Mar 20 2014

Electrical Nerve Stimulation for Migraine

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100 Responses to “Electrical Nerve Stimulation for Migraine”

  1. Billzbubon 20 Mar 2014 at 11:49 am

    Thank you Steve for posting this. My daughter who lives with her mom most of the time suffers from migraines, and her mom is a HUGE believer in everything woo by nature. I’m very happy to get the real scoop from you on this device.

    Can you recommend a concise, lay-person friendly resource that gives information for other migraine treatments like biofeedback so that I can know which ones are plausible and which ones are clearly pseudoscience?

  2. Heptronon 20 Mar 2014 at 12:52 pm

    Interesting article, Dr. Novella. A couple of things, though.

    1) “…and there is good reason to think that inhibiting trigeminal activity can make it less likely for a migraine attack to be trigger – raise the threshold at which a migraine headache occurs.”
    To me, pain is one way for the body to tell you that something is wrong. Isn’t raising this threshold like shutting off the alarm going off that tells you something is wrong? (please correct me if I’m wrong).

    2) Will this change how you deal with your migraines? Would you ever consider giving this thing a shot or would you wait until more evidence comes out?

  3. Steven Novellaon 20 Mar 2014 at 1:04 pm

    Heptron,

    1 – But migraine is a pathological pain condition. Migraines are not a warning alarm telling you something is wrong. It is the something that is wrong. Preventing migraines from being triggered will not in any way mask head pain that is protective. The real alarm bells will still work.

    2 – As I said, I may consider using it in patients with no other options, as a sort of open-label experiment. It’s reasonable to use experimental treatments if they are safe, plausible, and existing evidence is encouraging, if there are no other treatments available with better evidence. But I would not use it first line and I won’t oversell the claims to my patients.

    This is typical – as more and better data comes in showing something works, it gets moved up the priority list of treatments. For now this is on the bottom rung, but not off the list.

  4. pdeboeron 20 Mar 2014 at 1:13 pm

    This type of device is the sort of thing that I would love to either debunk or verify just through verifying that it does indeed provide enough electrical and magnetic stimulation to have an effect on nerves.

    Unfortunately debunking this would require me to buy the $350 son of a bitch. Thats more than double that of a good gauss/tesla metre.

    If anyone has a supply of strange possibly pseudoscientific electronic devices, give me a shout. I’d love to start a blog on it.

  5. Xplodyncowon 20 Mar 2014 at 3:57 pm

    This is interesting because I wonder if the FDA’s regulations apply to a website with a Canadian URL, and if that matters (or should matter) in the age of the world-wide-web.

    I think that FDA’s guidance on this is still evolving. As far as I know, as long as the U.S. site does not directly link to the Canadian site, the manufacturer is in the free and clear.

  6. Will Nitschkeon 21 Mar 2014 at 5:39 am

    @ Steven Novella

    “I am not sure why the FDA approved the device on this evidence alone.”

    “For myself, as a clinician with specialization in migraine, I may consider using the device.”

    So if my interpretation is correct, as clinician, specifically trained in this field, and using the Novella Skeptical Method ™, you complain in your article that there is lack of sufficient evidence to justify use of the device, but may consider using the device anyway… presumably in case you are wrong.

    If I read you correctly, you cannot use the Novella Skeptical Method ™ to reach a firm conclusion on a rather specialised, specific device, for which you have years of practical experience and medical training in.

    Yet… on topics which are unfathomably more complex, of which you have limited to little understanding of, i.e., mental models of the brain (where you reached the conclusion that we are ‘nearly there’) or climate change (where you decided upon very specific political policy outcomes), to select two recent examples anyway; well, you apparently have little or no doubt.

    Might it be safe to conclude that the level of certainty offered by The Method appears inversely proportional to the lack of understanding you have over the subject matter…?

  7. Newcoasteron 21 Mar 2014 at 5:42 am

    I’m surprised that they aren’t promoting it for Trigeminal Neuralgia, given the putative mechanism, but I guess they didn’t specifically study that.

    I suspect whether or not larger trials are ultimately supportive of this device for migraine, versions of it will be making their way to various quacks, as many of them already use TENS and similar devices to treat a variety of maledies.

    Thanks for the heads up on this one, Steve.

  8. grabulaon 21 Mar 2014 at 5:54 am

    Ah Will N, you’re such a ham!

    Again, as is always the case you’ve failed to really read the article and understand where Dr. Novella is going with it. How do I know you haven’t read it? Because all the answers to your query exist in the final paragraph:

    “For myself, as a clinician with specialization in migraine, I may consider using the device. Again, it has the virtue of safety and plausibility. But I consider the device still experimental and will use it as such. I also hope to see some academic clinical studies to provide further evidence as to its efficacy.”

    That’s what actual skepticism looks like my friend. Dr. Novella is open to the idea that it might work, and that research so far seems to indicate that it might work. He’s willing – because it’s safe and plausible…SAFE and PLAUSIBLE – I put it in caps so when you skim they may catch your eye – to give it a shot because he does practice in that arena and has some insight into whether it might actually work or not. Essentially he can contribute to the end result of determining whether it works or not.

    I have to imagine that after a few beers, some whisky and a bottle or two of wine, you saw a new article on Neurologica and just had to post! I just wish you’d at least make it sporting.

  9. Steven Novellaon 21 Mar 2014 at 7:12 am

    Will has demonstrated that he cannot read and understand my posts, for whatever reason.

    The bar for FDA approval is and should be higher than the bar for using a treatment on a preliminary or experimental basis, because it is safe and plausible, and when no other better established treatments are available. Also, giving FDA approval removes motivation from the company to fund more research, which is still needed. I said all of this in the post itself.

    When I am writing about scientific areas outside of my expertise, I am acting primarily as a skeptical science communicator. I am careful to understand and reflect the consensus of expert opinion – not inject my own opinion over that of the experts.

    In some articles I am focusing on critical thinking and process, and not so much on scientific details.

  10. Nitpickingon 21 Mar 2014 at 7:19 am

    Steve, I thought your specialty was ALS, not migraine.

    Other neurologists (e.g. Oliver Sacks) would, I think, argue that headache is not primary in migraine, merely the most common and obvious symptom. Sacks himself seems to experience visual disturbances as primary, for instance.

  11. Will Nitschkeon 21 Mar 2014 at 7:39 am

    @ Steven Novella

    “Will has demonstrated that he cannot read and understand my posts, for whatever reason.”

    Could you explain what part of your post I misunderstood and how I misunderstood it? You could start by reconciling the quotes I provided.

    With regard to deeply uncertain topics: nutrition, cosmology, climate change, cognition, and so on, may I suggest what you are actually doing here? You are professing that you have managed to identify a “consensus” position – which in itself is rather silly – you are admitting to performing a survey of expert opinion or ‘guessing’ and stating this tactic has some sort of merit… Let’s leave that aside. In the cognition example I would challenge you to identify how you did this — or whether you simply ‘made stuff up’ and expressed a personal opinion. For matters where you claim ‘consensus’ how do you demonstrate that you know what that happens to be?

    Let me suggest what you may be doing. You are making apparently deep and profound pronouncements on topics which you have researched and therefore identified as uncertain. Among your readership, this makes you appear deeply knowledgeable. Who but the brilliant would make certain bold claims regarding matters of such complexity? But in fact you have calculated that your opinion can be defended by virtue of the fact that while one expert may dispute it, another can be found to defend it. Hence you can declare one expert ‘sound’ and the other ‘unsound’. Or in other words one is part of your ‘consensus’ (supposed ‘majority vote’) and the other is not. How you acquired this information is, of course, left as a mystery.

    In Australia we have a colloquial expression for such grandiloquence. We call it ‘bullshitting’. Of course ‘bullshitting’ is usually harmless and your readership is small, so the potential for harm is small. However, the point I’m making is whatever it is you think you are doing, it is certainly not skepticism.

  12. grabulaon 21 Mar 2014 at 7:56 am

    @will

    “Could you explain what part of your post I misunderstood and how I misunderstood it? You could start by reconciling the quotes I provided.”

    I did that already…All of it.

  13. Bruceon 21 Mar 2014 at 8:09 am

    “Let me suggest what you may be doing. You are making apparently deep and profound pronouncements on topics which you have researched and therefore identified as uncertain. Among your readership, this makes you appear deeply knowledgeable. Who but the brilliant would make certain bold claims regarding matters of such complexity? But in fact you have calculated that your opinion can be defended by virtue of the fact that while one expert may dispute it, another can be found to defend it. Hence you can declare one expert ‘sound’ and the other ‘unsound’. Or in other words one is part of your ‘consensus’ (supposed ‘majority vote’) and the other is not. How you acquired this information is, of course, left as a mystery.”

    Followed directly by:

    “In Australia we have a colloquial expression for such grandiloquence. We call it ‘bullshitting’.”

    Thanks for condensing your verbose twaddle into one easy to remember word!

  14. BillyJoe7on 21 Mar 2014 at 8:17 am

    “A Kangaroo were hopping mad at this sort of talk.
    He thought himself far superior in intelligence to the others”

    JTull

  15. Steven Novellaon 21 Mar 2014 at 8:55 am

    One type of trolling behavior is derailing conversations in the comments, regardless of the topic, in order to pursue a person’s own agenda. In Will’s case that agenda is to assume the worse possible interpretation of whatever I write in order to convince himself that his a priori assumptions about skeptics are correct.

    I often allow such behavior to continue, for awhile, as long as it seems my other commenters are having fun with it. Will’s motivated reasoning, poor logic, and atrocious reading skills have been fun to deconstruct, but they are becoming predictable and tiresome.

    So consider this your warning, further trolling behavior will result in being banned. Occasional banning is necessary to preserve a productive and on topic discussion in the comments.

  16. DrJoeinCAon 21 Mar 2014 at 2:51 pm

    StevenNovella: Ah, I was wondering when this challenge would come up. I’m surprised it took this long.

    So, Steven, you are doing an “experiment” with your patients to see whether this new device, which has not really really reached the level of proven, science-based medicine, gives your patients relief of their symptoms. Patient relief is the endpoint of the experiment. I think that’s terrific and I agree with you. Physicians should always look for better ways to treat their patients, especially ways that have no side effects and do no harm. And telling the patients beforehand that this is a promising device though it hasn’t been studied enough is a good way to go.

    But it does raise another obvious question, doesn’t it? If you find in your “experiment” that the patients to a significant extent evaluate the device as beneficial — relieves pain, aborts attacks, etc. — I presume that you will continue to use it since it is safe and harmless. What would happen if in 2 years there comes a good, large-scale, randomized, double-blind study that shows, despite your personal clinical experience, that the device is no more beneficial than placebo? Would you continue to use it? Would your experience with patients guide your clinical practice more than the study?

    I think physicians face this kind of question a fair bit, where their clinical experience conflicts with scientific studies and where they have to decide whether or not to change their practice. Just wondering what you would do.

  17. BillyJoe7on 21 Mar 2014 at 3:03 pm

    DrJoe,

    “What would happen if in 2 years there comes a good, large-scale, randomized, double-blind study that shows, despite your personal clinical experience, that the device is no more beneficial than placebo?”

    The results of a large, randomized, double-blind study, especially if replicated, far outweigh the personal experience of one practitioner.

    “Would you continue to use it?”

    No.

    “Would your experience with patients guide your clinical practice more than the study?”

    No.
    Personal experience is contaminated by all sorts of biases.
    This is the reason to do the large randomised, double-blind study.
    This is what science based medicine is all about.

  18. steve12on 21 Mar 2014 at 3:08 pm

    “I think physicians face this kind of question a fair bit, where their clinical experience conflicts with scientific studies and where they have to decide whether or not to change their practice.”

    I know you’re asking Steve, but I think you should go with the scientific studies (with the caveat that the work was properly designed and conclusions replicated.) .

    Properly done studies are a much better indicator than a poorly controlled collection of anecdotes done in someone’s clinic. So why not move onto something that MIGHT actually work? YOu’ll get the placebo effect regardless, right?

  19. Hosson 21 Mar 2014 at 3:16 pm

    DrJoe,
    How would you answer your questions?

  20. DrJoeinCAon 21 Mar 2014 at 6:01 pm

    Since StevenNovella is the PHYSICIAN who set up the potential situation, I think I’ll wait for him to answer it rather than people who have no experience treating patients or dealing with such issues.

  21. Newcoasteron 22 Mar 2014 at 4:58 am

    @ DrJoe
    There are numerous examples in medicine of things that are plausible and safe, that doctors are willing to try for desperate patients while waiting for the final answers. Trigger point injections are something that I once used more commonly, until evidence accumulated that they are of no value. Arthroscopy for arthritic knees and prolotherapy are a couple of other things that come to mind. They sound plausible, seem safe and people report less pain, but large properly controlled trials showed them to be no better than sham treatments.

    I can’t answer for Dr Novella, and he’s a pretty busy guy so I don’t imagine he follows all the conversations here, but I suspect he would accede to the science, no matter what his personal clinical experience with the device may be. I think with those sorts of gadgets there is a lot of opportunity for placebo responses, and as Steve pointed out, he was curious about what kind of blinding was done and was critical of the small trial that was reported.

    As Mark Crisplip alway points out, the three most dangerous words in the English language are ” in my experience…”

  22. BillyJoe7on 22 Mar 2014 at 8:05 am

    DrJoe,

    Because of time constraints, Steven Novella will not necessarily get around to answering your questions. But I’m pretty sure most of us here know roughly what his answers would look like, so you might just have to be happy with that, especially if you don’t get a reply in the next day or two.

    But why so shy about answering your own questions?

  23. BillyJoe7on 22 Mar 2014 at 8:08 am

    …ah…should have read Newcoaster’s post before replying.

  24. DrJoeinCAon 22 Mar 2014 at 3:54 pm

    Newcoaster: Not to debate the issue of experience with you, but if I were trying to figure out whether I needed Tommy John surgery or not and if my livelihood depended on it — and I could afford the cost of the consultation — I would probably go to the orthopedic guy with the most experience to advise me. And when he says, “In my experience…” I would listen.

    I’m still curious about Steven’s response.

  25. steve12on 22 Mar 2014 at 5:08 pm

    “Since StevenNovella is the PHYSICIAN who set up the potential situation, I think I’ll wait for him to answer it rather than people who have no experience treating patients or dealing with such issues.”

    Ha ha ha! So douchey!

    But it does give me an idea…

    From now on, I will only communicate with other SCIENTISTS – PhDs only please. I don’t want to cavort with those who have no experience dealing with scientific issues.

  26. DrJoeinCAon 22 Mar 2014 at 5:15 pm

    Steve12: Maybe I should have added those who cannot be civil.

  27. BillyJoe7on 22 Mar 2014 at 7:37 pm

    DrJoe,

    “if I were trying to figure out whether I needed Tommy John surgery…I would probably go to the orthopedic guy with the most experience to advise me. And when he says, “In my experience…” I would listen.”

    On the other hand, I would ask the orthopaedic surgeon to give me the results of clinical trials that demonstrate whether or not the procedure is effective for my condition. Because his opinion about whether or not the procedure is effective based on his own personal experience is likely to be unreliable based on all the factors discussed here and on the science based medicine blog.

    The subjective experience of one person cannot possibly trump an objective clinical trial.

  28. DrJoeinCAon 22 Mar 2014 at 8:33 pm

    BillyJoe7: Against my better judgment….

    What I said was: “if I were trying to figure out WHETHER I needed Tommy John surgery.” So the unknown is whether surgery is expected to be helpful or not. And one consults the experts because when the expert says, “In my experience, this is what happens to patients with this finding on the MRI and this physical exam….” you listen. That is information you cannot get from a clinical trial. That’s why you consult the experts who have experience to give you the benefit of that experience.

    And that’s why you don’t ask non-physicians for advice on medicine.

  29. BillyJoe7on 22 Mar 2014 at 11:39 pm

    DrJoe,

    “this is what happens to patients with this finding on the MRI and this physical exam”…That is information you cannot get from a clinical trial.”

    Okay, there are two separate questions:

    1) Is Tommy John surgery useful in improving function in cases of Ulna Collateral ligament tears?

    The answer to this question can and should be obtained through a clinical trial. Get x patients. Give x/2 patients the reconstructive surgery. Give the remaining matched controls sham surgery. Compare the results. Replicate the trial. If there is no difference in the functional outcome, then the procedure is not useful and should be abandoned.
    So when you ask the surgeon if the procedure is useful you should expect him to give you the results of clinical trials – not his guess based on what he remembers about his flawed personal experience.
    If the procedure has been shown to be useful then the second question is:

    2) Would this procedure be useful in my particular case.

    For this question, the answer would depend on your particular circumstances. How old are you? What other injuries do you have? What is the condition of your elbow joint? What are your other comorbidities? Depending on your level of activity, is the injury of much functional significance?
    Here you are relying on the expertise and experience of the surgeon to assess your individual circumstances, measure it against similar cases he has treated in the past, and give you and estimate on the likelihood of success. His recommendations will necessarily be flawed, but it’s the best you can do.

  30. DrJoeinCAon 23 Mar 2014 at 1:30 am

    BillyJoe:

    1. That study as you described hasn’t been done. Not every surgery has been matched against sham surgery. So you are left with the surgeon’s “flawed personal experience” and “guess” as you term it. See below.

    2. Thus the value of experience of the surgeon which is what you rely on, and it’s the best you can do.

  31. BillyJoe7on 23 Mar 2014 at 2:20 am

    DrJoe,

    “Not every surgery has been matched against sham surgery”

    Of course not.

    Indeed, in many cases, it would be unnecessary and/or unethical to do a clinical trial.
    Appendicectomy does not require a clinical trial to establish effectiveness. It is obviously effective considering what we know about biology and pathology. It would also be unethical to do a clinical trial.

    However, the device that is the topic SN post, is crying out for a clinical trial.
    I assumed you were using Tommy John surgery analogously to the device that SN was discussing.
    If not, I’m not sure why you mentioned it, because it then seems irrelevant to this discussion.

  32. Newcoasteron 23 Mar 2014 at 6:13 am

    @DrJoe
    I wasn’t saying that experience is of zero value. Obviously if I need a surgery, then I would prefer the guy who has done a few thousand of them over the guy who just finished his residency. ( of course you could also make the case that the newly minted surgeon is more likely to be trained in the latest techniques). On the other hand, I don’t want JUST his opinion on his personal anecdotal experience, that is only relevant as far as post op complications and the like. He needs to be able to tell me there is good evidence that a surgery would benefit whatever my problem is.

    In fact, since surgeons do make the bulk of their income doing surgery, I tend to respect a surgeon who declines to do surgery even if the patient wants it. Discectomy or laminectomy for back pain come to mind. Patients must be properly chosen for those who are more likely to have a clinical benefit. Remember everything we do in medicine is about assessing risk vs benefit.

    We seem to be focusing on surgeries which is off the topic and while I’m a PHYSICIAN I am not a SURGEON, however, to carry on….

    Others have made the point that we can’t always do the RTC trials you seem to want, for obvious ethical reasons. We certainly aren’t going to randomize acute appendicitis to a surgery vs no surgery study. On the other hand, laparoscopic cholecystectomy became very common place before enough good data had accumulated to show it was at least as good, and had similar complication rates as open cholecystectomy. The reasons are partly just human…everyone likes a new toy, and procedural based specialties do get all the cool toys in medicine. But also, there were good animal models, it seemed safe and plausible, and the potential for decreased morbidity in terms of post op recovery time, pain and infection rates were pretty compelling. The fact that the first generation of Nintendo users were in training when laparoscopy was being introduced was also a factor.

    I don’t think anyone has mentioned mammary artery ligation surgery for angina yet…..so I just did. In the 1950s it seemed like a plausible idea (redirect more blood to the heart muscle), it was a relatively simple surgery, and patients said they had less angina afterwards. Then of course, it was compared with a sham surgery and found to be not superior, and overnight surgeons stopped doing it. Medicine learns from its mistakes

    So, yes, we are willing to try things that seem reasonable and safe, while awaiting better information, and then we will adjust our practice. I don’t think you can say that about any version of CAM ever.

  33. Steven Novellaon 23 Mar 2014 at 7:38 am

    Dr.Joe,

    That’s an easy question. Regardless of my clinical experience, if fairly definitive clinical trials showed the device was no more effective than placebo, I would stop using it. With clear evidence of lack of efficacy, it would be unethical, in my opinion, to continue using it.

    This is an easy one because it has been clearly established that anecdotal clinical experience is very misleading when it comes to response to treatments, especially with subjective symptoms like pain.

    In fact, I have stopped using treatments because subsequent trials showed lack of efficacy. I am not so arrogant and naive as to think that my anecdotal experience trumps careful scientific evidence.

    And – I would not call any use of an unproven treatment an “experiment” unless you were collecting data in some controlled manner. Rather I would simply consider it compassionate use of an unproven treatment because no other options are available. If you track your results in some formal way, then it is an open-label study, which is a very weak form of clinical evidence.

    Using trial and error to see which treatments work for which patients is not an experiment. It’s just individualizing treatment. But this should follow basic scientific and ethical guidelines – using proven therapies when available, and not using implausible, risky, or disproven therapies.

  34. DrJoeinCAon 23 Mar 2014 at 12:21 pm

    StevenNovella: Thanks for the response.

  35. steve12on 23 Mar 2014 at 12:56 pm

    “Steve12: Maybe I should have added those who cannot be civil.”

    After the “I don’t understand English” routine we had to wade through with you re: chiropractic, I’m afraid I don’t care. I think being purposefully obtuse so that you can maintain being “right” isn’t very civil behavior either.

    That you doubled-down on this with the “I’ll only talk to other physicians” routine was just too much to resist.

  36. grabulaon 23 Mar 2014 at 9:00 pm

    @DrJoeinCA

    While it’s fair to want to know Dr. Novellas opinion from his own mouth, I think the crux of the issue here is much like the last thread you spent a lot of time equivocating on. I was positive of Dr. Novellas response before he posted it because as do most of us, he insist on evidence to support claims and understands it’s unethical to apply processes and procedures to patients is unethical. You effectively tried to set up a situation where you were hoping for a response that might catch him contradicting his stated views, which shows an underlying inability to understand the process of following the evidence. I’m nor sure why this is worthy of pursuing.

    I’m honestly surprised more people haven’t jumped on Dr. Novellas willingness to try something that hasn’t been completely approved of. There’s a common misunderstanding amongst woo practitioners and proponents that trying something – especially as above when it’s effectively harmless and easy to apply, equates to stepping outside the bounds of science. The point ultimately is that there is nothing to lose, trying a new concept isn’t outside the bounds of science. woo practitioners leave those bounds when once science shows it doesn’t work, they continue to deny the evidence. Your argument FOR chirporacty in all its forms because a patient might perceive relief is a prime example of that.

  37. DrJoeinCAon 23 Mar 2014 at 9:44 pm

    Grabula: No, I wasn’t trying to “catch” him. It’s a reasonable question that if a super-skeptical doc is using an “unproven” treatment and his personal clinical experience is that it’s beneficial, how does he handle it if his experience is contradicted by a good clinical study.

    Steven says he will use it “because no other options are available.” Yet, he also says that even if, as I asked him, his clinical experience was that the treatment helped his patients, he would stop using it if a good study came out saying it didn’t work.

    I don’t know how a clinician who had, say, 75% success using a harmless therapy and was continuing to use it for years because his patients reported great pain relief with no side effects could suddenly do a 180 and stop doing what he thought was appropriate therapy for years because a study came out that said there was only, say, 30% success in that study. I think it would make you look back and say, what the hell happened there? How could I have been so wrong for so long? Maybe some clinicians do that though. I haven’t met many.

    He considers his personal clinical experience “anecdotal,” which it is by definition, but I consider that individual clinical experience builds judgment which presumably leads to better patient care. Individual clinical judgment is a very important part of medicine and complements the use of evidence-based medicine. Both are necessary.

  38. BillyJoe7on 23 Mar 2014 at 11:57 pm

    DrJoe,

    “I don’t know how a clinician who had, say, 75% success using a harmless therapy and was continuing to use it for years because his patients reported great pain relief with no side effects could suddenly do a 180 and stop doing what he thought was appropriate therapy for years because a study came out that said there was only, say, 30% success in that study.”

    Because its just a story you made up and it might have no parallel in the real world.
    Though I guess a 75% success for years and a clinical trial showing only 30% is possible if the clinician didn’t bother tracking patients who never returned for follow up and simply excluded them from his success story. Which is another reason why clinical trials are necessary.

    ” Individual clinical judgment is a very important part of medicine and complements the use of evidence-based medicine. Both are necessary.”

    But the important point is that science based medicine trumps personal experience.
    That’s probably one of the big lessons here.

  39. BillyJoe7on 24 Mar 2014 at 12:02 am

    “I’m honestly surprised more people haven’t jumped on Dr. Novellas willingness to try something that hasn’t been completely approved of.”

    I’m actually one of those.
    I would not use anything that hasn’t been shown to be useful via a clinical trial.
    There are just too many things out there that might possibly work but probably don’t, and I’m not going to try them all, so I’m not going to try any.

    However, I know SN’s view on this and grudgingly accept it as legitimate practise.

  40. DrJoeinCAon 24 Mar 2014 at 12:24 am

    BillyJoe: Clinical judgment complements evidence-based medicine in medical practice.

    “I would not use anything that hasn’t been shown to be useful via a clinical trial.” Well, I guess someone has already mentioned appendectomy.

  41. BillyJoe7on 24 Mar 2014 at 6:22 am

    DrJoe,

    “Well, I guess someone has already mentioned appendectomy.”

    Sorry, my fault.
    I should have said: I would not use anything for which there is no evidence of effectiveness.

    I was thinking of medication here. You got a condition, altmed has a solution. In fact many, many solutions. Take your pick. Most people who do pick, pick the one they are first exposed to. I refuse to pick at all unless and until the evidence is there. Saves time and money. And I hate to reward the people who market this stuff without evidence of effectiveness.

    ” Clinical judgment complements evidence-based medicine in medical practice.”

    I already said so a few posts ago.
    But if the replicated clincal trial (where applicable (; ) concludes that the thing doesn’t work, that’s the end of it.

  42. grabulaon 24 Mar 2014 at 7:21 am

    @billjoe7 – I think the point here however is that at the moment there seems to be some evidence for efficacy. Enough that an appropriately skeptical doctor might be willing to give it a shot and see what happens. In this case there’s nothing wrong or unethical about trying the device. As Dr. Novella pointed out, that line is only crossed once the science fails to support its use but you decide to use it anyway.

    @DrJoe

    “He considers his personal clinical experience “anecdotal,” which it is by definition, but I consider that individual clinical experience builds judgment which presumably leads to better patient care.”

    But the point is anecdotal evidence can be a trap. There are all sorts of reasons why it fails so can’t be relied on by a serious scientist or doctor. Something has to show through trial and error, and study that there is an actual measurable effect. That was the point about chiropracty in the other comments thread last week – once the science shows there’s no effect, it’s unethical to continue to practice or otherwise suggest the use of those procedures to patients. There’s all kinds of woo out there claiming it works – how many homeopathy fans will you find who swear the stuff works for them, even though they’re just drinking really clean water?

  43. Steven Novellaon 24 Mar 2014 at 12:41 pm

    Dr Joe wrote: “He considers his personal clinical experience “anecdotal,” which it is by definition, but I consider that individual clinical experience builds judgment which presumably leads to better patient care.”

    This is an assumption, and the evidence does not bear it out. Relying on personal clinical experience over published studies leads to worse care.

    Personal experience can be misleading with regard to treatment outcomes. You are assuming that if 75% of patients reports feeling better that is a real result. What if patients who don’t feel better don’t come back to me? What if they are doing multiple things and the treatment is an unnecessary additional variable? What if the patient who felt better we going to feel better anyway, partly because they came to me when their symptoms were at their worst, so regression to the mean kicks in?

    You can’t know from personal anecdotes alone if the treatment works, especially with a variable subjective symptom.

  44. DrJoeinCAon 24 Mar 2014 at 3:43 pm

    StevenNovella:

    “Relying on personal clinical experience over published studies leads to worse care.” I think that’s demonstrably true when talking about disease care like diabetes or perhaps heart disease. I suspect that when treating symptoms that would not necessarily be true, or at least would be hard to prove. I would think that the experienced clinician who is used to treating pain knows how to treat symptoms and knows what works and what doesn’t. Surely, that is the value of experience and judgment.

    “Personal experience can be misleading with regard to treatment outcomes.” But surely you, as a specialist, know who your patients are and what treatment they are using and you can monitor their care. In addition, as you are conducting an open-label “experiment” of an unproven treatment which you are interested in, you would want to follow these particular patients more closely. So you would know whether they were doing multiple things that might be helping to make them better. And you would know how many patients you lost. As to regression to the mean, this will be an ongoing treatment so the patient can report whether they have fewer or less severe instances, not specifically whether the one time you saw them with a bad headache they got better.

    Not from personal anecdotes alone, but experience and judgment, not just knowledge of the results of clinical trials, go a long way to making a good doctor.

  45. Mlemaon 24 Mar 2014 at 4:01 pm

    Is “regression to the mean” applicable in symptomologies? How would that work?

    I have to say, i’m relieved that no one said “it’s impossible that my patients could show better results with a particular treatment than that treatment was shown to provide in published studies.”

    Perhaps we realize that published studies can be inaccurate. How often do studies control for all other activities of the participant? The vitamin studies discussed here a while back didn’t take into account whether or not the participants were eating fortified food as part of their regular diet.

    Published studies are the most critically important form of evaluation that we have, no doubt. But we still need to remain skeptical and evaluate them critically, and in certain areas we still need to balance them against the weight of our experience. (imho)

  46. steve12on 24 Mar 2014 at 4:36 pm

    “Not from personal anecdotes alone, but experience and judgment, not just knowledge of the results of clinical trials, go a long way to making a good doctor.”

    But the “experience and judgement” is all based on the anecdotes, so the distinction is meaningless.

    You have a point, though, that is not being acknowledged. In a practical sense, every single medical decision cannot be guided by a carefully controlled study. This means that clinical experience is invaluable. I have no argument with that.

    But if you actually have real studies and STILL go by your experience, you’re being pre-scientific. Of course you may have a REASON to question the study directly – doesn’t apply to your patient, wasn’t replicated, whatever. That’s also different.

    Anecdotally-built experience trumping well-designed, replicated and applicable work is, however, ridiculous.

    I guess if you’re just trying to get a placebo effect, that’s more of an ethical issue that I’m not very interested in, TBH.

  47. Bruceon 24 Mar 2014 at 5:49 pm

    “Perhaps we realize that published studies can be inaccurate.”

    Yes, no one is denying this, but it is safe to say that anecdotal evidence is much weaker still, and more prone to inaccuracies and all those problems that might occur in even the weakest studies.

  48. grabulaon 25 Mar 2014 at 12:06 am

    ” But surely you, as a specialist, know who your patients are and what treatment they are using and you can monitor their care.”

    Yes, because patience never withhold information, whether willingly or not. While no one is denying that experience treating patients helps a great deal in solving certain issues or developing processes to help reach a better state of living, we’re also not throwing the baby out with the bathwater. I’m not sure why it’s so difficult to understand that one observer observing a small slice of individuals does not equal good science. If you’re attempting to contribute to an overall meta study it can be somewhat helpful but anecdotal evidence is garbage and without rigorous scientific methodology you have nothing.

  49. DrJoeinCAon 25 Mar 2014 at 1:38 am

    Grabula: I was answering StevenNovella’s statement that personal observations can be misleading by pointing out that one physician with known patients can do a reasonable “experiment” of a treatment modality and come to a conclusion about the efficacy of the modality. And I questioned his conclusion that he might not get good information by pointing out that he has all the information he needs to do so.

    If you personally wouldn’t use a particular treatment because there was no “rigorous scientific methodology” backing it up, that’s up to you, but Steven said he was going to. And I presume that he will use the results of HIS experiment to guide whether or not he continues to recommend the use of the modality to his patients.

    What he’s doing is obviously not a good scientific study, but he’s not trying to do a good scientific study. He’s trying out a modality that may benefit his patients, something physicians do all the time. He’s using his clinical judgment to see whether the results of his experiment warrant further use of the modality by his patients, and he’s acquiring experience in the use of the modality.

  50. grabulaon 25 Mar 2014 at 7:08 am

    “I was answering StevenNovella’s statement that personal observations can be misleading by pointing out that one physician with known patients can do a reasonable “experiment” of a treatment modality and come to a conclusion about the efficacy of the modality. And I questioned his conclusion that he might not get good information by pointing out that he has all the information he needs to do so.”

    Alone a single doctors observations do not make a reasonable experiment. Riding on preliminary data is one thing. He doesn’t have all the information he needs, it takes a much more thorough and robust series of studies and experimentation before you can make a final determination. I feel like you’re trying to twist the situation to suit your alternative views. Ultimately as he said, if the science comes out solidly against it not working/of no benefit he will discontinue it, regardless of what his patients claim. This flies in the face of you belief that the patient “knows best”.

  51. BillyJoe7on 25 Mar 2014 at 7:14 am

    DrJoe,

    “What he’s doing is obviously not a good scientific study”
    Agreed.

    “but he’s not trying to do a good scientific study”
    Agreed.

    “He’s trying out a modality that may benefit his patients”
    He’s trying it out on patients for whom the evidence based treatments don’t seem to be working using a treatment that at least has plausibility and no evidence that it is ineffective.

    “He’s using his clinical judgment to see whether the results of his experiment warrant further use of the modality by his patients”
    Or until replicated well controlled clinical trials show that the modality is ineffective.

    “and he’s acquiring experience in the use of the modality”
    And that experience might indicate to him that the modality does not work, in which case he is likely to stop recommending it to his patients unless replicated well controlled clinical trials show that, despite his personal experience suggesting otherwise, the modality is indeed effective

  52. Mr Qwertyon 25 Mar 2014 at 11:19 am

    BillyJoe7,

    ““and he’s acquiring experience in the use of the modality”
    And that experience might indicate to him that the modality does not work, in which case he is likely to stop recommending it to his patients unless replicated well controlled clinical trials show that, despite his personal experience suggesting otherwise, the modality is indeed effective”

    Well, actually, re-reading Steven Novella’s post, he is very specific about this – he does not hold physician’s personal experience in high regard and never states that he would use it to stop recommending a treatment to his patients:

    Steven Novella:
    “This is an easy one because it has been clearly established that anecdotal clinical experience is very misleading when it comes to response to treatments, especially with subjective symptoms like pain.”

    He considerds one scenario where personal experience can have some credibility:

    “And – I would not call any use of an unproven treatment an “experiment” unless you were collecting data in some controlled manner.”
    “If you track your results in some formal way, then it is an open-label study, which is a very weak form of clinical evidence.”
    “Using trial and error to see which treatments work for which patients is not an experiment.”

    Now, as pointless as it is to quote Steven’s posts above, it might be helpful considering how little understanding DrJoe shows when attempting to answering them, continuously misrepresenting Steve’s position:

    DrJoe:
    “If you personally wouldn’t use a particular treatment because there was no “rigorous scientific methodology” backing it up, that’s up to you, but Steven said he was going to.”

    Which is the opposite of what Steven said – it is striking that this isn’t obvious to DrJoe, it couldn’t have been said more clearer.

    So let me quote Steven again:
    “And – I would not call any use of an unproven treatment an “experiment” unless you were collecting data in some controlled manner. Rather I would simply consider it compassionate use of an unproven treatment because no other options are available. ”

    There is a distinct difference between this and when using an unproven treatment while there are proven ones (which is what DrJoe is trying to justify to himself – both in this thread, and in one of the previous ones regarding chiroporactic vs physiotherapy), in which case Steve says:

    Steven Novella:
    “Using trial and error to see which treatments work for which patients is not an experiment. It’s just individualizing treatment. But this should follow basic scientific and ethical guidelines – using proven therapies when available, and not using implausible, risky, or disproven therapies.”

  53. DrJoeinCAon 25 Mar 2014 at 12:47 pm

    MrQwerty: This is what Steven said: “Given the documented positive bias in such studies, whether or not this device actually works is a coin-flip, in my opinion. Combined with the safety and plausibility, however, it might not be unreasonable to try it, especially in patients who have daily refractory migraines.”

    So what he is doing is using an “unproven treatment” without “rigorous scientific methodology” on his patients who have not responded to the regular old scientifically-proven treatments. I have no problem with this at all as I have said several times over the weeks. Sometimes the regular stuff doesn’t work, and you have to call in the “alternative” stuff. This is what physicians do all the time. And, much to the chagrin of some, sometimes the alternative stuff works despite the lack of studies or the results of some studies. Go figure.

    BillyJoe: “And that experience might indicate to him that the modality does not work, in which case he is likely to stop recommending it to his patients unless replicated well controlled clinical trials show that, despite his personal experience suggesting otherwise, the modality is indeed effective.” I think you are suggesting that, if he found that a modality did not work with his patients and a study came up that said that it did in fact work, he would continue to use it. I doubt that.

    There’s a real difference between having experience that something does not work but continuing to use it because of studies that say it does work, and having experience that something works and then stopping its use because of studies. The latter is what I asked Steven to clarify.

    I was asking whether, if he found the modality did work in his experience and could overcome his questions about the validity of his personal observations, he would stop using it because a study found that it did not work in the study group.

    Grabula: “Ultimately as he said, if the science comes out solidly against it not working/of no benefit he will discontinue it, regardless of what his patients claim. This flies in the face of you belief that the patient ‘knows best’.” Of course, the way he would determine, in his clinical practice, that something worked or did not work to relieve his patents’ pain is based solely on the report of his patients. He asks them how their pain is, whether the use of the device relieved their pain or made the attacks less severe, and he uses this information to check the box under “worked” or “did not work.”

  54. steve12on 25 Mar 2014 at 3:19 pm

    Dr JOe:

    “So what he is doing is using an “unproven treatment” without “rigorous scientific methodology” on his patients who have not responded to the regular old scientifically-proven treatments. ”

    To selectively pick this without the qualifiers he gave is wrong. This is the umpteenth example of you ignoring what people are saying or feigning that you don’t understand. Someone might call it a straw man, but I all it what it is – lying.

    If you wanna have a real discussion with people, you need to be honest and you can’t seem to do that.

  55. DrJoeinCAon 25 Mar 2014 at 4:05 pm

    Steve12: Again, against my better judgment…

    What part of that quote is wrong? The man said the device was unproven, and he said he was going to use it on an experimental basis on certain patients “with no other options”. We know he is waiting further studies, which may or may not come forth. That’s what the ensuing discussion has been about. That doesn’t change the fact that he is using the device. Do you have a problem with what he’s doing? I don’t.

    And there’s that old “people who are civil” thing. If you don’t like what I’m saying, feel free to ignore it.

  56. BillyJoe7on 25 Mar 2014 at 4:55 pm

    DrJoe,

    ” I think you are suggesting that, if he found that a modality did not work with his patients and a study came up that said that it did in fact work, he would continue to use it. I doubt that.”

    I don’t.

    “There’s a real difference between having experience that something does not work but continuing to use it because of studies that say it does work, and having experience that something works and then stopping its use because of studies.”

    I don’t see a difference at all.

    “I was asking whether, if he found the modality did work in his experience and could overcome his questions about the validity of his personal observations, he would stop using it because a study found that it did not work in the study group.”

    I’m pretty sure he has already answered that in the positive.

    “and could overcome his questions about the validity of his personal observations”

    Whatever do you mean by that?

  57. DrJoeinCAon 25 Mar 2014 at 5:38 pm

    BillyJoe: “I think you are suggesting that, if he found that a modality did not work with his patients and a study came up that said that it did in fact work, he would continue to use it.” You think he would continue to use something on his patients that did not work for them? You think if your doctor was giving you medication that did not relieve your symptoms that he should continue to do that despite your not getting better? Really?

    “overcome his questions about the validity of his personal observations.” He had questions about why his personal observations might not be valid. I think he could address those questions satisfactorily.

    No, really. You would let your doctor continue to prescribe something for you that was not helping your symptoms?

  58. steve12on 25 Mar 2014 at 7:51 pm

    DrJoe

    “What part of that quote is wrong? The man said the device was unproven, and he said he was going to use it on an experimental basis on certain patients “with no other options”.

    Because you left out the “no other options” (and other statements) to make it seem like he’s being inconsistent. When you look at the totality of what he said, though, it’s perfectly consistent. You’re cherry picking quotes to make it seem otherwise.

    And I think your reading comprehension works just fine.

  59. DrJoeinCAon 25 Mar 2014 at 8:00 pm

    Steve12: As I said, he’s using it “on his patients who have not responded to the regular old scientifically-proven treatments.” See, that’s the same as having “no other options.” This is why these threads become so long.

    Surely there’s a Bingo game on the activities schedule at the home that you could be spending your time on.

  60. grabulaon 25 Mar 2014 at 10:54 pm

    @DrJoe

    ” Sometimes the regular stuff doesn’t work, and you have to call in the “alternative” stuff. This is what physicians do all the time. And, much to the chagrin of some, sometimes the alternative stuff works despite the lack of studies or the results of some studies. Go figure.”

    This is disingenuous. First, let’s not throw around alternative as if we’re using it with more than one meaning. When we here speak of alternative we mean, as another option. We’re not using Alternative to mean, all the crap science has already shown doesn’t work like many woo practitioners do.

    You’re equivocating and nitpicking out of context. In this very specific case, Steven is ok with using it since the science is promising, and there are no negative side effects. This is a simple concept. Once the science is in if it says it doesn’t work, he stops using it and stops giving it to his patients – the rational and moral choice.

    Let’s not also take out of context the idea that a patient can communicate to his doctor that a certain scientifically verified methodology is working for them or not. In some cases the doctor has to look at the evidence regardless to see if damage is being repaired. If it’s something subjective, say like the level of pain, then he has to work with the patient in order to determine a realistic alternative. At no time does a real and responsible doctor stray from what’s been proven to work beyond the shadow of a doubt, unless he’s part of a trial, or is applying something that is still being thoroughly investigated.

  61. DrJoeinCAon 25 Mar 2014 at 11:35 pm

    Grabula:” If it’s something subjective, say like the level of pain, then he has to work with the patient in order to determine a realistic alternative. At no time does a real and responsible doctor stray from what’s been proven to work beyond the shadow of a doubt, unless he’s part of a trial, or is applying something that is still being thoroughly investigated.”

    That is, unless what he is trying is not working. If it’s not working, then he has to try something else, maybe something that has not been thoroughly tested. Would you have him continue with a treatment that is not working?

    There’s no equivocation and definitely no nitpicking. The question on the floor is whether, if a physician uses a modality on patients who have “no other options”, and this treatment works to relieve pain and if he is getting good results and if he knows that his results are good, he will stop using it because a study says it doesn’t work. Would a physician who begins treatment with a modality then withdraw that treatment despite the fact that the patient says it is working because a study determines that it “does not work”?

    “Moral choice”? A patient is getting pain relief and you withdraw the treatment? That’s your moral choice? What is moral about that?

    Regarding “alternative” treatment, sometimes there is treatment that is not first line, that has not been shown in studies to work sufficiently to merit first-line recommendation by the specialty societies. And sometimes when the regular treatment does not work, the physician has to resort to these other modalities to try to relieve the patient symptoms.

    There is absolutely no “beyond a shadow of a doubt” standard for patient treatment. I don’t know where you are getting that standard, but it doesn’t exist.

    But all that is beside the point to the question on the floor.

  62. BillyJoe7on 25 Mar 2014 at 11:41 pm

    DrJoe,

    “You think he would continue to use something on his patients that did not work for them?”

    I think that if, in his experience, he felt that the treatment did not seem to work on the selected patients he tried it on, but that replicated controlled clinical trials showed that it did work, then he would continue to use on selected patients.
    Personal experience does not trump the results of replicated controlled clinical trials.
    How long is that going to take to sink in?

    “You think if your doctor was giving you medication that did not relieve your symptoms that he should continue to do that despite your not getting better? Really?”

    Do you see what you’ve done here.
    You’ve gone from the general to the particular.
    No, of course he wouldn’t continue to use it on patients who didn’t respond.

    “No, really. You would let your doctor continue to prescribe something for you that was not helping your symptoms?”

    So, please read and comprehend what posters write not what you imagine they’ve written that fits with your ready made response.
    No, really, try that for a change!

  63. steve12on 26 Mar 2014 at 12:22 am

    Goin’ with the ole’ gut is just as good as the scientific method! That’s why we’ve had space shuttles, smart phones and heart transplants for 1000s of years.

    Oh, wait…

  64. grabulaon 26 Mar 2014 at 1:04 am

    @DrJoe

    “There’s no equivocation and definitely no nitpicking. The question on the floor is whether, if a physician uses a modality on patients who have “no other options”, and this treatment works to relieve pain and if he is getting good results and if he knows that his results are good, he will stop using it because a study says it doesn’t work. Would a physician who begins treatment with a modality then withdraw that treatment despite the fact that the patient says it is working because a study determines that it “does not work”?”

    There most definitely is. You’re being extremely selective in how you interpret the situation, sort of giving it your own twist. First, the chances that a modality shows positive results in a patient after being scientifically vetted is slim to none. The most likely answer is that something else is happening to make the patient think the process is working and that should be explored.

    The point most of us have been trying to make that you’ve otherwise ignored is that a modality that is shown to not work, shouldn’t be given to patience on the perception that it helps. Perception isn’t enough. In fact a lot of woo relies on that trick in order to continue to thrive. Real Medicine does not. One data point does not override multiple, thorough studies and experiments.

    I’m starting to feel like we’re going around in circles because you’re unwilling to acknowledge the fact that the scientific methodology works and works well, and that when treating a patient the only ethical thing to do is to follow the science and not your gut or a patients ‘feeling’.

  65. Will Nitschkeon 26 Mar 2014 at 1:12 am

    @ Steven Novella

    “One type of trolling behavior is derailing conversations in the comments, regardless of the topic, in order to pursue a person’s own agenda. In Will’s case that agenda is to assume the worse possible interpretation of whatever I write in order to convince himself that his a priori assumptions about skeptics are correct.”

    What I am doing Steven is making a general point that is rather important. It contrasts your uncertainty over a subject matter which you have expert knowledge of, and have contrasted this with your high level of certainty over subject matters you have little or no expertise in. This is not a personal fault of you Steven, it’s actually, unfortunately, normative behaviour. (This is discussed further in the field called the Sociology of Science.) What this is hinting at is some of the problematical issues relating to your use of the word ‘consensus’ for informing your readership that you know what is ‘true’ and what is ‘not true’.

    By the way, ‘consensus’ is not a word or term that exists in the academic literature in epistemology or the history of philosophy of science. Or at least, it was not treated with any sort of importance or extensively discussed until very recently. It’s something of a ‘made-up’ term used by non-academics and advocates to promote certain claims in preference to the more challenging task of presenting arguments and evidence. Unfortunately, the word has gained significant traction outside those fields where such issues are actually studied.

    “I often allow such behavior to continue, for awhile, as long as it seems my other commenters are having fun with it. Will’s motivated reasoning, poor logic, and atrocious reading skills have been fun to deconstruct, but they are becoming predictable and tiresome. So consider this your warning, further trolling behavior will result in being banned. Occasional banning is necessary to preserve a productive and on topic discussion in the comments.”

    Steven, the reason why I’m engaging with you is that I’ve been lead to believe that you are one of the brightest members of this particular advocacy group. What I’ve observed is failure to read what I’ve written or address what is reasonable criticism or inconsistencies in certain of your posts. Many of your posts say nothing interesting (to me) or don’t touch on topics I find worth debating or discussing. Most of your responses so far have consisted of vague accusations and name calling. In a recent thread you ignored my specific criticism, called me lots of names, and restated your original position several times. That’s not defending your position. That’s very poor form, intellectually.

    None of this I understand. You could ignore the criticism and present yourself as ‘above the fray’. Or you could attempt serious engagement. Instead you call me names and invent labels. To what purpose? It just makes you look dumb, even if you are not.

    At some point unless you’re prepared to attempt serious engagement I’ll get bored with your boorishness and go away. Or you’ll view me as a ‘threat’ and ban me. (I don’t engage with your readership as they don’t appear to deserve serious attention. I noted in one or two posts I did read after my last post, that some of your readers rushed to defend the content of your article, something I did not criticise. What is the point of engagement if there is no comprehension?) Either way, your group is hardly of any personal importance to me. Name calling doesn’t bother me. So it’s doubtful threats will work either. So do your worst. ;-)

  66. grabulaon 26 Mar 2014 at 1:46 am

    @WillN

    missing the point again are we?

    “By the way, ‘consensus’ is not a word or term that exists in the academic literature in epistemology or the history of philosophy of science. ”

    mid 17th century: from Latin, ‘agreement’, from consens- ‘agreed’, from the verb consentire. – From the Oxford English Dictionary, since you want to get pedantic. The word is useful in describing a concept, a useful concept. It’s not anymore made up than any other word ever is. It’s used by certain professions because it accurately portrays the fact that a vast majority of that profession is in agreement.

    “What I’ve observed is failure to read what I’ve written or address what is reasonable criticism or inconsistencies in certain of your posts. Many of your posts say nothing interesting (to me) or don’t touch on topics I find worth debating or discussing. Most of your responses so far have consisted of vague accusations and name calling. In a recent thread you ignored my specific criticism, called me lots of names, and restated your original position several times. That’s not defending your position. That’s very poor form, intellectually.”

    This is where you reveal your true colors. As is typical of your posts Will, it’s so patently wrong its dipped well into the level of absurdity. Not only has Dr. Novella and several others very specifically addressed your complaints you’ve consistently shown an inability to read or comprehend and have also in general failed to directly address any of the criticisms leveled at you except ironically, this one.

    “At some point unless you’re prepared to attempt serious engagement I’ll get bored with your boorishness and go away.”

    Some of the more adept trolls, and those who truly are just misled in their beliefs who frequent these discussion sections are entertaining. They’ve learned to engage in the conversation, even when trolling. They attack very specific points, stay on target and even sometimes try to support their claims with whatever the source for their beliefs is. You should take some time to learn from those individuals since your ‘tactics’ and agenda are too transparent to be entertaining. It just so happens I have a boring, late night job and the time on my hands to tear your arguments.

  67. Will Nitschkeon 26 Mar 2014 at 1:50 am

    @ grabula

    I wrote:

    “By the way, ‘consensus’ is not a word or term that exists in the academic literature in epistemology or the history of philosophy of science..”

    This is why I don’t engage with Steven’s readership. (Barring this one exception.) You try to make a point by citing a dictionary definition in contrast to the very specific context of my remark. There cannot be engagement without comprehension.

  68. DrJoeinCAon 26 Mar 2014 at 2:02 am

    BillyJoe7: “I think that if, in his experience, he felt that the treatment did not seem to work on the selected patients he tried it on, but that replicated controlled clinical trials showed that it did work, then he would continue to use on selected patients. Personal experience does not trump the results of replicated controlled clinical trials. How long is that going to take to sink in?”

    You seem to think that there is something other worldly about medicine where the physician discounts what he has done and the results he gets and instead looks to other people to tell him what he should have seen or not seen. The physician who gets negative results from treatment does not continue with the treatment. That would be ridiculous.

    Oh, but then you say: “No, of course he wouldn’t continue to use it on patients who didn’t respond.” So then the physician is trusting his experience and, regardless of what the studies say, is not using the treatment. But earlier when I said I doubted he would continue to use a modality that didn’t work even when a study said that it did, you “doubt that.” Well, which is it? Is he going to use the therapy that HE FINDS does not work or isn’t he? And is he going to use a therapy that HE FINDS works or not?

    Grabula: “The point most of us have been trying to make that you’ve otherwise ignored is that a modality that is shown to not work, shouldn’t be given to patience on the perception that it helps.” I know that is the point you are trying to make. My point is that you are disregarding the experience of the clinician in deciding whether to use a modality or not.

    And the question is particularly important if the clinician is using an “unproven” modality in patients who have no other options, who have symptoms in spite of treatment with all the proven modalities. This is the scenario Steven proposed. Once the clinician gets results of the modality in these patients who have no other options AND those results are positive, the question becomes what to do if and when there is a study that shows otherwise. Does the clinician withdraw the treatment from those WITH NO OTHER OPTIONS who have shown benefit from the treatment merely because a study showed no benefit in the studied group? Does he take patients who are pain-free and force them to undergo pain again so he can say that he is “scientific?” I think not.

    “When treating a patient the only ethical thing to do is to follow the science and not your gut or a patients ‘feeling’.” I disagree with that also. There is nothing at all unethical in using a treatment that relieves a patient’s pain, does him no harm, and enables him to lead a comfortable life. That is in fact doing the right thing and is the purpose of medicine in the first place. What would be unethical is to withdraw that treatment which the patient reports has been working.

  69. grabulaon 26 Mar 2014 at 2:31 am

    @DrJoe

    You’re argument continues to follow the same line – that it’s ok to treat a patient with whatever, as long as the patient feels they are getting a benefit from it. While I can be sympathetic to a person who feels like they find relief it becomes unethical when you’re using something that has been proved to not work and especially when you’re charging money for it. I’m not sure why you are having difficulty understanding that one data point does not a positive make. One of the important duties a doctor performs is determining what treatments are best – including what work and what do not. While understanding whether a proven treatment is effective for an individual, those treatments must be proven. Otherwise what’s to stop non medically trained individuals from just doing whatever, like is going on in the woo corners today?

  70. grabulaon 26 Mar 2014 at 2:33 am

    @WillN

    “This is why I don’t engage with Steven’s readership. (Barring this one exception.) You try to make a point by citing a dictionary definition in contrast to the very specific context of my remark. There cannot be engagement without comprehension.”

    Exactly my point. I believe you don’t dare to really engage anyone here, including Dr. Novella on anything specific because you know you’re out of your league. If you don’t follow my point from your claim then that’s obvious.

  71. BillyJoe7on 26 Mar 2014 at 7:05 am

    DrJoe,

    “You seem to think that there is something other worldly about medicine where the physician discounts what he has done and the results he gets and instead looks to other people to tell him what he should have seen or not seen”

    You have a strange defintion of what a replicated controlled clinical trial is.
    “replicated controlled clinical trial” =/= “other people telling him what he should have seen”.

    “The physician who gets negative results from treatment does not continue with the treatment. That would be ridiculous”

    That is clearly incorrect.
    Not everyone responds to treatment that has evidence of effectiveness. For example, take a particular blood presure treatment with evidence of effectiveness from replicated controlled clinical trials. Does this mean that everyone will respond to this particular blood pressure treaatment. Of course not. Would you continue to treat a patient who has not responded to it. Of course you would not. Would you try it on others with newly diagnosed high blood pressure. Of course you would – because replicated controlled clinical trials have shown that it is effective in treating blood pressure.
    Please let this sink in before firing off a reply.

    “Oh, but then you say: “No, of course he wouldn’t continue to use it on patients who didn’t respond.” So then the physician is trusting his experience and, regardless of what the studies say, is not using the treatment.”

    He is not using the proven effective treatment ON THOSE WHO DON’T RESPOND.

    “But earlier when I said I doubted he would continue to use a modality that didn’t work even when a study said that it did, you “doubt that.””

    He would use it on other patients who have not yet been exposed to the treatment – because of the fact that replicated controlled clinical trials have shown that it is effective. HE WILL CONTINUE TO USE IT ON PATIENTS WHO RESPOND AND DISCONTINUE TO USE IT ON PATIENTS WHO DO NOT RESPOND.

    “Well, which is it? Is he going to use the therapy that HE FINDS does not work or isn’t he? And is he going to use a therapy that HE FINDS works or not?”

    I truly hope you can answer your own question now.

  72. steve12on 26 Mar 2014 at 11:57 am

    DrJoe:

    “Does the clinician withdraw the treatment from those WITH NO OTHER OPTIONS who have shown benefit from the treatment merely because a study showed no benefit in the studied group?”

    Assuming that the trial was well done and replicated, the benefit you’re seeing is almost certainly a placebo at this point. And in reality, there’s almost never a complete dearth of options for pain if you’re open to unproven methodologies.

    So… why not try something else that has no trials and a reasonable mechanism and MIGHT have an effect beyond placebo?

    The choice would seem:

    1. placebo effect + slim chance of non-placebo effect

    vs.

    2. placebo effect + almost no chance of non placebo effect.

    Why would you ever choose 1 over 2?

  73. DrJoeinCAon 26 Mar 2014 at 4:42 pm

    Grabula: “While I can be sympathetic to a person who feels like they find relief it becomes unethical when you’re using something that has been proved to not work and especially when you’re charging money for it.” The patient is paying for relief and he gets it. That’s ethical in my book.

    Steve12: “why not try something else that has no trials and a reasonable mechanism and MIGHT have an effect beyond placebo?” You do remember that there are no other options, right? Do you think that the patient cares whether their relief comes from “placebo effect” or not?

    BillyJoe: It’s exhausting trying to rehash all the permutations.

    The question is whether a doctor would continue to use a treatment on a patient who has no other options and who has gotten relief from that treatment despite the fact that a study in the future demonstrates “no benefit.” And if you would want the doctor to withdraw that treatment, would that withdrawal be ethical? See what I’m asking? You have an unproven treatment that works for a patient and along comes a study saying that in fact there is no benefit. What do you do?

  74. Mr Qwertyon 26 Mar 2014 at 5:02 pm

    DrJoe
    “The question is whether a doctor would continue to use a treatment on a patient who has no other options and who has gotten relief from that treatment despite the fact that a study in the future demonstrates “no benefit.” And if you would want the doctor to withdraw that treatment, would that withdrawal be ethical? See what I’m asking? You have an unproven treatment that works for a patient and along comes a study saying that in fact there is no benefit. What do you do?”

    The answers to your (poorly framed) question are present in this thread and other threads if you just read carefully. Which is something you have avoided to do so far, probably because it goes against what you are practicing, so you’re tirelessly trying to re-frame it in attempts to avoid cognitive dissonance.

    a.) If the treatment is safe, cheap and plausible and one study pops up which is is negative or ambigous, and there are no other treatments available then the answer is “probably yes, but without implying anything more than it is to the patient” – simply on the basis that there’s nothing to lose. If any of these conditions are not met then the answer is “probably no”.

    b.) If the treatment is of dubious plausibility (like Chiropractic) and is not entirely safe (like Chiropractic) and costly (like Chiropractic) and there is little science behind it (like Chiropractic) and there are other science-based alternatives (like physiotherapy) then the answer is “definitely not”.

  75. DrJoeinCAon 26 Mar 2014 at 6:14 pm

    MrQwerty: Well, there you go. You didn’t seem to have that much trouble answering the poorly framed question (a). I mostly agree with your answer, though not with the pop psychology analysis that accompanies it or the delineations of “conditions” which would satisfy you.

    There is much value in the clinician’s experience with the treatment and the patient, and it is the clinician’s experience that helps determine what is effective treatment for the individual patient, not only the results of clinical studies. Now that we have established this, perhaps we can move on.

  76. steve12on 26 Mar 2014 at 7:12 pm

    “You do remember that there are no other options, right?”

    Yeah, but I said:
    “And in reality, there’s almost never a complete dearth of options for pain if you’re open to unproven methodologies.”

    Are you not even going to address that I said this?

    “Do you think that the patient cares whether their relief comes from “placebo effect” or not?”

    This doesn’t answer my Q at all!!!!! We know we have a placebo effect!

    What about adding a potential actually effective treatment vs. one that might work? Don’t you want the BETTER for your patients? Are you capable of addressing anything I try to discuss with you?

    Again, respond to THIS please:
    1. placebo effect + slim chance of non-placebo effect
    vs.
    2. placebo effect + almost no chance of non placebo effect.
    Why would you ever choose 1 over 2?

  77. DrJoeinCAon 26 Mar 2014 at 7:53 pm

    Steve12: “Again, respond to THIS please: 1. placebo effect + slim chance of non-placebo effect
    vs. 2. placebo effect + almost no chance of non placebo effect. Why would you ever choose 1 over 2?”

    You’re asking me to choose between “slim” and “almost no”? Come on. What clinician practices like that? The clinician decides what modality might work on his patient, then he prescribes it. That’s how it works.

    “there’s almost never a complete dearth of options for pain if you’re open to unproven methodologies.” What’s your point? The premise is that “there are no other options.” Are you open to using unproven methodologies?

    How about answering mine: “Do you think that the patient cares whether their relief comes from “placebo effect” or not?”

  78. steve12on 26 Mar 2014 at 11:20 pm

    “You’re asking me to choose between “slim” and “almost no”? Come on. What clinician practices like that? The clinician decides what modality might work on his patient, then he prescribes it. That’s how it works.”

    Look – I asked Joe a Q about the basis for his decisions. And he didn’t answer. Again.
    I guess probability is also subordinate to Joe’s clinical experience because “That’s how it works.”. It’s magic.

    But this is exactly “how it works”. If something is more likely to work, by definition it is better.

    And you could give SOME explanation as to your reasoning process. Maybe the placebo effect in your view will NOT be equal for the two, as I’ve assumed in my little problem – you could have said that and why. Maybe you take a conservative view about changing treatment, and you don’t think the small change in p is worth it.OK.

    But that’s not what you do Joe. Other than the obfuscating and pretending you don’t understand Qs, the most annoying thing about you is that you come to a skeptic’c blog and want to substitute giving us the rationale behind your decisions with the “Trust me, I’m a Doctor” routine.

    Just as an example – look at your answer above:

    “You’re asking me to choose between “slim” and “almost no”? Come on. What clinician practices like that? The clinician decides what modality might work on his patient, then he prescribes it. That’s how it works.”

    When I ask you the BASIS for your decisions, you say that you choose the modality that works best. No shit Sherlock! Now WHY did you arrive at the decision that X works best – that’s what many have asked you.

    But YOU say (essentially) Trust me, I’m a doctor. Well, trust me. There’s plenty of very educated people here – scientists, engineers and generally bright people – who can handle your more detailed explanations, even though we’re not MDs. I don’t trust you because you have an MD. I trust you (or not) because you make sense (or not).

    “Are you open to using unproven methodologies?”

    Given the right circumstances (e.g., reasonable mechanism of action) and few other options, sure. But if there were well done and replicated clinical trials that said otherwise, no.

    ‘ How about answering mine: “Do you think that the patient cares whether their relief comes from “placebo effect” or not?” ‘

    I didn’t answer because it’s a rhetorical question – and loaded at that.

    No. But what does this mean? AS I SAID – the slightly more likely-to-work treatment ALSO has a placebo effect, right? So they BOTH have that going for them. BUT, it might have an effect IN ADDITION to the placebo. Wouldn’t that be nice?

    So let me ask you: do you think your patients would like most of their pain removed, but a little left over? Ya know, for the nostalgia? Just as ridiculous a question. And just as rhetorical.

  79. DrJoeinCAon 27 Mar 2014 at 2:31 am

    Steve12: Once again against my better judgment….

    You asked me to choose between slim and “almost no.” My answer is that there is no such choice made. Clinicians do not make that kind of decision. They do not think, well maybe there’s placebo in this and maybe a slim chance of non-placebo effect in that. That’s just not how it is done. That’s the answer to your question. That decision of what to use on a patient is not made on that basis. The decision is made on what gets results according, frequently, to the experience of the clinician and the report of the patient, not on what combination of placebo and non-placebo effects there are. The clinician realizes that many treatments have some combination of both, but it irrelevant to the care of the patient what the contribution of each is. You don’t understand that.

    And finally you grudgingly admit that the patient does not care about whether their relief comes from A or B. That’s a significant breakthrough for you, and you should be proud to have made one. The patient wants relief, and he would like relief with a minimum of side effects, discomfort, inconvenience, and cost. You may object to certain treatments and not think that a physician should choose to use them, but most patients really don’t give a crap. So now we have their doctor not making a decision based on differences between “slim” and “none” but only what works (in his experience and according to his clinical judgment and the reports of his patient), and the patient not caring as long as his unpleasant symptoms go away with a minimum of hassle. The only one who seems to think it matters is, no surprise here, you.

  80. grabulaon 27 Mar 2014 at 4:38 am

    @DrJoe

    What you are ultimately saying is that it’s ok for you to point your patient to a chiropractor or homeopathy practitioner if they believe it helps them, no matter the cost?

  81. BillyJoe7on 27 Mar 2014 at 7:02 am

    DrJoe,

    “It’s exhausting trying to rehash all the permutations”

    It looks pretty straight forward to me.
    But nice way to evade the answer.

    “You have an unproven treatment that works for a patient and along comes a study saying that in fact there is no benefit. What do you do?”

    The first thing is to not use it on any more patients.
    What to do with the existing patient would depend on the circumstances. If the patient reports that he feels better on a treatment that has been shown to be of no benefit, the effect of that treatment on the patient must be purely psychological. Whether it would be appropriate to explore this diagnosis with the patient and refer him appropriately, would depend on what the practitioner knows about the patient and his openess to acepting the correct diagnosis and its treatement.
    Finally, this potential situation is probably a good argument for not using any treatments without evidence of effectiveness in the first place.

  82. DrJoeinCAon 27 Mar 2014 at 12:26 pm

    BillyJoe: “Whether it would be appropriate to explore this diagnosis with the patient and refer him appropriately, would depend on what the practitioner knows about the patient and his openess to acepting the correct diagnosis and its treatment.”

    We’re not talking about “diagnosis.” We’re talking about treatment of symptoms. And so if it’s not appropriate or productive to confront the patient and if the patient “reports that he feels better”, then the treatment continues, no?

    Grabula: As I said, cost is a factor with some patients, as are side effects, hassle, inconvenience. Of course, it’s appropriate to refer a patient for a trial of chiropractic treatment for appropriate problems because, as we discussed ad nauseam, it works. Homeopathy does not work and a physician should not refer a patient to a homeopath.

  83. steve12on 27 Mar 2014 at 1:59 pm

    Ponder this until your mind explodes:

    “You asked me to choose between slim and “almost no.” My answer is that there is no such choice made.”
    Clinicians do not make that kind of decision.”

    They never have to choose between 2 remedies with similar liklihood of being effective? I have literally watched my doctor do this.

    “They do not think, well maybe there’s placebo in this and maybe a slim chance of non-placebo effect in that. That’s just not how it is done. ”

    Doctors don’t think about how their remedies might work? You in particular don’t consider placebo effects?
    OK, so you would think that the next part might tell us how it IS done, right? Not so much…

    “That’s the answer to your question. ”

    No, that wasn’t an answer to any question ever.

    When you get pinned to choose A or B, you simply declare that “that’s not how it’s done”, don’t tell us HOW it’s done, and wriggle out of answering.

    So how is it done? Joe will say: clinical experience over and over, as if it is an answer unto itself that cannot be further explicated.

    “And finally you grudgingly admit that the patient does not care about whether their relief comes from A or B. That’s a significant breakthrough for you, and you should be proud to have made one.”

    There was no grudging. Of course they don’t care. The only reason I didn’t answer initially is because it was a rhetorical Q. But maybe your patients could be recieving MORE pain reduction (or whatever) if you actually tried to be a little more scientific. And besides – this doesn’t answer anything about the BASIS for the decisions on how these people are being treated.

    I forgot – the basis is your clinical experience. Clinical experience – the monolithic explanation that deifies more detailed explanation. Except, of course, that you could exactly spell it out – you just won’t.

    Also, I just wanted to show you what it’s like when someone ANSWERS A F*&^ING QUESTION, so maybe you might have a template to go on.

    There’s my lack of civility for someone who’s clearly trying to BS me again. Gotta be nice to people who are trying to lie to you!

  84. BillyJoe7on 27 Mar 2014 at 4:38 pm

    DrJoe,

    “We’re not talking about “diagnosis.” We’re talking about treatment of symptoms. And so if it’s not appropriate or productive to confront the patient and if the patient “reports that he feels better”, then the treatment continues, no?”

    No.

    It’s ironic that whilst CAM practitioners accuse doctors of treating only the symptoms, here you are, a medical practitioner, promoting the use of CAM for the treatment of symptoms only.
    No, when you can make a diagnosis, you make a diagnosis. And then you treat that condition with the evidence based treatments for that condition. If there is a psychological dimension to the illness, you use eidence based psychological treatments.
    It’s rarely a good idea to fool your patients, let alone to fool yourself.

    And that is what I think you are doing.

  85. DrJoeinCAon 27 Mar 2014 at 4:50 pm

    Steve12: “You asked me to choose between slim and “almost no.” My answer is that there is no such choice made. Clinicians do not make that kind of decision.”

    And your response: “They never have to choose between 2 remedies WITH SIMILAR LIKELIHOOD of being effective?” So “slim” and “almost no” have similar likelihood of being effective, as I said. And the choice doesn’t matter because THEY HAVE SIMILAR LIKELIHOOD OF BEING EFFECTIVE. You asked for a choice between two remedies WITH SIMILAR LIKELIHOOD OF BEING EFFECTIVE. The doc goes with his experience since they have SIMILAR LIKELIHOOD OF BEING EFFECTIVE. Come on. Even you can do better than that. Or maybe I’m fooling myself into thinking you are growing when the evidence is to the contrary.

    BillyJoe: Now your answer is to NOT continue the treatment if you don’t want to confront the patient and if the patient reports benefit? Seriously, think about what you’re saying.

    We’re talking about symptoms. Pain is a symptom, remember? This whole thing started with Steven’s treatment of pain, remember?

    Psychological dimension to the illness? Where in God’s name are you getting that?

  86. steve12on 28 Mar 2014 at 3:07 am

    “The doc goes with his experience since they have SIMILAR LIKELIHOOD OF BEING EFFECTIVE. ”

    But one has a SLIGHTLY HIGHER likelihood of working because you have science that says the other doesn’t work!!

    Why would you not choose the other? Because “clinical experience” might dictate that more is actually less?

    YOU DON’T MAKE ANY SENSE!!!!

    “Even you can do better than that.”

    Incivility!!! Incivility!!!

  87. BillyJoe7on 28 Mar 2014 at 6:41 am

    DrJoe,

    I have to agree with Steve that you’re not making sense.
    In fact, you never have right from the very start, but it’s getting worse with every post.
    And I’m pretty sure that that is your stradegy to avoid responding to the very reasonable solutions we have offered to situations you have posed where you feel compelled to keep using treatments that have been shown to be ineffective.

  88. DrJoeinCAon 28 Mar 2014 at 5:15 pm

    Steve12: Seriously, there must be some activity at the home that will keep you amused instead of trying to invent arguments that don’t exist.

    BillyJoe: See above.

    This is why I requested answers from the PHYSICIAN who posed the question.

  89. BillyJoe7on 29 Mar 2014 at 12:59 am

    DrJoe,

    Nice dismissive post.

    You have been at pains in this thread to justify your referral of patients for treatments that have no evidence of efficacy and to justify your continued referral for those treatments even when those treatments have been shown not to work.

    You have justified this by:
    - denying that the results of replicated controlled clinical trials apply to your patients who feel better.
    - denying that what patients report is not necessarily the truth.
    - denying that there are psychological dimensions to pain.

    In short, you have lost all credibility.
    …and it doesn’t take a physician to see that.

  90. DrJoeinCAon 29 Mar 2014 at 1:09 pm

    BillyJoe7: “You have justified this by:
    - denying that the results of replicated controlled clinical trials apply to your patients who feel better.
    - denying that what patients report is not necessarily the truth.
    - denying that there are psychological dimensions to pain.”

    You have repeatedly shown that you are unable to comprehend the written word, know nothing about the practice of medicine and the patient/doctor relationship, exaggerate to the point where it takes 4 or 5 posts to try to correct you, try to slip false premises into almost every post, and generally obfuscate the obvious. It’s just not worth discussing stuff with you when you’re obviously not up to rational discussion.

    Dismissed. Back to the Bingo game for you.

  91. herbw.on 29 Mar 2014 at 1:30 pm

    Dr. Novella, we’ve seen lots of this. As a long time skeptic and retired physician from clinical neurosciences, we might paraphrase the amazing randi, “They have gone from stating the facts to writing titillating plausibilities.”

    Clearly, the evidence in favor of the device is very weak. Because the standard for scientific confirmation is that there be at LEAST 2-3 well done, carefully controlled, prospective scientific studies, NOT done by the manufacturers or promoters, published in good, peer reviewed journals, we can take a “not Proved” position on the Cephaly nerve stimulator.

    One finds it hard to believe that a competent study would simply ASK without any objectifying evidence, if the migrain patient using the device “felt it helped”. How do we know? Self-verification is simply too fraught with problems to be convincing. Empirical introspection has long been a problem in pain control and diagnosis. However, we DO know that migraine exists, because there are confirming clinical signs/symptoms reported too often by reasonable persons to be ignored. But in individual cases, how do we know?

    My neice has real migraine HA’s and we can trace that back 4 generations. But she would as often as some seizure patients do, fake one to get out of something she didn’t want to do.

    Why spend money on something which doesn’t work beyond all reasonable, scientific doubt? Most health insurers would conclude that as well. This is simply quackery approved by the FDA. I’m sure Randi (“The Faith Healers”) would be as appalled as we are.

    Herbw.

  92. BillyJoe7on 29 Mar 2014 at 5:10 pm

    DrJoe,

    The following are true whether or not you practise medicine:

    1) The results of replicated controlled clinical trials apply to patients who report pain.
    2) A patient’s report of pain is not necessarily true.
    3) There are psychological dimensions to pain.

    I know you will continue to refer patients for treatments that have been shown to be ineffective.
    But just don’t kid yourself that you are practising science based medicine.

  93. DrJoeinCAon 29 Mar 2014 at 6:45 pm

    BillyJoe: Or maybe mah-jongg is on the activities calendar for you today. Maybe you can convince some of your more demented home-mates that you know something about medicine or how to treat patients. You haven’t convinced me.

  94. BillyJoe7on 30 Mar 2014 at 1:08 am

    DrJoe,

    Unfortunately you are not alone.

    Many medical practitioners refer patients for treatments that have been shown to be ineffective. This makes them no better than the acupuncturists, chiropractors, and homoeopaths they refer them to. What is supposed to separate you from them is a science base to your practise. This is not evident in your discourse here. So much the worse for you I’m afraid.

    What patients need (and it may not be what they demand of their doctor) is treatments that have been shown to be effective (or, at least, not proven to be ineffective) and they need medical practitioners that will refer them for treatments that have been shown to be effective, not whatever it is the patient has decided works. Patients can be educated. But, alas, it does take more time than a quick referral.

    Anyway, there’s loads to learn both here and at http://www.sciencebasedmedicine.org
    Cheers.

  95. Mr Qwertyon 30 Mar 2014 at 2:30 pm

    DrJoe:
    > BillyJoe: Or maybe mah-jongg is on the activities calendar for you today. Maybe you can convince some of your more demented home-mates that you know something about medicine or how to treat patients. You haven’t convinced me.

    What is scary is that you are (possibly) a licensed physician and showing the will to use motivated reasoning to reach wrong conclusions about medicine and how to treat patients.

    To solid arguments you answer with insult, straw men and appeal to authority, and never actually addressing the points.

    I feel deeply sorry for anyone possibly under your care. I guess it shows that there’s always few bad apples – medical degree or no medical degree.

  96. DrJoeinCAon 30 Mar 2014 at 8:32 pm

    MrQwerty: Your knowledge, training, and experience in treating patients is quite obviously, like BillyJoe and Steve12, nada. So I will accept your opinion for what it is based on — ignorance.

  97. BillyJoe7on 31 Mar 2014 at 6:36 am

    DrJoe,

    Can I ask you two last questions?
    Are you a medical doctor, or a “doctor” of chiropractic?

  98. Bill Openthalton 31 Mar 2014 at 7:29 am

    DrJoeinCA –

    This reminds me of a discussion I had, sometime in the 1990ies, with an MD of my acquaintance. It concerned prescribing antibiotics for viral infections, and over-prescribing antibiotics in general. His attitude was that his patients should leave his practice “satisfied” — meaning that if they wanted antibiotics, he’d give them antibiotics. If they wanted a day off work, he’d give them a certificate. If they wanted homeopathic remedies, he’d prescribe them. He knew the dangers of over-prescribing antibiotics, he admitted that delivering a certificate to a healthy person was fraud, and that homeopathy was bunk, but he was there “to serve his patients”, not to uphold standards of medicine, science or ethics.

  99. steve12on 31 Mar 2014 at 12:23 pm

    “MrQwerty: Your knowledge, training, and experience in treating patients is quite obviously, like BillyJoe and Steve12, nada. So I will accept your opinion for what it is based on — ignorance.”

    Go away for long weekend and Dr. Joe is still talking about me!! Nice.

    I’m a scientist, not a clinician, as I told you. And much of what you’re saying does not make sense where the science is concerned.

    I gave due deference to clinical experience above, and I mean it:

    “In a practical sense, every single medical decision cannot be guided by a carefully controlled study. This means that clinical experience is invaluable. I have no argument with that.”

    But you want your clinical experience to trump all considerations, to the point where you will not even explain your rationale! “Clinical experience” is not a catch-all that insulates MDs from being questioned. You’re using it as such and catching shit for it.

  100. Mr Qwertyon 01 Apr 2014 at 6:54 am

    BillyJoe7
    > Can I ask you two last questions?
    > Are you a medical doctor, or a “doctor” of chiropractic?

    That’s what I was thinking! It’s funny how he always plays a degree card when cornered, without actually ever saying what his field is. I suspect my degree in software engineering is probably as relevant to medicine as is his.

    Reminds me of this:
    https://www.youtube.com/watch?v=i3u2mBVFEHc

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