I think it is important to tell patients when all evidence based options have been tried and exhausted…..

The problem isn’t merely the fact of recommending an option that isn’t evidence based – e.g. an experimental therapy with insufficient data behind it. The crux of the problem is recommending options that have been studied scientifically and not only lack evidence of efficacy, but there’s heaps of evidence against their efficacy (for example homeopathy).

Instead of referring your patients to CAM practitioners, why not recommend some type of exercise, swimming or jogging, or relaxation activity, while *truthfully* implying that it will help with their general health and, possibly, with the specific symptoms that are bothering them currently. The placebo effect (however you envision it) will be there, the activity will be beneficial instead of useless (or worse than), and belief in woo will not be promoted.
How would such a recommendation fail to harness your idea of a placebo effect?

“That there’s nothing that science-based medicine can do for them at present, but more funding might help find better treatments in the future….”

I agree….I’ve told many a patient this, or something similar….I think it is important to tell patients when all evidence based options have been tried and exhausted…..

I think the crux of the issue is:

1) Is the “placebo effect”, through which inert therapies can promote positive changes in subjective perception of symptoms, a true phenomenon, or merely a function of trial participation, and

2) If so, is there a feasible way we can assist our patients in accessing this effect to their benefit…

I agree with you wholeheartedly that most CAM is not science-based, or at most, is based so loosely on science as to become easily untethered, and I do wish that there was a way that money could be kept out of the hands of its practitioners…..yet, as a believe that there the placebo effect is a real phenomenon, and patients do appreciate any subjective improvement that leads to improvement in function and QoL, how do you propose how we can assist patients in accessing it…

Of course, if you believe that the placebo effect is not real, than its a moot point……

Laura

The whole thing seems outrageous to me, allowing someone to feel better without objectively changing their illness? Recipe for disaster.

+1

We could…tell them the truth?

That there’s nothing that science-based medicine can do for them at present, but more funding might help find better treatments in the future.

The alternative seems to be to pour money into the pockets of quacks and charlatans who are in the business of selling false hope to desperate people. False hope is no hope at all.

I might be selling a false dichotomy here, but I can’t see a middle way. Either a treatment is supported by science or it’s not.

Sure….I wish everyone would give more money to charity…..i’m sure everyone has at somepoint is wasteful spending or unnecessary consumerism that could have been more charitally directed….

and if someone had a value system through which healing could be achieved through charitable donation, that I would have no problem with a patient following this course (of course though, only as in addition to proven evidence-based therapies)….

So then, where are we at for the people who don’t believe that a charitable donation will improve their fibromyagia symptoms?

Laura

What does this mean Dr. Novella? Belief in spaceships and aliens? Belief in God? Belief in the supernatural?
Or are you talking about supposed scientific beliefs, like whether or not vaccines cause autism? Or that magnets help arthritis?
Or is it all the same to you?

I don’t really see “competing in the rough and tumble world of free information” as being equivalent to “surviving close or open scrutiny”. People gravitate to the information that appeals to them. Only the people who are already critically-minded will take advantage of skeptical web sites to analyze all the info they find about any given topic. But I don’t really see too many Skeptic sites analyzing scientific info in such a systematic way. (there are exceptions

I find everyone’s comments here most insightful and agree with them all. If a skeptic hopes to overcome ignorance and fraud through online information, the information needs to be packaged in a “non-denominational” kind of way (for lack of a better description). if you want to criticize religion – do it over here. And if you want to expose a fraudulent product, do it over here. Otherwise, the mish-mosh of beliefs that most people tend to be made up of will prevent them from getting at the salient info you’re trying to provide.

“So here’s the rub with CAM, say I have patient with low back pain. That’s difficult to treat. I’ve tried conventional, and it hasn’t helped them. They ask about acupuncture. I tell them that there’s no evidence that it helps, but some patients report a subjective benefit to it. We decide that a subjective improvement is better than no improvement. Patient goes to acupuncturist. Acupuncturist does their thing, patient feels better. Acupuncturist then suggest that they can treat their asthma, or hypertension, or whatever. Is that acceptable?”

Not in the slightest….what is necessary in your communication to the patient is CAM is not a replacement for proven conventional medicine for condition where failure to control the underlying pathologic process may lead to dire consequences….so no, I would no recommend CAM for the treatment of hypertension, where failure tocontrol the underlying process increases the risk of cardiovascular and renal disease, or of asthma, where failure to control airway inflammation can lead to sudden respiratory failure…..conversely, if a patient with asthma, who was being managed appropriately for their asthma, expressed a desire to see a practioner of Reiki, of have their congregation prayer on his or her behalf, while I would explain that I cannot think of a sciewntific reason why that would be of benefit, that I am not going to be obstructive…..

Keep in mind, that as a physician, I am not a “gatekeeper” to CAM…if someone is set on using CAM, and I have nothing further to offer, I think my job is to minimize harm by advising them of the scientific non-validity of CAM, and steering them away from potentially hazardous CAM…in the end, its better to remain part of the patient’s care than to alienate them, which may make them more susceptible to suggestions by unethical CAM providers…..

as for “recipe for disaster”….I’m referring more to disease processes that are purely disorders of perception and of pain….where there underlying cause of disease is either known, or so poorly characterized that effective therpaies directed at the root underlying pathophysiology are yet to be developed…of course, I am 100% in favour of further research to better delineate these processes, and for the development of pharmacologic and non-pharmacologic therapies directed at these mechanisms….but until that day, subjective improvement for these conditions are the goals of therapy. and when we reach the limits of effectiveness for the therapies that we do have, I have little issue with trying to capture any further improvement the placebo effect may offer….

Lastly, perhaps we can refocus the discussion a bit….. I understand the resistance to using CAM, even to harness a placebo effect….so can anyone propose a way that this effect can be tapped without resorting to CAM…..I know for certain patients, I can provide anodyne advice about changing diet or exercising more, that of course have numerous health benefits, even if not for IBS or fibromyalgia, and this may provide placebo benefits for those who believe (or can be suggested to believe) the healing power of diet and exercise….any other ideas?

I’d suggest they throw their money at some legitimate research charity.