham give an unfair advantage to acupuncture. So when these studies STILL show that AP doesn’t work, it’s actually quite astonishing. IOW, not only is AP not better than placebo, it’s not even better than a shitty transparent placebo.

    How about this? You tell me why the experimenter knowing which condition they’re adminstering (real or sham) AND the subjects being able to tell which condition they’re in (real or sham) would result in no difference between AP and sham?

    If AP really works, how would these specific experimental flaws drive a result of no difference between sham and AP?

    I await your interpretation – and BE SPECIFIC!!!!

  70. DrJoeinCAon 09 May 2014 at 5:00 pm

    Steve12: A crappy study is a crappy study. If the study is not good, the results are not good. All you have to do is read how the study was done, and, if it was crappy, you don’t even go to the results. There is no point at all in trying to dissect HOW the flaws affected the outcome.

    It’s the same as you saying that results of a crappy study that show acupuncture is effective are not to be believed.

  71. BillyJoe7on 09 May 2014 at 6:03 pm

    DrJoe,

    “study results are based on what patients report”

    Correct.

    “you believe the study patient when he tells you he has pain relief”

    Incorrect.
    You don’t believe (or disbelieve) the patient’s report, you simply record that they reported that they had pain relief. The reasons you don’t automatically believe the patient’s report is because you are aware of all the reasons why they might give a false report (ie wanting to please the practitioner who is trying to help them).

    “if you base the results of the study on these patient reports, why would you not believe the actual patient when he tells you the same?”

    Non-sequitur.
    You don’t believe (or disbelieve) the trial patient’s report, you simply record their report. Similarly, you should not believe (or disbelieve) the clinic patient’s report, you simply record it in your clinic notes. Because you know all the reasons why patients might give a false report even when they themselves are not even aware that their report is false.

    “If a patient tells you they are better, you disbelieve him.”

    You misunderstood what I said, or perhaps I wasn’t clear. What I said or what I meant to say is that you don’t necessarily believe their report, because you are aware of the many reasons why patients might give a false report.

    “you fall back on your assertion that physician and patient experience is wrong, inaccurate, while the studies alone are accurate”

    This is not an assertion. It is a fact that physician experience is unreliable. The very fact that one physician’s experience leads him to a conclusion that is diametrically opposed to the conclusion of another physician should tell you that personal experience is unreliable. This is exactly the reason to do clinical trials.
    Also, I did not assert that clinical trials are accurate. They need to have proper random allocation, they need to have proper controls, they need to have adequate blinding. and they need to be properly analysed. Many clinical trials are fatally flawed, many more are methodologically flawed.

    “Perhaps the studies, some of which are in conflict, are not accurate”

    Incorrect – SOME of these trials are not accurate.
    And it is telling that, as far as acupuncture is concerned, the more methodologically sound the trial the less effect that is seen from the acupuncture treatment, and that the most methodologically sound trials show no effect. This further demonstrates that the personal experience of physicians regarding the value of acupuncture is false.

    “if personal and professional experience shows the practitioner that his patients get relief from acupuncture, why would this trained professional who relies on his powers of observation and diagnostic and therapeutic acumen then begin to doubt his abilities?”

    There is no doubt that professional experience is unreliable. It has been demonstrated time again. Every time the personal experience of one physician conflicts with that of another physician, we can conclude that the experience of at least one of them is inaccurate.
    This is the exact reason for doing clinical trials.

    “Really, why? How did these powers of observation and doctor ability get lost all of a sudden?”

    They are not lost. They are inaccurate. They must be tested against reality. If the systematic analysis of properly controlled clinical trials demonstrate that acupuncture does not work, then the physician must conclude that his observations about the value of acupuncture have been inaccurate. He might even avail himself of the literature on cognitive biases that will explain to him why his observations and conclusions could have been so wrong.

  72. steve12on 09 May 2014 at 6:16 pm

    “All you have to do is read how the study was done, and, if it was crappy, you don’t even go to the results. There is no point at all in trying to dissect HOW the flaws affected the outcome.”

    It’s like you don’t know anything about science at all. Oh, that’s right, you don’t. In the actual world of science, this is what is known as Total F*cking Horseshit (TM).

    All studies (ALL STUDIES) have flaws. What those flaws are are very important. Some are fatal, some limit interpretations in a particular way, some require new experiments for clarification of specific issues, etc.

    In the example that I was discussing (because you brought it up re: problems with sham AP) there are problems – yet, a null result can be telling for the SPECIFIC reasons I cited. I asked you to comment on this SPECIFIC instance. As usual, you cannot and instead replied with some vague nonsense about not reading “crappy” studies.

    But what can we expect from a fake doctor?

    Still waiting for you to tell me why transparently fake AP would be as good as real AP at relieving pain. I’m sorry – I’m asking you to respond to specifics again. You don’t (can’t) do that, I forgot.

  73. Hosson 09 May 2014 at 6:29 pm

    Joe
    “The point is that the patient reports are used to determine whether a treatment for pain, for example, works or doesn’t work. That’s the criterion for all studies regarding treatment for pain. What does the patient report, pain relief or no pain relief? That’s how you measure whether the treatment is effective, by asking the patient.”

    There are also other questions that can be asked such as a decrease in current pain medication. You also need freaking controls. A biased survey is not an efficacy study. You advocate a study design that maximizes false positives.

    “A crappy study is a crappy study. If the study is not good, the results are not good. All you have to do is read how the study was done, and, if it was crappy, you don’t even go to the results. There is no point at all in trying to dissect HOW the flaws affected the outcome.
    It’s the same as you saying that results of a crappy study that show acupuncture is effective are not to be believed.”

    I think that was the first relevant tautology I’ve ever heard. /end sarcasm

    I’m going to disagree with you. Obviously a better designed study would be optimal, but a study design that is heavily biased towards a type 1 error and still isn’t able to reject the null hypothesis is a meaningful result. Not the same.

    I don’t know what this means, but if I could, I would give you a logic enema.

  74. DrJoeinCAon 09 May 2014 at 6:53 pm

    Steve12: My response is that a crappy study’s conclusions are as valid as the study. Come on. Your gold standard is a randomized placebo-controlled double blind study, and this kind of study of acupuncture is not possible. We then go to other studies and look at the results from them. But wait, your response is that these other studies which show that acupuncture is perhaps efficacious are not randomized double blind studies so we should disregard them. Isn’t that the case? You can’t have it both ways.

    BillyJoe7: You record the study patient reports but you don’t believe them? You question the accuracy of the study parameters and yet you draw conclusions based on those parameters? You only record the patient’s responses in the chart but you don’t draw any conclusions based on those responses?

    Physician experience is “unreliable?” Why not have medical assistants plug in the patient’s complaints and consult a database to prescribe the right treatment? No need for a physician after all, is there? Because you know “from studies” that pain is treated this way and dizziness is treated that way and fatigue is treated another way. No need for judgment or experience. That’s just ridiculous.

    You are confusing physician experience, acumen, diagnostic ability, powers of observation with the results of clinical studies. They are not even in the same ballpark.

    Hoss: Few clinical studies of pain treatments include parameters other than pain relief.

  75. steve12on 09 May 2014 at 7:15 pm

    “My response is that a crappy study’s conclusions are as valid as the study. Come on.”

    Which is sufficiently vague as to be meaningless.

    “Your gold standard is a randomized placebo-controlled double blind study, and this kind of study of acupuncture is not possible. We then go to other studies and look at the results from them.”

    There are many studies that would be perfect but cannot be done. YOu use the best evidence you can get, and flawed experiments are superior to clinical anecdotes.

    “But wait, your response is that these other studies which show that acupuncture is perhaps efficacious are not randomized double blind studies so we should disregard them.”

    Never said this.

    “Isn’t that the case?”

    No, because I never said this. When did I say we should disregard studies sight unseen? I said I’d like to see gold standard trials. You said there’s a problem with the sham. I agreed, and showed you why that actually works against your point. Instead of thinking about what someone here has to say, however, you reflexively disagree without really understanding.

    “You can’t have it both ways”

    Right. But I don’t want it both ways because I never said that.

    Seriously – instead of pretending to be a doctor and pontificating about subjects you know nothing about, you might try actually listening to what people are saying to you. I was listening to you when you pointed out why double-blind might not be possible, and I agreed and modified my position.

    You can’t learn anything until you stop pretending that you know everything.

  76. DrJoeinCAon 09 May 2014 at 8:02 pm

    Steve12: What I know is that the studies that show that acupuncture works are generally pooh-poohed as (a) Chinese, (b) not randomized, (c) not blinded, (d) not big enough. I’m not so sure that “flawed” experiments are superior to clinical anecdote. Where are you getting that nugget?

    I also know that, despite the skeptical pooh-poohing, acupuncture is now an accepted part of medical practice, accepted by patients, physicians, medical groups, hospitals, medical schools. This is because it works. I and the aforementioned groups know that acupuncture benefits patients. I know that acupuncture is a harmless and effective treatment with no downside whatsoever. I know that physicians’ experience is an integral part of the practice of medicine.

    It may surprise you that the treatment of symptoms is not so frequently “evidence-based,” often anecdotal, more often than not dependent on the experience of the practitioner, and despite all that is effective. Good doctors are good not only because they know what the studies say, but also because they listen to their patients and work with them to improve their lot. They know when the traditional stuff is not working or not applicable, and when that happens they know something else should be done.

    The ideas that physician experience is BS and that patients can’t be trusted to tell the truth is contrary to the practice of medicine. Dismissing patients as ignorant and physicians as lazy for using acupuncture is just stupid.

    Arguing that acupuncture doesn’t work is a meaningless exercise that has no relevance to the way medicine is practiced.

  77. grabulaon 09 May 2014 at 9:34 pm

    @JoeinCa

    “It’s only because you rely on the correct interpretation of the studies that now you actually doubt the patient report”

    See Joe, even you are starting to understand!

    “Another option is to question the studies”

    Seems reasonable as long as you question in reasonable terms. It’s important to understand how the study was done and who is doing it.

    “There is some medical opinion that acupuncture is effective for treatment of migraine”

    Opinion is not evidence.

    “Oh, people are “ignorant” when they use acupuncture?”

    Of course they are. Studies show it doesn’t work. Either they are ignorant of these studies are they are being purposely ignorant in ignoring them.

    “So you don’t think that patients are entitled to make informed choices about their treatment?”

    Absolutely, as long as that informed choice is based on reasonable evidence. Hearing from a friend that it worked for them is not reasonable, or evidence.

    “In addition, many medical practitioners who prescribe acupuncture do not do the acupuncture themselves, but instead refer patients. So the medical practitioners do not make money from prescribing acupuncture”

    A couple of issues with this line of argument. First this assumes that medical practitioners cannot be ignorant of the evidence or efficacy of crapmed. For example, you call yourself Dr here, but you don’t seem to understand the evidence against it. On the issue of making money, you often point out that it’s being embraced in legitimate medical facilities around the world. In this country this is often motivated by money. Now instead of that money going outside of a practice or hospital, they can point the ignorant down the hall to the local crapmed practitioner so the hospital still gains. It’s an unfortunate side effect of treating people for profit.

    “Rather than try something different, they continue to follow the cookbook despite the fact that it doesn’t work in a particular patient.”

    Something different is fine, soemthing that mounds of evidence shows does not work is useless.

    Finally, when it comes to acupuncture Joe, what you’re saying is it doesn’t matter that it’s shown to not work as long as sticking a bunch of needles in someone makes them believe they are treated?

  78. DrJoeinCAon 09 May 2014 at 11:02 pm

    Grabula: No, what I’m saying is that it does work. The medical establishment uses it, patients like it, it gives relief of patient symptoms. The medical establishment apparently looks at the studies differently than you do.

  79. grabulaon 09 May 2014 at 11:18 pm

    @Joe

    ” No, what I’m saying is that it does work. The medical establishment uses it, patients like it, it gives relief of patient symptoms. The medical establishment apparently looks at the studies differently than you do.”

    You say this as if the medical community has whole heartedly embraced crapmed. In fact it’s still on the fringe and many credible organizations admittedly take it into the fold for purely monetary reasons. This doesn’t in anyway validate it’s effectiveness. But I guess no mountain of evidence is enough to convince a true believer he’s wrong. You’ll continue to use crappy rationale to legitimize in your mind the fleasing of your customers. Ironically, you and your ilk will continue to point fingers at science based medicine as being motivated by money, meanwhile the only reasons to practice crapmed is 1 – to make money on the ignorant, or 2 – because you’re too ignorant to understand the science.

    Which is it for you Joe?

  80. DrJoeinCAon 10 May 2014 at 12:24 am

    Grabula: Yeah, sure, the reason the medical establishment is embracing acupuncture is for money, because the public is clamoring for still another treatment that costs a lot of money and does not work. Is that what you think? That physicians realize that acupuncture does not work but choose to use it on their patients?

    YOU know that acupuncture does not work, but multitudes of medical professionals just don’t see it like you do. Gee, perhaps you are wrong. That’s what I think.

    The medical establishment (hospitals, healthcare organizations, medical schools) at all levels is adopting the use of acupuncture because it works, is cost effective, is requested by patients, and has no side effects. It’s harmless.

    Incidentally, you keep ranting that patients who use acupuncture are “ignorant.” Do you happen to have statistics on the education level of patients who use CAM? I would bet that people who choose to use CAM are better educated than those who choose not to use CAM. That’s been my experience.

    So you have better educated people and medical professionals both wanting to use a treatment which is efficacious and harmless. And your response is to call them ignorant. I dunno.

  81. grabulaon 10 May 2014 at 12:31 am

    @JoeinCA

    Since when did ignorance mean uneducated? I’m educated but ignorant on subatomic physics except in the most basic terms and I have no idea about the biology of the sea cucumber. Are you trying to build a strawman?

    Where’s the evidence acupuncture works Joe. We’ve addressed how it’s been shown to not work enough to satisfy, now where’s your evidence. before you start to build your case, here you go, have a read:

    http://www.wisegeek.org/what-is-anecdotal-evidence.htm

    http://en.wikipedia.org/wiki/Anecdotal_evidence

    http://en.wikipedia.org/wiki/Argumentum_ad_populum

  82. DrJoeinCAon 10 May 2014 at 1:19 am

    Grabula: You seem to think that acupuncture advocates are preying on the ignorant. And I tell you that educated people, people who presumably know how to think about things are more likely to favor alternative medicine than people less educated. These are not the ignorant. These are the smart.

    I am not going to argue the evidence of acupuncture. I’ve looked at the evidence in the past and I have some experience with acupuncture, enough to convince me that it does work. To me, this question has been asked and answered by the medical community who make these kinds of clinical judgments for those who are ignorant about medicine and how to treat patients. While there are conflicting studies of the efficacy of acupuncture, the decision to use acupuncture in a particular patient for a particular symptom is made both by the physician and the patient.

    I know you don’t accept clinical experience or clinical judgment as valuable, but you just can’t start from zero every time. One builds on one’s experience which hopefully leads to better judgment and better decision making. My experience tells me that it works in more patients than not, and that’s what counts, more than the results of a sham acupuncture study of 200 patients. My experience tells me that many patients know what is best for them, and, as I said, the more educated patients are more likely to choose alternative methods of treatment.

    To be clear, it’s not that more people are using it — though that is the case. It’s that more medical professionals are using it. The people who know medicine and know patient care are increasingly using alternative medicine because they know that it works.

  83. grabulaon 10 May 2014 at 2:36 am

    @Joe

    “And I tell you that educated people, people who presumably know how to think about things are more likely to favor alternative medicine than people less educated.”

    Evidence for this claim?

    “I am not going to argue the evidence of acupuncture”

    Of course you’re not Joe. You don’t have any. That’s the problem with crapmed, the people who buy into it can’t be bothered with evidence or the scientific method.

    “I know you don’t accept clinical experience or clinical judgment as valuable”

    I’ve never said this. Dr. Novella has already pointed out in another blog comment thread that clinical experience can be useful, but not when it flies in the face of real evidence. You’re suggesting it’s ok to forego that evidence if someone tells you they feel different about it. This kind of touchy feely crap is why people like Stanislaw Byrzinski get away with fleecing people and almost literally murder. You’d rather appeal to someone’s ignorant system of beliefs then acknowledge the evidence, and the understanding that sometimes our ‘instincts’ don’t carry any weight when it comes the scientific method.

    My final point Joe is that you’ve been unable to produce any evidence supporting your claims over several threads of discussion, which is telling. While Dr. Novella has posted multiple blog posts containing dozens of examples of how it does not work, you’ve been unable to produce anything close to enough evidence to begin to refute it. You continue to fall back on anecdotal evidence and feel goodness to explain your interest in quack. I’m guessing that’s why medical school was never an option for you, it’s too hard, and requires you to face the science involved. It’s much easier to get a cheap certificate from another woo scheister so you can go out and earn money off the ignorant.

  84. BillyJoe7on 10 May 2014 at 3:07 am

    DrJoe,

    “BillyJoe7: You record the study patient reports but you don’t believe them?”

    Now you are resorting to outright lies.
    Here is what I said:
    “You don’t believe (or disbelieve) the patient’s report, you simply record that they reported that they had pain relief. The reasons you don’t automatically believe the patient’s report is because you are aware of all the reasons why they might give a false report (ie wanting to please the practitioner who is trying to help them)”
    And again:
    “You don’t believe (or disbelieve) the trial patient’s report, you simply record their report. Similarly, you should not believe (or disbelieve) the clinic patient’s report, you simply record it in your clinic notes. Because you know all the reasons why patients might give a false report even when they themselves are not even aware that their report is false”
    And a third time:
    “You misunderstood what I said, or perhaps I wasn’t clear. What I said or what I meant to say is that you don’t necessarily believe their report, because you are aware of the many reasons why patients might give a false report”
    I even added italics!
    So, Joe, why are you lying about what I said?
    Is it because you have no arguments against what I did say?

    “You question the accuracy of the study parameters and yet you draw conclusions based on those parameters? You only record the patient’s responses in the chart but you don’t draw any conclusions based on those responses?”

    Did you miss this then:
    “those treated with real acupuncture who report that they are better are equal in number to those treated with sham acupuncture who report they are better. So, not only do the trails not implicitly believe the patients’ reports, they actually demonstrate that those reports are false”
    In other words, comparing real with sham acupuncture enables you to draw the conclusion that acupuncture does not work.

    “Physician experience is “unreliable?” Why not have medical assistants plug in the patient’s complaints and consult a database to prescribe the right treatment? No need for a physician after all, is there? ”

    How do you get from “physician experience is unreliable” to “no need for a physician”?
    You need your physician to know what clinical trials say about the efficacy of various treatments so that you can make an informed choice about what treatments to use. If there are no clinical trials, or if what the say is unclear, you will need to rely on his personal experience. This is unreliable but not completely useless and about the best you can do in these circumstances.

    “Because you know “from studies” that pain is treated this way and dizziness is treated that way and fatigue is treated another way. No need for judgment or experience. That’s just ridiculous.”

    I don’t have to defend that because I didn’t say that.

    “You are confusing physician experience, acumen, diagnostic ability, powers of observation with the results of clinical studies.”

    I did no such thing.
    Joe, you are now resorting to mischaracterisations, strawmen, and outright lies.
    Why is that?

  85. grabulaon 10 May 2014 at 3:20 am

    “Is it because you have no arguments against what I did say?”

    “Joe, you are now resorting to mischaracterisations, strawmen, and outright lies.”

    It’s what you end up with when you have no evidence to back up your work.

  86. grabulaon 10 May 2014 at 6:55 am

    I’ll get you started Joe,

    http://scienceblogs.com/insolence/2014/05/08/the-kudzu-of-quackademic-medicine-infiltrates-the-university-of-florida/

  87. DrJoeinCAon 10 May 2014 at 12:01 pm

    Grabula: And I’m telling you that the evidence for acupuncture efficacy is there. There is just no reason to argue over individual studies. (It’s as stupid as arguing whether there is an afterlife.) I’ve looked at the evidence, and the medical establishment has looked at the evidence. I concluded as they have that there is value in offering acupuncture to patients for treatment of their symptoms because it works.

    I don’t know why you refuse to accept that MEDICAL PROFESSIONALS who presumably know more about medicine that you do have accepted acupuncture as an alternative treatment. The ship has sailed and the argument is over. You don’t like the conclusions that the medical professionals have reached. Fine. Don’t use acupuncture. That’s your decision. But don’t get all high-horsey on medical professionals who know more about medicine than you do. Consider than an argument from authority.

    As to the education level of CAM users, this is what I could find:

    http://www.utoronto.ca/CAMlab/publications/col_who_seeks_alt_health.html

    BillyJoe7: You “record” the results of patient studies where patients report whether their pain is better or not and then you use these reports to determine whether a treatment works or not. You accept the patient report as honest and believable. What you said is you “don’t automatically believe the patient’s report.” Of course you do. How would you do the study if you didn’t take the patient report as accurate? Seriously, the patient reports a pain level of 9 at the beginning and 3 at the end of the study. These reports are NOT questioned. These are your data. If you question their accuracy, then there is no study. Don’t you see that?

    “You need your physician to know what clinical trials say about the efficacy of various treatments so that you can make an informed choice about what treatments to use.” But why does this have to be a physician? You as a non-physician have already formed your interpretation of clinical trials. Why couldn’t a medical assistant Google it as well as you can?

    Your trouble is that you refuse to accept that physicians use acupuncture as a treatment option. This is so hurtful to you that you question why they would do that when the results of the studies are so obvious to you. In fact, the role of the physician is to work with the patient to determine what the best treatment for the individual patient is. This involves input from the patient. Physician experience has a large role to play in the decision, and physician experience may include acupuncture as an option.

  88. DrJoeinCAon 10 May 2014 at 12:06 pm

    Grabula: Ha! Nice link. Funny how they all (big choir there) ranted against Florida. Maybe they should also realize that among the non-Florida hospitals using acupuncture are Children’s Hospital of LA and Memorial Sloan-Kettering Cancer Hospital in NY. Embrace the tide!

  89. grabulaon 10 May 2014 at 9:38 pm

    Joe, can you tell me what an argument from authority is? Can you also tell me that medical professionals are infallible?
    Finally, can you tell me who primarily makes the business related decisions at a hospital or school?

  90. DrJoeinCAon 10 May 2014 at 9:50 pm

    Grabula: Yes I can. No they are not. The administrators and suits.

    Now can you tell me which are the only professionals qualified by virtue of their education to make medical decisions?

  91. grabulaon 10 May 2014 at 10:03 pm

    I’m not arguing who’s more qualified but all you need to see why this stuff is infiltrating real medicine is in your answers

  92. DrJoeinCAon 10 May 2014 at 10:29 pm

    Grabula: Uh, no. The reasons why this stuff is infiltrating real medicine are: (a) patients like it because it makes them feel better; (b) doctors prescribe it because it makes their patients feel better with no concerns about side effects; (c) high patient satisfaction tends to lead to higher revenues thus satisfying the suits; and (d) see a-c. I would bet that the demand for this stuff comes from patients, and the reason for that is it makes them feel better. Their satisfaction with this stuff is high.

    The answer to my question is physicians, by the way. Physicians are the ones qualified to make medical decisions, and they are the ones who prescribe this stuff.

  93. BillyJoe7on 11 May 2014 at 4:02 am

    ChiroJoe,

    Thanks for simply repeating what you said in the first place instead of actually responding to what I said in reply. Progress zero. I take this to mean that either you are simply ignorant about clinical trials or you simply have no argument against my point. My bet is that is is a bit of both.

    Also, are you going to deny you are a chiropractor?
    If so, I’ll stop calling you one.

  94. DrJoeinCAon 11 May 2014 at 11:53 am

    BillyJoe7: Your posts are so long and fragmented that I have trouble selecting the pertinent questions. You can call me whatever makes you happy.

    My response to you stands on its own. You should examine exactly why you are so much against acupuncture when the medical establishment and patients are embracing it. Work on that for the next class, will you?

  95. BillyJoe7on 11 May 2014 at 5:57 pm

    I’ll make it short then…

    The only thing that matters is the evidence.
    The argument from popularity is a cognitive error.
    At one time blood-letting was popular.

    Get it now?

  96. BillyJoe7on 11 May 2014 at 5:59 pm

    …what’s the bet that now you’re going to swing round and ask for a bit of detail. :)

  97. DrJoeinCAon 11 May 2014 at 6:25 pm

    BJ7: And I tell you again that there is evidence that acupuncture works. I’m not arguing from popularity when I tell you that patients want to use it because it works and relieves their symptoms, and doctors prescribe it because it works and relieves their patients’ symptoms.

    Your interpretation of the evidence is in conflict with the interpretation of medical professionals who prescribe it and see positive results from it.

    Blood-letting? Really, is that what you’re down to? Not witch doctors?

  98. grabulaon 11 May 2014 at 10:23 pm

    Lol at witch doctors. .. is that what Dr means in the joeinca?

    I find it curious you’re so deceptive about your background Joe. You’d think of all this stuff you claim works, actually did, you wouldn’t feel you need to hide.

    Still argument from popularity…

  99. DrJoeinCAon 11 May 2014 at 10:52 pm

    Grabula: What do my credentials have to do with whether acupuncture works?

    No, it’s not an argument from popularity. Patients like it because it works FOR THEM. Doctors like it because it works FOR THEIR PATIENTS.

  100. grabulaon 11 May 2014 at 11:23 pm

    Joe, I think it shows an inherent distrust and embarrassment associated with woo. Either you are a medical doctor who believes in woo and knows this might hurt his practice or your a woo practitioner who’s purloined the title to make you seem more legitimate.

    Dr. Novella isn’t housing his credentials, why would you? I’d think I’d you include “dr” in your title in earnestness you’d have no problem sharing the source and background.

  101. BillyJoe7on 12 May 2014 at 7:25 am

    ChiroJoe,

    “And I tell you again that there is evidence that acupuncture works”
    Nope.

    “I’m not arguing from popularity when I tell you that patients want to use it because it works”
    Nope. Some patients think it works, but the evidence is that it does not work.

    “and doctors prescribe it because it works and relieves their patients’ symptoms”
    Some doctors think it works, but the evidence is that it does not work.

    “Your interpretation of the evidence is in conflict with the interpretation of medical professionals who prescribe it”
    But not with those who have done systematic reviews and who conclude that it does not work’

    “and see positive results from it”
    Nope. They think they see positive results, but all they are seeing is a placebo response.

    “Blood-letting? Really, is that what you’re down to?”
    Nope. That’s what acupuncture is down to.

  102. DrJoeinCAon 12 May 2014 at 11:27 am

    BJ7: Yep.

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